Emphysema is a chronic obstructive pulmonary disease (COPD) that is characterized by

abnormal, permanent enlargement of the air spaces past the terminal bronchioles, which
results in the destruction of respiratory walls. The syndrome includes both chronic
bronchitis and emphysema. COPD affects almost 15 million people and is the fourth
leading cause of death overall in the United States. Approximately 5% to 6% of male
adults and 1% to 3% of female adults have emphysema.

In emphysema, the affected terminal bronchioles contain mucous plugs that, when they
are enlarged, eventually result in the loss of elasticity of the lung parenchyma, thus
causing difficulty in the expiratory phase of respiration. The alveolar walls are destroyed
by abnormal levels of enzymes (proteases) that break down respiratory walls. Gas
exchange is impaired by the reduced surface area that results from the destruction of
alveolar walls.

Four types of emphysema have been identified: paraseptal emphysema, which affects
the periphery of the lobule; panacinar or panlobular emphysema, which affects the lower
anterior segments or the entire lungs; centriacinar or centrilobular emphysema, the most
common form, which destroys respiratory bronchioles and is associated with chronic
bronchitis and cigarette smoking; and bronchiectasis or chronic necrotizing infection that
leads to abnormal and permanent bronchial dilation, which occurs rarely. Complications
from emphysema include cor pulmonale, respiratory failure, pneumothorax, and
recurrent respiratory tract infections. Emphysema is the most common cause of death
from respiratory disease in the United States.

The actual cause of emphysema is unknown. Risk factors for the development of
emphysema include cigarette smoking, living or working in a highly polluted area, and a
family history of pulmonary disease. Frequent childhood pulmonary infections have been
identified as a cause of bronchiectasis.

Nursing care plan assessment and physical examination

Establish a history of dyspnea, determining if it has increased over time. Ask if the
dyspnea is extreme during exertion and present even during rest. Determine if the patient
has experienced anorexia, weight loss, and weakness. Ask if the patient has had a cough
and, if so, for how long. Determine if there are signs of oxygen deficiency; ask significant
others if the patient has been restless or confused or has experienced changes in mental
status. Ask if the patient lives or works in a highly polluted area. Establish cigarette
smoking habits, including how long, how many, and whether they are unfiltered. Elicit a
history of family pulmonary disease or frequent childhood pulmonary infections.

Inspect the patient for a decreased muscle mass and increased anteroposterior diameter
(also known as barrel chest). Observe respirations for the use of accessory muscles, such
as the sternocleidomastoid and pectoral muscles, as well as pursed-lip breathing during
expiration. Assess the patient’s respirations for rate, rhythm, and quality. Inspect the
patient for neck vein distension or liver congestion. Note signs of oxygen deficiency,
such as restlessness, changes in mental status, confusion, and tachycardia.

A cough may be present during the later stages of the disease; the small amount of
sputum it produces is usually mucoid. Upon palpation, note decreased tactile fremitus.
Percussion may elicit a diffusely hyper-resonant sound. Auscultate for decreased or
absent breath sounds, distant heart sounds, wheezes, and possibly crackles. Examine the
patient for peripheral cyanosis or clubbing of the fingers.

Patients with emphysema may be anxious or restless, depending on the degree of

dyspnea they are experiencing. Emphysema may necessitate role or occupational
changes that could lead to depression. Assess the patient’s emotional, financial, and
social resources to determine if they are available to the patient to help cope with a
chronic disease.

Nursing care plan primary nursing diagnosis: Impaired gas exchange related to
destruction of alveolar walls.

Nursing care plan intervention and treatment

Viral or bacterial infections may lead to bronchospasm or increased mucus secretions.
Acute exacerbations are accompanied by dyspnea, fatigue, and even respiratory failure.
Low flow oxygen therapy based on arterial blood gas results is often administered to treat
hypoxemia. For the patient with increasing airway obstruction and plugging, endotracheal
intubation and perhaps mechanical ventilation may be needed to maintain adequate
airway and breathing. Adequate hydration is also necessary to help liquefy secretions.

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 avoidinfection, 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 nonessential 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.

Nursing care plan discharge and home health care guidelines

Be sure the patient and family understand any medication prescribed, including dosage,
route, action, and side effects. Instruct the patient to report any signs and symptoms
ofinfection to the primary healthcare provider. Explain necessary dietary adjustments to
the patient and family. Recommend eating small, frequent meals, including high-protein,
high-density foods. Encourage the patient to plan rest periods around his or her activities,
conserving as much energy as possible. Arrange for return demonstrations of equipment
used by the patient and family. If the patient requires home oxygen therapy, refer the
patient to the appropriate rental service, and explain the hazards of combustion and
increasing the flow rate without consultation from the primary healthcare provider.