EMPHYSEMA

____________________

A Case Analysis presented to the

 Faculty of the Nursing Department
Mrs. Rodeliza Faith B. Guillermo, RN, MN

____________________

In Partial Fulfilment of the 

Requirements in NCM – 214 
Fluid and Electrolytes Nursing Rotation

Submitted by:

Loraine Ann Cruda, St. N

Marc Lewin Go, St. N

Eight Beryl Lao, St. N

Stephanie Mhae Tabasa, St. N

Warren Todd Torsiende, St. N

BSN-3A - GROUP 2 – SUBGROUP 1

Table of Contents

I.  Introduction
II. General Objectives and Specific Objectives
III. Pathophysiology        

A. Etiology
B. Symptomatology
C. Disease Process

a. Diagram
b. Narrative
D. Diagnostics and Laboratory Confirmatory Tests

a. Medical Diagnosis
i. Imaging Studies
ii. Laboratory Studies
iii. Other Studies
b. Nursing Diagnosis

E. Management
a. Medical Management
b. Surgical Management
c.Pharmacological Management
d.Non-pharmacological Management
e. Nursing Management
F. Prognosis

IV. Discharge Planning

V. Related Nursing Theory
VI. Review of Related Literature
VII. Drug Study
VIII. Nursing Care Plan
 IX. References

I.  Introduction

In our third year as student nurses in San Pedro College, we believe that having
the passion and love for our work makes everything fulfilling. Nothing could explain the
happiness in our hearts when we see the health of our patients improving. This gives us
more inspiration and motivation to do better and provide effective and excellent nursing
care. With this, we are able to give a brighter future not only for our own experience, but
also for our future patients and their loved ones.
Chronic obstructive pulmonary disease (COPD) is a chronic condition requiring
lifelong contacts within the healthcare system and continuous interactions with
healthcare professionals for effective and efficient self-management. A COPD self-
management intervention should be individualized and people with COPD should be
supported to maintain a healthy lifestyle, to change their behavior if needed, and to
develop skills for managing their disease. Pulmonary rehabilitation, an intervention in
which self-management promotion is one of the strategies recommended for all people
living with COPD.
COPD symptoms include breathing difficulty, cough, mucus (sputum) production
and wheezing. These symptoms have a destructive impact on patients' function (i.e.
activity limitation, decreased mobility) and quality of life. COPD is often a combination of
two conditions: emphysema and chronic bronchitis. People with COPD are at a much
greater risk of developing heart disease, lung cancer and a variety of other conditions.
The good news is, COPD is treatable. With proper management, most people with
COPD can control their symptoms and enhance quality of life, as well as reduce their
risk of other associated conditions.

As student nurses, our main goal is to provide optimum care for our patient. To be
able to help them cope in the best way they can with their pre-existing conditions. We
also strive to be the ones to lighten their minds with every medical procedure that they
are going to undertake.
 The purpose of this case analysis is to understand the disease and learn how to
treat it in order to help our client’s condition. The significance of this case analysis is to
help patients in coping up with their health status and to help us, student nurses,
understand it as well.

II. General Objectives and Specific Objectives

After the three (3) weeks of Fluids and Electrolytes Nursing Rotation, the
students will be able to present a complete comprehensive case analysis in contribution
to the knowledge that will be embodied by the student nurses to expand and create new
frontier for the nursing research and guide the future researchers, and to introduce or
enhance the nursing practice of the student nurse. More specifically, the proponents of
this study aim to:

a. Present an introduction which outlines the rotation, disease, relevant statistics,

and nursing implications of the study;
b. compose objectives that are specific, measurable, attainable, realistic, and time-
bounded;
c. discuss the etiologic factors that lead to the development of the disease;
d. indicate the symptomatology of the disease;
e. outline the disease process of Emphysema;
f. trace the pathophysiology of the disease through a schematic diagram;
g. list potential diagnostic or laboratory confirmatory tests viable to the case;
h. identify the possible observations during a physical assessment on a client with
Emphysema;
i. explain the possible medical management, its indication relating to the disease
including diagnostic, laboratory examinations, and possible medications;
j. generate a prognosis based on the outcomes of the disease;
k. outline a discharge planning using the METHOD approach;
l. associate appropriate nursing theories and theorists to serve as foundation for
nursing care;
m. present a summary on a related literature published not earlier than 5 years from
conduct of this study;
n. formulate nursing diagnosis relevant to the disease; and,
o. arrange an alphabetical list of references used in the study using APA format.
III. Pathophysiology    
A. Etiology

Predisposing Factors Rationale

Age People exposed to various irritants such

as smoking begin to experience signs
and symptoms of emphysema between
the ages of 40 and 60 because lung
damage in emphysema develops
slowly.

Genetic Disorder (Alpha-1 Individuals with A1AD may develop

Antitrypsin Deficiency) chronic obstructive pulmonary diseases
like emphysema during their thirties or
forties even without a history of the
usual risk factors, although a history of
risk factors like smoking does greatly
increase the risk of developing COPD.

Precipitating Factors Rationale

Smoking Emphysema is mainly caused by

cigarette smoking but other kinds of
smoking such as marijuana are also
susceptible to emphysema. Smoking
damages the lungs gradually by causing
inflammation, which can lead to the
narrowing of air passages and can
eventually damage the air sacs.

Second-hand smoking Second-hand smoking is the smoke

that an individual can passively inhale
from someone else’s cigarette, cigar, or
 pipe. Individuals who live with or are
around smokers have a significant
chance of getting emphysema
compared to those who are not.

Long-term occupational exposure Exposure to occupational hazards such

to airborne irritants
as toxic fumes and dust from wood, or
mining products can irritate the lungs
and prolonged exposure to these
irritants can eventually cause lung-
related diseases such as emphysema

Air pollution In a recent study, long-term exposure to

air pollution was linked to the increase
in cases of emphysema. Air pollutants
such as exhaust fumes, and smokes
from industrial factories can irritate the
lungs and airways thus can lead to the
risk of emphysema

B. Symptomatology

Symptom Rationale

Dyspnea Emphysema destroys the walls between

the air sacs in the lungs. This can create
fewer but larger air sacs which can lead
to a smaller total surface area for the
exchange of gas. Emphysema causes
air trapping and diminished gas
exchange which can also contribute to
dyspnea

Productive Cough COPD can cause the lungs to produce

excess mucus leading to frequent
productive coughing due to the
inflammation in the lungs. The body
makes even more mucus when reacting
to irritants such as air pollutants and
 smoking.

Wheezing Inflammation of the lungs can cause the

airways to be narrowed, from the throat
out to the lungs and can result in
wheezing. When you exhale and air is
forced through obstructed airways in the
lungs, a whistling or musical sound,
called wheezing can be produced.

Weight loss Weight loss is a sign of severe

emphysema. When the lungs aren't
working as well as they should, the body
has to work harder to breathe. This can
cause patients with emphysema to burn
up to 10 times more calories than usual.
The symptoms of emphysema such as
dyspnea and chronic cough can also
lead to a decreased appetite which can
contribute to eventual weight loss.

Barrel Chest Emphysema patients can show signs of

a barrel chest in the later stages of the
diseases because of the nature of the
disease which is the overinflation and
the trapping of air in the air sacs, so the
rib cage stays partially expanded most
of the time.

C. Disease Process
a. Diagram
b. Narrative
 In emphysema, there are predisposing factors that put the individual at
risk for developing emphysema, age, and the deficiency of Alpha-1 Antitrypsin
or A1AD. The factors that can give rise to increased chances of developing
emphysema are smoking, second-hand smoking, exposure to air pollution, and
long-term occupational exposure to airborne irritants of the respiratory system
such as dust, and toxic chemical fumes depending on the individual’s nature of
occupation. Emphysema is a form of COPD (Chronic Obstructive Pulmonary
Disorder) that is characterized by the structural changes in the lungs specifically
the destruction of the alveoli. When the lung tissues are exposed to irritants like
cigarette smoke, it triggers an inflammatory response that affects the alveolar
walls and affects the flow of gasses. Free radicals can also decrease the
function of alpha-1 antitrypsin and can lead to inflammation. Inflammatory
responses attract various immune chemicals such as the cytokines LTB4
(Leukotriene B4), Interleukin-8 (IL-8), and tumor necrosis alpha (TNF), as well
as proteases such as metalloproteinases. The release of cytokines increases
the number of neutrophils and the goblet cells trigger an increased mucus
production and leads to a productive cough. The release of proteases breaks
down the structural proteins of the alveolar wall such as elastin and collagen
compromising the integrity of the alveolar wall, which leads to the problem seen
in emphysema which is the loss of elasticity of the alveolar walls, which makes
the alveoli more compliant, so when the person exhales, the alveolar walls
collapse and can lead to air trapping. Air trapping causes O2 and CO2 retention
which makes the alveoli swell. Overinflation of the alveoli causes barrel chest.
Collapsed bronchioles cause wheezing, dyspnea, and weight loss due to
increased energy expenditure. If emphysema is not treated, it can affect more
alveoli, which massively impairs gas exchange, which can lead to hypoxic
pulmonary vasoconstriction, increased workload of right ventricle and pulmonary
artery, pulmonary hypotension, cor pulmonale, hypoxia, heart failure, and
eventually death. However, if emphysema is treated properly, the signs and
symptoms will be controlled, and minimized which leads to a good prognosis.

D. Diagnostic and Laboratory Confirmatory Test

a. Medical Diagnosis
i. Imaging Studies
1. Chest radiograph
a. X-rays are generally not useful for detecting early stages of
emphysema. However, X-rays can help diagnose moderate or
severe cases

Result/Findings:
Frontal and lateral chest radiographs reveal signs of hyperinflation:
flattening ("coving") of diaphragms, increased retrosternal air space
and a long narrow heart shadow. Rapid tapering vascular shadows
accompanied by hyperlucency of the lungs are signs of
emphysema. With complicating pulmonary hypertension, the hilar
vascular shadows become prominent; right ventricular enlargement
and an opacity in the lower retrosternal air space may also occur.

2. CT scan
a. High-resolution CT (HRCT) scanning is more sensitive than
standard chest radiography. HRCT scanning is highly specific for
diagnosing emphysema and outlines bullae that are not always
observed on radiographs. A CT scan is indicated when the patient is
being considered for a surgical intervention such as bullectomy or
lung-volume reduction surgery.CT is able to discriminate between
centrilobular, panlobular, and paraseptal emphysema

Result/Findings:
i. Centrilobular emphysema
It appears as focal lucencies (emphysematous spaces) which
measure up to 1 cm in diameter, located centrally within the
secondary pulmonary lobule, often with a central or peripheral dot
representing the central bronchovascular bundle.
 ii. Panlobular emphysema

Predominantly located in the lower lobes, has a uniform distribution

across parts of the secondary pulmonary lobule, which are
homogeneously reduced in attenuation.

iii. Paraseptal emphysema

Paraseptal emphysema is located adjacent to the pleura and septal
lines with a peripheral distribution within the secondary pulmonary
lobule. The affected lobules are almost always subpleural and
demonstrate small focal lucencies up to 10 mm in size.
ii. Laboratory Studies
1. Arterial blood gas analysis
This test measures the amount of oxygen and carbon dioxide in
blood from an artery. It is a test often used as emphysema worsens. It is
especially helpful in determining if a patient needs extra oxygen. Patients
with mild chronic obstructive pulmonary disease (COPD) have mild-to-
moderate hypoxemia without hypercapnia. As the disease progresses,
hypoxemia worsens and hypercapnia develops.

2. Hematocrit
Chronic hypoxemia may lead to polycythemia. A hematocrit value
higher than 52% in men and higher than 47% in women is indicative of
the condition. Patients should be evaluated for hypoxemia at four times:
at rest, with ambulation, with exertion, and during sleep. Correction of
hypoxemia should reduce secondary polycythemia in patients who have
quit smoking.

3. Serum bicarbonate
Chronic respiratory acidosis leads to compensatory metabolic
alkalosis. In the absence of blood gas measurements, serum bicarbonate
levels are useful for following disease progression.

4. Complete Blood Count

 This simple blood test usually shows normal amounts of white and
red blood cells. In advanced emphysema, your body produces more red
blood cells to make up for decreased oxygen. If white blood cell count is
higher than normal, that’s a possible sign of infection.

5. Sputum evaluation
In patients with stable chronic bronchitis and in emphysema, the
sputum is mucoid and the predominant cells are macrophages. With an
exacerbation, the sputum becomes purulent, with excessive neutrophils
and a mixture of organisms visualized through Gram staining.
Streptococcus pneumoniae and Haemophilus influenzae are pathogens
frequently cultured during exacerbations.

6. AATD Testing
All individuals with COPD regardless of age or ethnicity should be
tested for AATD. Of the approximately 75 different alleles for alpha1-
antitrypsin (AAT) deficiency variants, 10-15 are associated with serum
levels below the protective threshold of 11 mmol/L. The diagnosis of
severe AAT deficiency is confirmed when the serum level falls below the
protective threshold value (ie, 3-7 mmol/L). More than 95% of all severely
AAT deficient individuals have either the ZZ or SZ genotype.

iii. Other Studies

1. Pulmonary Function Test
In patients with emphysema, there may be an increase in total
lung capacity (TLC), but a decrease in vital capacity) and forced
expiratory volume (FEV), the maximum amount of air which can be
exhaled. Diffusing capacity is another important measurement. The
diffusing capacity for carbon monoxide (DLCO) is a measure of the
conductance of gas transfer of carbon monoxide to red blood cells.

2. Spirometry
 A spirometry or PFT tests the lungs’ volume by measuring airflow while a
patient inhales and exhales. This test is done by taking a deep breath and
then blowing into a tube that is hooked up to a spirometer machine.
3. Pulse oximetry
Pulse oximetry is a means of measuring oxygen saturation or the
percentage of hemoglobin saturated with oxygen in arterial blood--
to check pulmonary function, and how well the lungs are working.

b. Nursing Diagnosis
● Activity Intolerance r/t imbalance between oxygen supply and
demand
● Ineffective Airway Clearance r/t bronchoconstriction, increased
mucus, ineffective cough, infection
● Anxiety r/t breathlessness, change in health status
● Death Anxiety r/t seriousness of medical condition, difficulty being
able to “catch breath”, feeling of suffocation
● Impaired Gas Exchange r/t ventilation-perfusion inequality
● Imbalanced Nutrition: Less than body requirements r/t decreased
intake because of dyspnea, unpleasant taste in mouth left by
medication, increased need for calories from work of breathing
● Ineffective Breathing Pattern related COPD and pneumonia as evidenced by
shortness of breath

E. Management
a. Medical Management
● Medicines to open the airways of the lungs, decrease swelling and
inflammation in the lungs, or treat an infection may be given. The
patient may need 2 or more medicines. A short-acting medicine
relieves symptoms quickly. Long-acting medicines will control or
prevent symptoms. Ask the healthcare provider how to use your
medicines safely.
● Pulmonary rehabilitation is a program to help patients manage
their symptoms and improve their quality of life. It may include
nutritional counselling and exercise, such as walking, to strengthen
the lungs.
● Oxygen may help patients breathe easier and feel more alert if the
patient has severe COPD.
● Surgery is sometimes done if all other treatments have failed. A
lung reduction is surgery to remove part of the damaged lung. A
lung transplant is the replacement of the lung with a donor lung.
Ask the healthcare provider for more information about surgery for
emphysema.

b. Surgical Management
Depending on the severity of your emphysema, your doctor may
suggest one or more different types of surgery, including:

● Lung volume reduction surgery. In this procedure, surgeons

remove small wedges of damaged lung tissue. Removing the
diseased tissue helps the remaining lung tissue expand and work
more efficiently and helps improve breathing.
● Lung transplant. Lung transplantation is an option if you have
severe lung damage and other options have failed. Lung transplant
surgery is a complex procedure in which a patient’s diseased lung
 or lungs are replaced with lungs from a deceased donor in an effort
to cure or improve a variety of end-stage pulmonary diseases,
including cystic fibrosis and pulmonary hypertension.
● Bullectomy. Large air spaces (bullae) form in the lungs when the
walls of the air sacs (alveoli) are destroyed. These bullae can
become very large and cause breathing problems. In a bullectomy,
doctors remove bullae from the lungs to help improve air flow.
c. Pharmacological Management
● Bronchodilator Medications: Bronchodilators are medications
that relax the bronchial muscles and improve airflow.
Bronchodilators are available as inhalers in both metered dose form
and powder inhalers, and through nebulizer machines (they convert
a liquid to aerosol). There are short-acting and long-acting
bronchodilators. The short-acting drugs work faster but don’t last as
long. The long-acting ones don’t work as fast, but they last longer. If
your emphysema symptoms are mild, your doctor may recommend
you take short-acting bronchodilators during flare ups. As your
symptoms get worse, you may have to take daily doses of long-
acting bronchodilators.

Examples of short-acting bronchodilators include:

● Albuterol (ProAir HFA, Ventolin HFA, others)
● Ipratropium (Atrovent HFA)
● Levalbuterol (Xopenex)

Examples of long-acting bronchodilators include:

● Aclidinium (Tudorza Pressair)

● Arformoterol (Brovana)
● Formoterol (Perforomist)
● Indacaterol (Arcapta Neoinhaler)
● Tiotropium (Spiriva)
 ● Salmeterol (Serevent)
● Umeclidinium (Incruse Ellipta)
● Inhaled steroids: Inhaled corticosteroid medications can reduce
airway inflammation and help prevent exacerbations. Side effects
may include bruising, oral infections and hoarseness. These
medications are useful for people with frequent exacerbations of
COPD.

Examples of inhaled steroids include:

● Fluticasone (Flovent HFA)

● Budesonide (Pulmicort Flexhaler)
● Combination inhalers: Some medications combine
bronchodilators and inhaled steroids.

Examples of these combination inhalers include:

● Fluticasone and vilanterol (Breo Ellipta)

● Fluticasone, umeclidinium and vilanterol (Trelegy
Ellipta)
● Formoterol and budesonide (Symbicort)
● Salmeterol and fluticasone
● (Advair HFA, AirDuo Digihaler, others)
● Antibiotics: Antibiotics may be used to help fight respiratory
infections common in people with emphysema, such as acute
bronchitis, pneumonia and the flu. Antibiotics help treat episodes of
worsening COPD, but they aren't generally recommended for
prevention. Regular treatment with antibiotics like azithromycin and
erythromycin may help manage COPD. Some studies also show
that certain antibiotics, such as azithromycin (Zithromax), prevent
episodes of worsening COPD, but side effects and antibiotic
resistance may limit their use.
 ● Oxygen Therapy: As a patient's disease progresses, they may find
it increasingly difficult to breathe on their own and may require
supplemental oxygen. Oxygen comes 14 in various forms and may
be delivered with different devices, including those you can use at
home.
● Protein Therapy: Patients with emphysema caused by an alpha-1
antitrypsin (AAT) deficiency may be given infusions of AAT to help
slow the progression of lung damage.
d. Non-pharmacologic management:
● Pulmonary rehabilitation. A pulmonary rehabilitation program can
teach you breathing exercises and techniques that may help reduce
your breathlessness and improve your ability to exercise.
● Nutrition therapy. You'll also receive advice about proper nutrition.
In the early stages of emphysema, many people need to lose
weight, while people with late-stage emphysema often need to gain
weight.
● Supplemental oxygen. If you have severe emphysema with low
blood oxygen levels, using oxygen regularly at home and when you
exercise may provide some relief. Many people use oxygen 24
hours a day. It's usually administered via narrow tubing that fits into
your nostrils. 1-2 liters is enough to give oxygen.

e. Nursing Management
● 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 non essential 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.
F. Prognosis

In determining the prognosis of emphysema, Doctors use the GOLD (Global

Initiative for Chronic Obstructive Lung Disease) emphysema staging system to
determine how effective is the function of the lungs when it comes to expelling air
within 1 second or also known as FEV1 (Forced Expiratory Volume in 1 second).
The result of the FEV1 will be the basis for staging the Emphysema. Group A
(GOLD 1-2) have mild symptoms, with an FEV1 of 80% or more. You might have
had no exacerbation over the past year, or perhaps just one. You weren’t
hospitalized for your symptoms. Group B (GOLD 1-2) have an FEV1 of between
50% and 80%. This is the stage where most people see their doctor for coughing,
wheezing, and shortness of breath but had one major exacerbation haven’t been in
 the hospital for your symptoms within the past year. Group C (GOLD 3-4) Air flow
into and out of your lungs is severely limited and has an FEV1 between 30% and
50%. Group D (GOLD 3-4) have difficulty when it comes to breathing and had 2
episodes of exacerbation or were hospitalized in the past years. Doctors also use
the BODE index in evaluating how emphysema impacts the daily life of an
individual in four main areas mainly BMI (body mass index), Airflow limitation,
Dyspnea, and Exercise.

According to Patino, M.(2017) Emphysema has no cure since it can be triggered

by irritants that are present in the environment. However, the symptoms of
emphysema can be controlled and managed with early detection, Lifestyle
modifications like smoking cessation, slow-paced cardio exercises like walking,
avoiding the consumption of foods that can cause excess gas and bloating like
fried foods, broccoli, cabbage, and carbonated beverages, deep breathing
exercises, and wearing of mask when going to crowded places. Medical treatments
can aid in relieving the symptoms of emphysema like bronchodilators, antibiotics,
oxygen therapy, protein therapy and such.

IV. Discharge Planning

MEDICATIONS.
Take home medications religiously as ordered by the physician to promote
recovery and wellness. Medications such as
● Bronchodilators. These drugs can help relieve coughing, shortness of
breath and breathing problems by relaxing constricted airways.
● Inhaled steroids (Corticosteroid drugs). Inhaled as aerosol sprays
reduce inflammation and may help relieve shortness of breath.
● Antibiotics. Antibiotics need to be taken seriously and religiously to
prevent resistance of bacteria.
EXERCISES.
4 Types of Exercises for COPD
 These four types of exercise can help patients with COPD. How much patient
focus on each type depends on the COPD exercise program the health care provider
suggests to every patient.

● Stretching exercises lengthen muscles, increasing flexibility.

● Aerobic exercises use large muscle groups to move at a steady,
rhythmic pace. This type of exercise works the heart and lungs, improving
their endurance. This helps the body use oxygen more efficiently and, with
time, can improve breathing. Walking and using a stationary bike are two
good aerobic exercises if a patient has COPD.
● Strengthening exercises involve tightening muscles until they begin to
tire. When the patient does this for the upper body, it can help increase
the strength of breathing muscles.
● Breathing exercises for COPD patients, it will help to strengthen
breathing muscles, get more oxygen, and breathe with less effort. Here
are two examples of breathing exercises that the patient can begin
practicing. Work up to 5 to 10 minutes, three to four times a day.
- Pursed-lip breathing
- Diaphragmatic breath

TREATMENT.

● Smoking cessation. This is the most important measure a patient can

take for his/her overall health and the only one that might halt the
progression of emphysema. Join a smoking cessation program if the
patient needs help giving up smoking. As much as possible, avoid second-
hand smoke.
● Get recommended vaccinations. Be sure to get an annual flu shot and
pneumonia vaccinations as advised by your doctor.
● Prevent respiratory infections. The patient needs to do their best to
avoid direct contact with people who have a cold or the flu. If the patient
 has to mingle with large groups of people during cold and flu season, wear
a face mask, wash your hands frequently and carry a small bottle of
alcohol-based hand sanitizer to use when needed.

HYGIENE.

● Hand washing. Frequent and thorough hand washing with soap and
warm water is a simple and very effective way for COPD patients to avoid
many types of infections.
● Take a bath daily. To promote cleanliness all over the body.
● Brushing teeth every after meals and visits the dentist regularly. This
means that practicing good dental habits is another way that COPD
patients can help to manage their disease. Good dental habits include:
Brushing of teeth every after meal and flossing daily.

OUTPATIENT.
● Follow a scheduled check up by the doctor. Visit the doctor for a
scheduled check-up to monitor and evaluate current status of the
patient/client.
● Protect yourself from cold air. Cold air can cause spasms of the
bronchial passages, making it even more difficult to breathe. During cold
weather, wear a soft scarf or a cold-air mask — available from a pharmacy
— over mouth and nose before going outside, to warm the air entering
your lungs.
● Avoid other respiratory irritants. These include fumes from paint and
automobile exhaust, some cooking odors, certain perfumes, even burning
candles and incense. Change furnace and air conditioner filters regularly
to limit pollutants

DIET.
● Eat a variety of healthy foods such as vegetables, fruits, whole grains,
dairy products, and proteins. High-fiber foods are especially important.
 They help with digestion, control blood sugar levels, reduce cholesterol
levels, and can help control weight.
● Drink plenty of water. Not only does it help prevent gas when patients
eat high-fiber foods, but water helps thin mucus so the patient can cough it
up easier. Most people need six to eight 8-ounce glasses of water a day.
Check with the doctor, though, because some health conditions require
that you limit your fluids.
● Ask about certain foods. Certain nutrients, such as omega-3 fatty acids,
may help reduce inflammation and improve lung function. Ask the health
care provider.
● Avoid salt. Salt (sodium) makes the body retain water, which increases
swelling. This makes breathing more difficult.
● Avoid foods that cause gas or bloating. Everyone knows how
uncomfortable that full-stomach feeling is. And it may make breathing
more difficult.
● If a patient needs to gain weight. The health care needs to recommend
foods that are more high-protein, high-calorie foods such as cheese,
peanut butter, eggs, milk, and yogurt. Ask about nutritional supplements to
increase the number of calories and nutrients the patient needs to get
each day.
V. Related Nursing Theory

Nursing theories provide nurses the necessary tool to improve and uphold the
qualities of nursing implications in education, practice, and research.

Florence Nightingale’s Environmental Theory

Florence Nightingale’s Environmental Theory in Nursing is defined as “the act of
using the environment of the patient to assist a patient in recovery”. It involves the
nurse’s resourcefulness to enhance the environmental settings appropriate for the
restoration of the patient’s health. Since, the external factors associated with the
patient’s surroundings/environment affects the patient’s development. (Gonzalo, 2019).
The environmental factors that affect health, as identified in the theory, are fresh air,
pure water and sufficient food supplies, cleanliness of the patient and its environment,
and light particularly direct sunlight. If any of these is lacking, the patient may
experience diminished health.
Environmental Theory describes Nursing as the act of using the patient's
environment to assist him in his recovery. It includes the effort of the nurse to configure
environmental settings suitable for the gradual restoration of the wellbeing. The nurse
should manipulate and alter the environment of the patient by removing the triggers that
can be found in the environment. To ensure removal of these triggers, there should be a
clean environment.
In relation to the patient with emphysema, this theory would tell that the
surroundings of the patient has a big factor in getting the disease. Especially in the
community who has a lot of smokers that can trigger the health of the patient. So this
theory could tell us that maintaining our environment clean and green will lessen the
worsening of the disease. In addition, the client should have an adequate rest and in
order to achieve optimum level of wellness. The patient should also increase oral fluid
intake and to follow the diet recommended by the physician. A nurse’s role in a patient’s
recovery is to alter the environment in order to gradually create the optimal conditions
for the patient’s body to heal itself.
Katharine Kolkaba’s Theory of Comfort
The Theory of Comfort was developed when Katharine Kolcaba conducted a
concept analysis of comfort that examined literature from several disciplines, including
nursing, medicine, psychology, psychiatry, ergonomics, and English. Kolcaba described
comfort existing in three forms: relief, ease, and transcendence. If specific comfort
needs of a patient are met, the patient experiences comfort in the sense of relief.
According to Kolcaba, comfort is the product of holistic nursing art.
Comfort is a massively important concept of nursing and this theory is designed
to bring comfort to patients. Comfort is the immediate experience of being strengthened
by having needs for relief, ease and transcendence met in four contexts (physical,
psychospiritual, social, and environmental). Nurses identify needs of patients and
families which have not been met. These needs are modified by intervening variables
which are factors that nurses cannot change. With these concepts in mind, nurses
formulate a comfort care plan.
In relation to this case, the Kolcaba’s comfort theory is applicable due to the
feeling of discomfort because of the pain due to the symptoms of emphysema such as
the chest pain due to chest tightening. It gives a feeling of discomfort that is why it is
necessary for us to ensure and provide relief to our patient by administering
medications and giving ease to our patient as we provide quality care in order for the
patient to attain appropriate healing.
VI. Review of Related Literature

In a recent study done by (Hu et al., 2020), a total of 968 patients with confirmed
COPD were requested to fill out a questionnaire involving their basic information and
medical history. All subjects underwent one overnight polysomnography and were then
divided into an OVS group or a COPD only group according to their apnea–hypopnea
index. The purpose of the study was to assess the prevalence of hypertension,
diabetes, cardiovascular disease, arrhythmia and cerebrovascular disease. These were
compared and risk factors for comorbidities in COPD patients were identified.
Compared with the COPD only group, the prevalence of hypertension was significantly
higher in the OVS group, however, the prevalence rates of the other four kinds of
diseases were not statistically different between the two groups. In COPD patients, the
prevalence of hypertension increased with the severity of OSA and the prevalence of
arrhythmia increased with airflow limitation severity. Risk factors for OSA in patients
with COPD included BMI, FEV1%, Epworth Sleepiness Scale score and the Sleep
Apnea Clinical Score. OSA was an independent risk factor for hypertension. The other
risk factors for hypertension in COPD patients included age, BMI, CAT score and
alcohol consumption. Age, lower FEV1% may be risk factors for arrhythmia. OVS
patients were associated with a high prevalence rate of hypertension, while OSA was
an independent risk factor for hypertension.

Another study conducted by (Lundell et al., 2020), sought to explore how people
with COPD experience COPD-related interactions with healthcare professionals in
primary care, and how these interactions influence their self-management and how they
cope with their disease. Interviews were done with eight women and five men with
COPD, and grounded theory guided the data collection and analysis of the study. The
research study found that decision-making was an important aspect in the interaction.
Participants preferred shared decision-making in a regular and trustful relationship with
healthcare professionals, and their description of this relationship can be compared to
the meaning of partnership. A patient-provider relationship that is characterized by
respect and regularity, along with a personal positive and accepting view on the
diagnosis of COPD, is important for patient empowerment, self-management, and
acceptance. The study suggests that in order to strengthen the possibilities for
enhancing empowerment, COPD-related competence among healthcare professionals,
and their understanding of the value of regular, respectful and empowering interactions
must be increased.

Veering microscopically, COPD is the seventh leading cause of death in the

Philippines. (Novartis, Philippine College of Chest Physicians launch COPD awareness
campaign | Novartis Philippines, 2017) Smoking is the most common cause of Chronic
Obstructive Pulmonary Disease (COPD), non-smokers are also at risk of developing
this debilitating and life-threatening inflammatory disease that causes obstructed airflow
from the lungs. People exposed to large amounts of secondhand cigarette smoke, air
pollution, and fumes from burning fuel for cooking and heating in poorly ventilated
homes are at risk of developing COPD. To help address this problem, the Philippine
College of Chest Physicians (PCCP) and Novartis Healthcare Philippines have
launched the BREATHE initiative. BREATHE, which stands for Broadening Reach,
Enhancing Awareness, and Transforming Health Education, aims to increase public
awareness on avoiding or mitigating COPD risk factors as well as to enhance the
knowledge of local healthcare professionals in COPD diagnosis and management.
VII. Drug Study

GENERIC NAME: Albuterol Nebule

BRAND NAME: Salbutamol, Proventil,

Ventolin, Accuneb, airet,
Novo-Salbutamol,Proventil
HFA, Gen-salbutamol,
Ventodisk, Ventolin HFA,
Volmax, VoSpira E, Asthalin

CLASSIFICATIONS:
Therapeutic Class:

Pharmaceutical Class:

MODE OF ACTION: Moderately selective beta2-adrenergic agonist

that acts prominently on smooth muscles of
trachea, bronchi, uterus, and vascular supply to
 skeletal muscles. Inhibits histamine release by
mast cells. Produces bronchodilation by relaxing
smooth muscles of the bronchial tree.
Bronchodilation decreases airway resistance,
facilitates mucous drainage, and increases vital
capacity.

DOSAGE/ROUTE: · Severe bronchospasm

Adult: Via nebulizer: 2.5-5 mg, up to 4 times daily,

alternatively, may be given continuously at a rate of 1-2
mg/hr. Child: ≥4 yr. Same as adult dose.

· Acute bronchospasm

Adult: As a metered-dose aerosol or dry powder

inhaler (90 or 100 mcg/actuation): 1 or 2 inhalations up
to 4 times daily. Max: 800 mcg daily. Child: 6-12 years
old, 1 inhalation, may be increased to 2 inhalations as
necessary.

· Acute severe asthma

Adult: As metered-dose inhaler (100 mcg/actuation)

via spacer device: Initially, 4 inhalations, then a further
2 inhalations every 2 min according to response. Max:
10 inhalations.

· Prophylaxis of exercise-induced bronchospasm

Adult: As a metered-dose aerosol or dry powder

inhaler (90 or 100 mcg/actuation): 2 inhalations 10-15
min prior to exercise. Child: 6-12 yr 1 inhalation 10-15
min prior to exercise.
 INDICATIONS: Severe bronchospasm

Acute bronchospasm

Acute severe asthma

Prophylaxis of exercise-induced bronchospasm

CONTRAINDICATIONS: Hypersensitivity to salbutamol

Tachyarrhythmias and tachycardia caused by

digitalis intoxication

Patients with degenerative heart diseases

SIDE EFFECT: CNS: Restlessness, apprehension, anxiety, fear, CNS

stimulation, vertigo, headache, weakness, tremors,
drowsiness 18

CV: Cardiac arrhythmias, palpitations, tachycardia

Dermatologic: Sweating, pallor, flushing

GI: nausea, vomiting, heartburn, unusual, or bad taste

in the mouth

Respiratory: Respiratory difficulties, pulmonary edema,

coughing, bronchospasm, paradoxical airway
resistance with repeated, excessive use of inhalation
preparations

ADVERSE EFFECT: Body as a Whole: Hypersensitivity reaction.

CNS: Tremor, anxiety, nervousness, restlessness,

 convulsions, weakness, headache, hallucinations.

CV: Palpitation, hypertension, hypotension,

bradycardia, reflex tachycardia.

Special Senses: Blurred vision, dilated pupils.

GI: Nausea, vomiting.

Other: Muscle cramps, hoarseness. Potentially Fatal:

Paradoxical bronchospasm

DRUG INTERACTION: With epinephrine and other sympathomimetic

bronchodilators, possible additive effects;

· Mao Inhibitors, Tricyclic Antidepressants -

potentiate action on vascular system;

· Beta-Adrenergic Blockers - antagonize the effects

of both drugs.

NURSING 1. Check and verify with the doctor's order and

INTERVENTIONS: kardex.

2. Monitor ECG, serum electrolytes and thyroid

function test results.

3. Administer accurately because adverse

reactions and tolerance might occur.

4. Auscultate lungs for presence of adventitious

breath sounds that may signal pulmonary edema,
airway resistance or bronchospasm. 19
 5. Provide oral care or let the patient gurgle after
inhalation to get rid of the unpleasant aftertaste of
the inhalation.

6. Place the client in a position of comfort to

facilitate optimum rest and sleep.

7. Raise side rails up because clients might be

restless and drowsy because of this drug.

8. Keep the room well-lit and see to it that the

client has a person with him closely in case of
vertigo.

9. Inspect the client's nail bed and oral mucosa for

pallor.

10. Instruct patient/watcher not to use OTC drugs

without prescriber approval. Many medications
contain drugs that may intensify albuterol action.

GENERIC NAME: Fluticasone

BRAND NAME: Apo-Fluticasone, Arnuity

Ellipta, Cutivate, Flonase,
Flonase Allergy Relief,
Flovent Diskus, Flovent HFA,
 VeramystXhance

CLASSIFICATIONS: Therapeutic Class: Prevents,

controls inhalation

Pharmaceutical Class:
Corticosteroid

Controlled Substance Schedule:

Pregnancy Category:

MODE OF ACTION: Controls rate of protein synthesis, depresses migration

of polymorphonuclear leukocytes, reverses capillary
permeability, stabilizes lysosomal membranes.
DOSAGE/ROUTE: · Allergic rhinitis

Intranasal (Flonase): ADULTS. ELDERLY: Initially, 200 mcg

(2 sprays in each nostril once daily or 1 spray in each nostril
q12h). MAINTENANCE: 1 spray in each nostril once daily.
May increase to 100 mcg (2 sprays in each nostril).
MAXIMUM: 200 mcg/day (2 sprays each nostril).

(Veramyst): ADULTS, ELDERLY, CHILDREN12 YRS AND

OLDER: 110 mcg (2 sprays in each nostril) once daily.
Maintenance: 55 mcg (1 spray in each nostril) once daily.
CHILDREN 2-11 years: 55 mcg (1 spray in each nostril) once
daily.

(Xhance): ADULTS, ELDERLY: 93 mcg (1 spray) per nostril

twice daily. May increase to 2 sprays twice daily.

Use Topical Dosage

Note: Ointment for adults only.

Topical: ADULTS, ELDERLY, CHILDREN 3 MOS AND

OLDER: Apply sparingly to affected area once or twice daily.

· Maintenance Treatment for Asthma

Inhalation Powder (Arnuity Ellipta): ADULTS, ELDERLY,

CHILDREN 12 YRS AND OLDER: 100-200 mcg once daily.
Maximum: 200 mcg/day.

· Maintenance Treatment for Asthma (Previously Treated

with Bronchodilators)

Inhalation Powder (Flovent Diskus): ADULTS, ELDERLY,

CHILDREN 12 YRS AND OLDER: Initially, 100-200 mcg once
daily. Maximum: 500 mcg twice daily.
 Inhalation Powder (Flovent HFA): ADULTS, ELDERLY,
CHILDREN 12 YRS AND OLDER: 88 mcg twice daily.
Maximum: 440 mcg twice daily.

· Maintenance Treatment for Asthma (Previously Treated

with Inhaled Steroids)

Inhalation Powder (Flovent Diskus): ADULTS, ELDERLY,

CHILDREN 12 YRS AND OLDER: Initially, 100-250 mcg once
daily. Maximum: 500 mcg twice daily.

Inhalation Powder (Flovent HFA): ADULTS, ELDERLY,

CHILDREN 12 YRS AND OLDER: 88-220 mcg twice daily.
Maximum: 440 mcg twice daily.

· Maintenance Treatment for Asthma (Previously Treated

with Oral Steroids)

Inhalation Powder (Flovent Diskus): ADULTS, ELDERLY,

CHILDREN 12 YRS AND OLDER: 500-1000 mcg once daily.

Inhalation Powder (Flovent HFA): ADULTS, ELDERLY,

CHILDREN 12 YRS AND OLDER: 440-880 mcg twice daily.

· Usual Pediatric Dose (4-11 YRS OLD)

(Flovent Diskus): Initially, 50 mcg twice daily. May increase to

100 mcg twice daily. (Flovent HFA): 88 mcg twice daily.

· Dosage in Renal/Hepatic Impairment

No dose adjustment. (Arnuity Ellipta): Use caution in hepatic

impairment.

INDICATIONS: ● Asthma prophylaxis

● Allergic rhinitis
 ● Nasal polyps
● Corticosteroid-responsive dermatoses

CONTRAINDICATION Hypersensitivity to fluticasone. (Arnuity Elipta, Flovant

S: Diskus): Severe hypersensitivity to milk proteins or lactose.
Inhalation: Primary treatment status asthmaticus, acute
exacerbation of asthma, other acute asthmatic conditions.
Cautions: Untreated systemic ocular herpes simplex;
untreated fungal, bacterial infection; active or quiescent
tuberculosis. Thyroid disease, cardiovascular disease,
diabetes, glaucoma, hepatic/renal impairment, cataracts,
myasthenia gravis, seizures, GI disease, risk for osteoporosis,
untreated localized infection of nasal mucosa. Following acute
MI; concurrent use with strong CYP3A4 inhibitors.

SIDE EFFECT: Frequent Inhalation: Throat irritation, hoarseness, dry

mouth, cough, temporary wheezing, oropharyngeal
candidiasis (particularly if mouth is not rinsed with water after
each administration). Intranasal: Mild nasopharyngeal
irritation, nasal burning, stinging, dryness, rebound
congestion, rhinorrhea, altered sense of taste. Occasional:
Inhalation: Oral Candidiasis, headache. Topical: Stinging,
burning of skin.

ADVERSE EFFECT: Significant: Adrenal suppression (e.g. suppression of

hypothalamic-pituitary-adrenal axis, hypercortisolism,
Cushing’s syndrome), immunosuppression (prolonged
use), pneumonia, local oropharyngeal candidiasis, local
nasal effects (e.g. epistaxis, nasal septal perforation,
ulceration, or erosion), visual disturbances (e.g. blurred
vision, increased intraocular pressure, glaucoma,
 cataract, central serous chorioretinopathy), decreased
bone mineral density, growth retardation in children,
hyperglycaemia or glycosuria, delayed wound healing,
localised reactions (e.g. skin atrophy), rebound of pre-
existing dermatoses, withdrawal symptoms (e.g.
joint/muscle pain, lassitude, depression).

Gastrointestinal disorders: Nausea, vomiting, abdominal

pain, diarrhoea, toothache, dyspepsia.

General disorders and admin site conditions: Fatigue,

malaise.

Musculoskeletal and connective tissue disorders:

Arthralgia.

Nervous system disorders: Headache, dizziness,

unpleasant taste or smell.

Respiratory, thoracic and mediastinal disorders:

Hoarseness, dysphonia, cough, sinusitis,
nasopharyngitis, rhinalgia, nasal or throat dryness,
irritation, burning and soreness.

Skin and subcutaneous tissue disorders: Pruritus, local

skin burning, contusions, skin thinning, erythema, striae,
pigmentation changes, hypertrichosis.

DRUG INTERACTION: DRUG: CYP3A4 inhibitors (carbamazepine, ketoconazole,

phenytoin, rifAMPin) may increase concentration. Ritonavir
may reduce serum cortisol concentration. HERBAL:
Echinacea, St. John’s wort may decrease
concentration/effects. FOOD: None known. Lab values: None
 significant.

NURSING · Baseline Assessment

INTERVENTIONS:
Establish baseline history of skin disorder, asthma, rhinitis.
Question hypersensitivity, especially milk products or lactose.
Question medical history as listed in precautions.

· Interventions

Monitor rate, depth, rhythm, type of respiration; quality/rate of

pulse. Assess lung sounds for rhonchi, wheezing, rales.
Assess oral mucous membranes for evidence of candidiasis.
Monitor growth in pediatric patients. Topical: Assess involved
area for therapeutic response to irritation.

· Patient/family teaching:

- Patients receiving bronchodilators by inhalation

concomitantly with steroid inhalation therapy should use
bronchodilator several minutes before corticosteroids aerosol
(enhances penetration of steroid into bronchial tree).

- Do not change dose/schedule or stop taking drug; must

taper off gradually under medical supervision.

- Maintain strict oral hygiene.

- Rinse mouth with water immediately after inhalation

(prevents mouth/throat dryness, oral fungal infection).

- Increase oral fluid intake (decrease lung secretions

viscosity).

- Intranasal: Clear nasal passages before use.

 - Report if no improvement in symptoms or if
sneezing/nasal irritation occurs.

- Improvement noted in several days.

- Topical: Rub thin film gently into affected area.

- Use only for prescribed area and no longer than ordered.

- Avoid contact with eyes.

GENERIC NAME: Azithromycin

BRAND NAME: Zithromax

CLASSIFICATIONS: Chemical Class: Azalide

Therapeutic Class: Antibiotic

Pharmaceutical Class:

Controlled Substance
Schedule:

Pregnancy Category: B
 MODE OF ACTION: Binds to a ribosomal subunit of susceptible bacteria,
blocking peptide translocation and inhibiting RNA-
dependent protein synthesis. Drug concentrates in
phagocytes, macrophages, and fibroblasts, which
release it slowly and may help move it to infection
sites

DOSAGE/ROUTE: PO: ADULTS, ELDERLY: 250–600 mg once daily or

1–2 g as single dose. (Zmax): 2 g as a single dose.

CHILDREN 6 MOS AND OLDER: 5–12 mg/kg

(maximum: 500 mg) once daily or 30 mg/kg
(maximum: 1,500 mg) as single dose. (Zmax):60
mg/kg as a single dose.

NEONATES: 10–20 mg/kg once daily

INDICATIONS: To treat mild community-acquired pneumonia, otitis

media, pharyngitis, tonsillitis, and uncomplicated skin
and soft-tissue infections capsules, oral suspension

CONTRAINDICATIONS History of cholestatic jaundice or hepatic dysfunction

: associated with prior use of azithromycin;
hypersensitivity to azithromycin, erythromycin, ketolide
antibiotics, or other macrolide antibiotics

CNS: dizziness, seizures, drowsiness, fatigue, headache

SIDE EFFECT: CV: TORSADES DE POINTES, chest pain, hypotension,
palpitations, QT interval prolongation
 Derm: ACUTE GENERALIZED EXANTHEMATOUS
PUSTULOSIS, DRUG REACTION WITH EOSINOPHILIA
AND SYSTEMIC SYMPTOMS (DRESS), STEVENS-
JOHNSON SYNDROME, TOXIC EPIDERMAL
NECROLYSIS, photosensitivity, rash
EENT: ototoxicity
F and E: hyperkalemia
GI: HEPATOTOXICITY, CLOSTRIDIOIDES DIFFICILE-
ASSOCIATED DIARRHEA (CDAD), abdominal pain,
diarrhea, nausea, cholestatic jaundice, ↑ liver enzymes,
dyspepsia, flatulence, melena, oral candidiasis, pyloric stenosis
GU: nephritis, vaginitis
Hemat: anemia, leukopenia, thrombocytopenia
Misc: HYPERSENSITIVITY REACTIONS (INCLUDING
ANAPHYLAXIS AND ANGIOEDEMA)

ADVERSE EFFECT: CNS: Aggressiveness, agitation, anxiety, asthenia,

dizziness, fatigue, headache, hyperactivity, malaise,
nervousness, paresthesia, seizures, somnolence,
syncope, vertigo CV: Arrhythmias, chest pain, edema,
elevated serum CK level, hypotension, palpitations,
prolonged QT interval, torsades de pointes, ventricular
tachycardia EENT: Hearing loss, mucocutaneous
candidiasis, perversion or loss of taste or smell,
tinnitus ENDO: Hyperglycemia GI: Abdominal pain,
anorexia, cholestatic jaundice, constipation, diarrhea,
dyspepsia, elevated liver function test results,
flatulence, hepatic necrosis or failure, hepatitis,
nausea, pancreatitis, pseudomembranous colitis,
vomiting GU: Acute renal failure, elevated BUN and
serum creatinine levels, nephritis, vaginal candidiasis
HEME: Leukopenia, neutropenia, thrombocytopenia
MS: Arthralgia SKIN: Erythema multiforme,
photosensitivity, pruritus, rash, aztreonam 121 A
Stevens-Johnson syndrome, toxic epidermal
 necrolysis, urticaria Other: Allergic reaction,
anaphylaxis, angioedema, elevated serum phosphorus
level, hyperkalemia, infusion-site reaction (such as
pain and redness), new or worsening myasthenia
syndrome, superinfection

DRUG INTERACTION: Drugs antacids that contain aluminum or magnesium:

concentration (give 1 hr before or 2 hrs after antacid).
May increase levels of amiodarone, cycloSPORINE,
dronedarone, QT-prolonging medications, thioridazine,
toremifene, ziprasidone. QUEtiapine may increase
concentration. HERBAL: None significant. FOOD:
None known. LAB VALUES: May increase serum
creatine phosphokinase (CPK), ALT, AST, bilirubin,
LDH, potassium.

NURSING Tell patient to take azithromycin capsules 1 hour before or

INTERVENTIONS: 2 to 3 hours after food.

Take the full course prescribed. Do not take with antacids.

Tablets and oral suspension can be taken with or without
food.

Instruct patient to take tablets or suspension without regard

to food.

Report severe or watery diarrhea, severe nausea or

vomiting, rash or itching, mouth sores, vaginal sores

Monitor symptoms of high plasma potassium levels

(hyperkalemia), including bradycardia, fatigue, weakness,
numbness, and tingling. Notify physician because severe
cases can lead to life-threatening arrhythmias and
paralysis.
VIII. Nursing Care Plan
DATE & CUES NEED NURSING DIAGNOSIS PATIENT INTERVENTION IMPLEMENTATION EVALUATION
TIME OUTCOME

D Subjective: A Impaired gas exchange Within 8 hours of Establish rapport with 1

E C related to alveolar damage nursing care, the client Marc Lewin R. Go,
C -“Dong, naga lisud T as evidenced by mild client should St. N.
E ko ug hinga ug I hypoxemia demonstrate R – To gain client’s trust
M luya kayo ako V improved and cooperation
B paminaw, kapoy I Rationale: oxygenation of
E maglihok lihok” T tissues as Maintain a clear airway 2
R Y In emphysema, the walls evidenced by:
between many of the air R – Ensure there are no
1 Objective: & sacs are damaged. As a -Absence of obstructions and make
0 result, the air sacs lose dyspnea breathing easier for
-Dyspnea E their shape and become client
2 X floppy. This damage also -Display PaO2
0 E destroys the walls of the air between normal Place patient with 3
-PaO2 – 76mmHg
2 R sacs, leading to a fewer, values (80-100) proper body alignment
0 C but larger sized air sacs for maximum breathing
-Restlessness I -Absence of
instead of many tiny ones. pattern
@ S This reduces the surface restlessness
-Reduced activity E R – a sitting position
tolerance area of the lungs and, in
7:00 turn, the amount of oxygen -Improved activity permits maximum lung
that reaches your tolerance excursion and chest
AM -Blue nail beds expansion
bloodstream
-Pink nailbeds
Reference: Monitor respiratory rate 4

R – Evaluate
Cukic, V. (2014). The
interventions and
Changes of Arterial ensure respiratory rate
Blood Gases in is still within normal
COPD During Four- range
year Period. Medical
Archives, 68(1), 14. Encourage 5
doi:10.5455/medarh.2 expectoration of
014.68.14-18 sputum; suction when
needed
R – Thick secretions are
a major source of
impaired gas exchange
in small airways. Deep
suctioning may be
required when the
cough is ineffective for
expectoration of
secretions. 6

Encourage deep-slow
or pursed-lip breathing

R – Breathing exercises
decrease airway
collapse, dyspnea, and
work of breathing. 7

Assist client with

activities of daily living,
as necessary

R - Conserves energy
and avoids overexertion
and fatigue 8

Encourage frequent rest

periods and teach client
to pace activity

R – Extra activity can

worsen shortness of
breath. Ensure the
patient rests between
strenuous activities. 9

Provide humidified
oxygen as ordered

R – Administering
humidified oxygen
prevents the drying out
of airways, decrease
convective moisture
losses, and improves
compliance 10

Monitor ABG values as

ordered

R – Chronic carbon
dioxide retention may
have chronically
compensated
respiratory acidosis with
a low normal pH and a
PaCO2 higher than 50
mmHg
DATE & CUES NEED NURSING PATIENT INTERVENTION IMPLEME EVALUATION
TIME DIAGNOSIS OUTCOME N
TATION
D SUBJECTIVE: A Ineffective Airway Within 8 hours of  Teach the patient the proper
E  “Sige ko ug ubo C Clearance related to nursing ways of coughing and 1
C Ma’am unya T increased intervention, the breathing.
E naga-lisod ko ug I production of patient will be able R: The most convenient way to
M ginhawa.” V secretions as to breathe remove most secretions is
B OBJECTIVE: I evidenced by effortlessly and gain coughing. So, it is necessary to
E  Difficulty of T persistent coughing more knowledge assist the patient during this
R breathing Y with sputum and understanding activity. Deep breathing, on the
 Wheezes/crackles production about his condition other hand, promotes oxygenation
noted upon A as evidenced by: before controlled coughing.
3, auscultation on N RATIONALE:
both lung field D Maintaining a patent  Position the patient upright if Loraine Ann C. Cruda, St. N
2  Nasal flaring airway is vital to life. a. Verbalize tolerated. Regularly check the 2
0  Dyspnea R Coughing is the methods patient’s position to prevent
2  Restlessness due E main mechanism for that are help sliding down in the bed.
0 to excessive S clearing the airway. improve R: Upright position limits
coughing T However, coughing easy abdominal contents from pushing
@ breathing upward and inhibiting lung
 Persistent may not always be
P such as high expansion. This position promotes
coughing with easy to everyone
7AM A fowler’s better lung expansion and
sputum especially to those
T position and improved air exchange.
production
T patients with breathing
 VS:
E respiratory problem techniques  Maintain humidified oxygen
- Temp.: 36.4
R s such as b. Demonstrat as prescribed. 5
- RR: 28 cpm
N emphysema. e behaviors
- PR: 86 bpm R: Increasing humidity of
Thus, increased to improve
- BP: 140/80
airway
inspired air will reduce
mmHg production of thickness of secretions and aid
secretions in clearance
 Arterial Blood such as their removal.
Gas: conditions such as
emphysema, cough
PaO₂= 76 effectively  Encourage patient to increase
pneumonia and
mmHg such can oppress and fluid intake to 3L per day 7
these mechanisms expectorate within the limits of cardiac
the, coughing all the secretions, reserve and renal function.
sputum will help the R: Fluid help minimize mucosal
patient spit out drying and maximize ciliary
sputum to help the c. maintain action to move secretions.
patient breath clear, open
effortlessly. airways as  Give medications as
evidence by prescribed, such as
REFERENCE: normal 3
antibiotics, bronchodilators,
breath and corticosteroid and note
Wayne, G. (2019). sounds, for effectiveness and side
Ineffective Airway normal rate effects.
Clearance Nursing and depth of
Care Plan. R: A variety of medications are
respirations
Retrieved on prepared to manage specific
December 9, 2020 problems. Most promote
clearance of airway secretions
and may reduce airway
resistance.

 Coordinate with a respiratory

therapist for the nebulization
management and for the 6
chest physiotherapy as
indicated.
R: Chest physiotherapy
includes the techniques of
postural drainage and chest
percussion to mobilize
secretions from smaller
airways that cannot be
eliminated by means of
coughing or suctioning.

 Provide postural drainage,

 percussion, and vibration as 4
ordered.
R: Chest physical therapy helps
mobilize bronchial secretions;
it should be used only when
prescribed because it can
cause harm if patient has
underlying conditions such as
cardiac disease or increased
intracranial pressure.

 Provide oral care every 4

hours. 8
R: Oral care freshens the
mouth after respiratory
secretions have been
expectorated.

 Pace activities especially for

patients with reduced energy. 9
Maintained planned rest
periods. Promote energy-
conservation methods.
R: Fatigue is a contributing
factor to ineffective coughing.
Effective coughing requires
enough energy and may
consume an extra effort to the
patient.

 Consider verbalization of
10
feelings.
R: Recognize reality of
situation. Anxiety adds to
oxygen demand, and
hypoxemia potentiates
respiratory distress or cardiac
symptoms, which in turn
increase anxiety.
Date/Time Cues Need Nursing Diagnosis Patient Outcome Interventions Implementation
 Subjective cues: Ineffective Breathing After the 8 hours of Assess the patient's vital
Pattern related COPD my nursing care, the
“Ma lisodan ko ug hinga, and pneumonia as patient will be able to signs and characteristics of
1
ug sakit kaayo akong evidenced by shortness of achieve effective respirations at least every 4
D
tiyan” as verbalized by breath，SpO2 level of 85％, breathing pattern as hours.
E the pt productive cough, and evidenced by:
R: To assist in creating an
greenish phlegm.
a. respiratory rates accurate diagnosis and
C
Rationale: between 12 to 20 monitor effectiveness of
E breaths per medical treatment
Shortness of breath and minutes,
M Objective cues: Administer supplemental
ineffective breathing
-Temp: 36.4 patterns are caused by b. oxygen saturation oxygen，as prescribed.
B -BP:140/80 mm/Hg between 88% to
ineffective respiratory
-RR: 28cpm mechanics of the chest 92%,
E -PR: 86bpm wall and lung resulting
Place a pillow when the
R from air trapping, c. verbalize ease of
-Nasal flaring ineffective diaphragmatic client is sleeping.
breathing.
movement, airway 3
R: Provides adequate lung
-Presence of non- obstruction, the metabolic
productive cough expansion while sleeping.
10, cost of breathing, and
-Wheezes/crackles on stress.
Administer the prescribed
auscultation on both lung
fields COPD medications（e.g.
2020
bronchodilators，steroids，or
‌
@ combination inhalers 2
7am nebulizers）and antibiotic
medications.
R: To alleviate and treat the
patient’s condition.
Reference:
nursestudynet@gmail.co Encourage verbalization of 4
m. (2020, May feelings
15). Chronic R: To provide appropriate
Obstructive emotional supportive care
Pulmonary
Disease COPD
Provide adequate periods of
Nursing Diagnosis
rest and sleep. 5
Care Plan.
NurseStudy.net; R: To minimize impairment and
NurseStudy.net. promote healing.
https://nursestudy.
net/copd-chronic-
obstructive- Provide psychological and
pulmonary- emotional support to the 6
disease- patient.
pathophysiology- R: This helps in patient’s
care-plan-for- assurance and calming.
nursing-students/
Provide respiratory support.
Oxygen inhalation is given 7
as ordered.
R: Aid in relieving the patient
from dyspnea.

Provide bedside care.

R: To assist the patient in
any activity limited to their 8
reach.
7 Chronic Obstructive
Pulmonary
Disease (COPD) Reference:
Nursing Care
Plans -
Nurseslabs. 7 Chronic Obstructive
(2019, September Pulmonary Disease (COPD)
28). Nurseslabs. Nursing Care Plans -
https://nurseslabs. Nurseslabs. (2019,
com/chronic- September 28). Nurseslabs.
obstructive- https://nurseslabs.com/chron
pulmonary- ic-obstructive-pulmonary-
disease-copd- disease-copd-nursing-care-
nursing-care- plans/3/
plans/3/
‌ ‌
Date
Implementatio
Tim Cues Need Nursing Diagnosis Patient Outcome Interventions Evaluation
n
e
N Imbalanced Nutrition: less Within 8 hours of nursing care Give the explanations to
Subjective: U than body requirement related intervention, the patient will be the patient about the 7
“Maglisod ko ug T to expand lung volume size able to recognize the benefits of adequate Stephanie Mhae
R
hinga pagnaga-kaon which result for the lungs and importance of proper nutrition nutrition C. Tabas a St. N
I
ko” T stomach to push against each requirements and it benefits, as The patient will
I other that cause discomfort evidenced by; understand the
Objective: O when eating as evidenced by requirements of daily 8
 Poor muscle N chronic cough and shortness a. Verbalization of the nutrition for the body
tone of breath secondary to importance of adequate
 BMI A Emphysema nutrition. Ensure
N
Underweight proper positioning while 9
D b. Eat small but frequent
 Paradoxical eating.
meals throughout the
abdominal M Rationale: day To avoid the risk of
movement E Weight loss is a sign of aspiration while having a
 Pursed lip T severe emphysema. When c. Avoidance of gas- meal 1
A the damage of the lungs is producing foods,
breathing
B severe, there will be an carbonated drinks and Explain to the patient
noted O very hot/cold drinks.
expand of the lung volume that it is better to have
 + wheezing 2
L size, which flatten the frequent but small
 Dry and I diaphragm reducing the d. Create a meal plan helpings of food.
cracked lips C space between the lungs and consist of a variety of The patient will have
stomach. When this happens, whole-grain enhanced appetite and
 Prominent
P the lungs and stomach will carbohydrates and fresh good food digestion.
clavicle bone fruits and vegetables.
A push against one another and
noted T cause discomfort when
 Diffusely T eating. A flattened diaphragm Ascertain understanding
decreased E also makes breathing more of individual nutritional
breath sound R difficult which can cause needs
 Prolonged N patients with emphysema to Rationale: To determine
expiration burn up to 10 times more informational needs of
 Moderate calories than client and SO.
 mucus usual. Symptoms of COD 3
production such as shortness of
 Dyspnea breath and a chronic cough Assess dietary habits,
can lead to a decreased recent food intake. Note
appetite, eventual weight degree of difficulty with
loss, and even cachexia. eating. Evaluate weight
and body size (mass). 4
Rationale: Patient in
Reference: acute respiratory
Cherney, K (2020). How weight distress is often
loss relates to Chronic anorectic because of
Obstructive Pulmonary Disease dyspnea, sputum
(COPD) retrieved from production, and
medications. In addition, 5
https://www.healthline.com/h
ealth/copd/weight-loss#why- many COPD patients
weight-loss-happens on habitually eat poorly,
December 7, 2020 even though respiratory
insufficiency creates a
hypermetabolic state 11
with increased caloric
needs. As a result,
patient often is admitted
with some degree of
malnutrition. People who
have emphysema are 12
often thin with wasted
musculature.

Auscultate bowel
sounds. 7
Rationale: Diminished or
hypoactive bowel
sounds may reflect
decreased gastric 10
motility and constipation
(common complication)
related to limited fluid
intake, poor food
choices, decreased
activity, and hypoxemia.

Give frequent oral care,

remove expectorated
secretions promptly,
provide specific
container for disposal of
secretions and tissues.
Rationale: Noxious
tastes, smells, and
sights are prime
deterrents to appetite
and can produce nausea
and vomiting with
increased respiratory
difficulty.

Encourage a rest period

of 1 hr before and after
meals. Provide frequent
small feedings.
Rationale: Helps reduce
fatigue during mealtime,
and provides opportunity
to increase total caloric
intake.

Avoid gas-producing
foods and carbonated
beverages.
Rationale: Can produce
abdominal distension,
which hampers
abdominal breathing and
diaphragmatic
movement and can
increase dyspnea.

Avoid very hot or very

cold foods.
Rationale: Extremes in
temperature can
precipitate or aggravate
coughing spasms.

Weigh as indicated.
Rationale: Useful in
determining caloric
needs, setting weight
goal, and evaluating
adequacy of nutritional
plan. 

Administer supplemental
oxygen during meals as
indicated.

Rationale: Decreases
dyspnea and increases
energy for eating,
enhancing intake.
References:

COPD. (n.d.). Practicing Good Hygiene. Retrieved on December 7, 2020 from

Practicing Good Hygiene | COPD.net

Drugs.com. (2020). Emphysema. Retrieved on December 7, 2020 from

https://www.drugs.com/cg/emphysema.html

Gonzalo, A. (2019). Florence Nightingale’s Environmental Theory Study Guide. Retrieve

on December 7, 2020, from https://nurseslabs.com/florence-nightingale-environmental-
theory/

Healthline. (n.d.). COPD Drugs: A List of Medications to Help Relieve Your Symptoms.
Retrieved on December 7, 2020 from
https://www.healthline.com/health/copd/drugs#corticosteroids

Hu, W., Zhao, Z., Wu, B., Shi, Z., Dong, M., & Xiong, M. (2020). Obstructive Sleep
Apnea Increases the Prevalence of Hypertension in Patients with Chronic Obstructive
Disease. COPD: Journal of Chronic Obstructive Pulmonary Disease.
https://www.tandfonline.com/doi/full/10.1080/15412555.2020.1815688

‌ undell, S., Wadell, K., Wiklund, M., & Tistad, M. (2020). Enhancing Confidence and
L
Coping with Stigma in an Ambiguous Interaction with Primary Care: A Qualitative Study
of People with COPD. COPD: Journal of Chronic Obstructive Pulmonary Disease.
https://www.tandfonline.com/doi/full/10.1080/15412555.2020.1824217

Mayo Clinic. (n.d). COPD. Retrieved on December 7, 2020 from

https://www.mayoclinic.org/diseases-conditions/copd/diagnosis-treatment/drc-20353685

Mayo Clinic. (n.d). Emphysema – Treatment and Management. Retrieved on December

5, 2020 from https://www.mayoclinic.org/diseases-conditions/emphysema/diagnosis-
treatment/drc-20355561

Novartis, Philippine College of Chest Physicians launch COPD awareness campaign|

Novartis Philippines. (2017). Novartis.com.Ph.
https://www.novartis.com.ph/news/media-releases/novartis-philippine-college-chest-
physicians-launch-copd-awareness-campaign#:~:text=Chronic%20Obstructive
%20Pulmonary%20Disease%20(COPD,is%20that%20it%20is%20treatable.

Nursing Theory. (n.d.). Kalkoba’s Theory of Comfort. Retrieved on December 8, 2020

from https://www.nursing-theory.org/theories-and-models/kolcaba-theory-of-comfort.php

RNPedia. (n.d). Emphysema – Nursing Care Plan and Management. Retrieved on

December 5, 2020 from https://www.rnpedia.com/nursing-notes/medical-surgical-
nursing-notes/emphysema/
WebMD. (n.d.) COPD and Exercise: Breathing and Exercises Programs for COPD.
Retrieved on December 6, 2020 from https://www.webmd.com/lung/copd/copd-and-
exercise -breathing-and-exercise-programs-for-copd