Emphysema is a lung disease that gradually damages the air sacs (alveoli). Over time, the sacs weaken and rupture, reducing the surface area of the lungs and the amount of oxygen reaching the bloodstream, which results in dyspnea.
Gradually, damage to the alveoli causes the lungs to overfill, making breathing increasingly difficult. The alveoli won’t work properly when exhaling, which causes air to become trapped, reducing the ability to inhale. Emphysema may occur with chronic bronchitis, which is inflammation of the bronchioles. Both conditions occur under the umbrella term of chronic obstructive pulmonary disease (COPD).
There is no cure for emphysema, but symptoms can be managed through medications, pulmonary rehabilitation, surgery, and smoking cessation.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Knowledge
- Impaired Gas Exchange
- Impaired Spontaneous Ventilation
- Ineffective Airway Clearance
Nursing Process
Because emphysema is a progressive disease, the nursing role is crucial in long-term support. Nurses can deliver interventions that aim at reducing symptoms and preventing complications. Educating the patient about the disease process and how to slow progression will aid in improved quality of life.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to emphysema.
Review of Health History
1. Assess the patient’s general symptoms.
Symptoms of emphysema are:
- Chronic, productive cough
- Shortness of breath, especially with exertion
- Barrel-chest appearance
- Prolonged expiration
- Wheezing
- Anxiety
- Weight loss
2. Determine the causative factor.
Smoking is the number one cause of emphysema. Other factors that may cause emphysema include:
- Air pollutants
- Occupational exposure to chemical fumes
- IV drug use
- HIV infection
- A genetic condition called alpha-1 antitrypsin deficiency
3. Track the patient’s smoking history.
Focus on their starting age and total pack years. Inquire how long it has been since the person last smoked if they have quit. Assess if they are exposed to second-hand smoke.
4. Ask the patient to describe their experience of dyspnea.
The cough and shortness of breath gradually worsen as symptoms progress. Exertional dyspnea may not occur late into the disease. Patients will experience more difficulty with exhaling than inhaling.
5. Identify the presence of a “smoker’s cough.”
Patients may present with a cough producing clear or white sputum that is worse in the morning and is known as a “smoker’s cough.”
Physical Assessment
1. Observe the patient’s breathing.
Note the following observations:
- Rapid breathing
- Increased respiratory rate
- Difficulty of breathing with mild exertion
- Use of accessory muscles
- Exhaling through pursed lips (improves airway pressure and prevents airway collapse during respiration)
2. Assess the forced expiratory time.
A forced expiratory time of > 6 seconds indicates severe expiratory airflow obstruction. Patients with emphysema take longer to exhale than to inhale.
3. Auscultate lung and heart sounds.
The following findings can be heard upon auscultation:
- Diffuse or focal wheezes
- Crackles at the base of the lungs
- Diminished breath sounds
- Distant heart sounds
4. Palpate and examine the thoracic area.
Palpation may reveal the following:
- During exacerbations, a paradoxical contraction of the lower intercostal gaps becomes visible
- Increased anterior to posterior diameter (2:1) – called “barrel chest”
5. Percuss the chest.
Findings may include increased resonance or hyperresonance (indicating hyperinflation as the airway obstruction worsens).
Diagnostic Procedures
1. Review pulmonary function testing.
Spirometry confirms diagnosis, disease severity and progression, and current health status.
2. Complete an AATD workup.
All patients with emphysema should be tested for alpha-1 antitrypsin deficiency (AATD). AATD is linked to several disorders, such as:
- Panniculitis
- Granulomatosis with polyangiitis
- Liver disease
3. Obtain samples for laboratory tests.
The following laboratory tests may be useful:
- AST, ALT, GGT, albumin, bilirubin, and coagulation panel to evaluate liver function
- Complete blood count (CBC) to evaluate hematocrit and polycythemia
- Serum bicarbonate to evaluate for acidosis or alkalosis
4. Obtain an ABG.
Obtain blood samples to test arterial blood gas (ABG) levels to evaluate hypoxemia and hypercapnia.
5. Evaluate the sputum.
Patients with emphysema have mucoid sputum with macrophages. The sputum becomes purulent during an exacerbation with an increased number of neutrophils and the presence of pathogens.
6. Prepare the patient for imaging scans.
Anticipate the following imaging tests to evaluate for complications:
- Chest radiograph
- CT scan
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with emphysema.
Slow the Disease’s Progress
1. Enroll the patient in a smoking cessation program.
The most successful treatment for most patients with emphysema is quitting smoking. Encourage the patient to commit and adhere to the smoking cessation treatment plan. Offer resources to self-help, group therapy, physician-delivered, and community programs.
2. Administer medications as ordered.
These are the medications given to patients with emphysema:
- Bronchodilators
- Short-acting bronchodilators
- Long-acting bronchodilators
- Long-acting beta-agonists (LABA)
- Long-acting muscarinic agonists (LAMA)
- Phosphodiesterase (PDE) inhibitors
- Anti-inflammatory therapy
- Oral and inhaled corticosteroids (ICS)
- Antibiotics
- Mucolytic agents
- Anticholinergics
- Intravenous alpha1 antitrypsin augmentation therapy
3. Administer oxygen therapy as prescribed.
Give supplemental oxygen to patients with severe resting hypoxemia or who experience desaturation during exercise or sleep.
Prevent and Treat Exacerbations
1. Encourage vaccinations.
Vaccines prevent respiratory infections and are safe for patients with emphysema. Encourage pneumococcal and influenza vaccines.
2. Advise on nutritional support.
Refer the patient to a dietitian to assist them in their nutritional needs. Insufficient body weight and inadequate nutrition are linked to poor pulmonary function, decreased diaphragmatic mass, decreased exercise capacity, and higher mortality rates.
3. Support ventilation.
Patients with acute respiratory failure who receive noninvasive positive pressure ventilation (NPPV) experience a lower morbidity and mortality rate.
4. Manage exacerbations.
Bronchodilators, antibiotics, and steroids are used to treat emphysema exacerbations.
5. Discuss the possibility of surgical treatment.
Several surgical approaches reduce emphysema symptoms and restore respiratory function. Surgical options include:
- Bullectomy (removal of large bullae)
- Lung volume reduction surgery (removal of diseased lung portion)
- Endobronchial valve placement
- Lung transplantation
6. Refer the patient to pulmonary rehabilitation.
Patients who are symptomatic and in stable medical condition benefit from pulmonary rehabilitation (PR). Outpatient or community-based treatment usually lasts eight weeks (two to three sessions per week). PR includes:
- Exercise training
- Breathing retraining techniques
- Anxiety management
- Concurrent behavioral interventions
- Elevating self-efficacy
- Fostering group self-management abilities
7. Avoid air pollutants.
Remind the patient to avoid secondhand smoke, dust, pollen, paint fumes, and air pollution when possible. Wearing a mask may reduce exposure.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for emphysema, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for emphysema.
Activity Intolerance
Chronic dyspnea, especially with exertion, is a common feature of emphysema and can ultimately lead to reduced physical ability.
Nursing Diagnosis: Activity Intolerance
Related to:
- Inefficient breathing pattern
- Oxygen supply and demand imbalance
- Gas exchange limitations
- Peripheral muscle fatigue
As evidenced by:
- Reports of fatigue
- Physical inactivity
- Dyspnea on exertion
- Dyspnea at rest
- Orthopnea
Expected outcomes:
- Patient will display reduced dyspnea during regular physical activities.
- Patient will display respiratory and pulse rates within normal limits during activity.
- Patient will participate in pulmonary rehabilitation.
Assessment:
1. Assess the patient’s physiological response to activity.
Assess vital signs and respiratory patterns with movement, self-care, and exercise to assess the degree of severity and limitations.
2. Determine wants versus needs with activity.
Is the patient limited to activities in the home? Can they climb stairs? Is exercise limited to 10 minutes or none at all? Can they partake in self-care, such as bathing? Patients may need to decrease expectations or may require additional resources.
Interventions:
1. Encourage exercise as tolerable.
In the later stages of emphysema, exercise may not be possible. Exercise should be undertaken as long as possible as it increases lung capacity.
2. Stop smoking.
This is the most important intervention to prevent worsening emphysema. Smoking irritates the airways and makes it harder to breathe. Continuing to smoke will significantly limit the patient’s tolerance for activity.
3. Educate the patient on energy conservation techniques.
Instruct on working at an even pace, placing frequently used items within reach, resting between tasks, and taking naps to reduce oxygen consumption and fatigue.
4. Encourage pulmonary rehab.
Pulmonary rehabilitation will instruct the patient with a lung disease on achieving exercise with less dyspnea.
5. Instruct on inhaler use.
Patients with emphysema use steroid inhalers and bronchodilators. Educate that bronchodilators are used first to open the airways, and steroid inhalers are used next to allow the medication to enter the airways.
Deficient Knowledge
Patients with emphysema need health-related education to support them in managing their illness and preventing further complications.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Unfamiliarity with information
- Information misinterpretation
- Cognitive limitation
As evidenced by:
- Statements displaying misconceptions
- Progression of preventable symptoms
- Inaccurate understanding and demonstration of instructions
- Request for information
Expected outcomes:
- Patient will show increased interest and willingly participate in the learning process.
- Patient will initiate necessary lifestyle changes and adhere to the treatment regimen.
Assessment:
1. Assess the patient’s readiness to learn and their individual learning needs.
Assessing how willing a patient is to learn about their condition and specific needs will help determine how much is needed to be taught and which teaching strategies will be effective.
2. Identify support persons or significant others requiring information.
Involving the patient’s family or significant others will ensure better adherence to care.
3. Assess for any individual risk factors that may aggravate the condition.
The number one leading cause of emphysema is smoking. It is important to determine any habits the patient has that may contribute to worsening their condition so that they can be addressed.
Interventions:
1. Educate the patient on the importance of regular follow-up consultations.
It is essential to monitor the disease process so that necessary changes in the treatment plan can be done to match their changing needs. This includes follow-up with a pulmonologist, pulmonary function tests, and imaging as needed.
2. Encourage vaccinations.
Patients with chronic lung diseases should receive pneumococcal and influenza vaccinations to prevent worsening lung health.
3. Prevent infections.
Instruct on preventing infections through handwashing, proper nutrition, and avoiding sick people or large crowds. A patient with emphysema is at a higher risk of developing pneumonia.
4. Encourage the patient and their significant others to control risk factors.
Second-hand smoke is also a contributor to emphysema. Areas of high air pollutants or workplaces that use fumes are additional risk factors. Instruct patients to wear masks or respirators in these settings.
Impaired Gas Exchange
Damaged alveoli in emphysema lead to a reduced surface area for gas exchange.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Ventilation perfusion imbalance
- Alveoli destruction
- Alveolar-capillary membrane changes
- Infectious process
- Increased sputum production
As evidenced by:
- Abnormal respiratory pattern
- Dyspnea
- Restlessness
- Confusion
- Reduced tolerance for activity
- Abnormal ABGs
- Cyanosis
- Tachycardia
Expected outcomes:
- Patient will display improved ventilation and adequate oxygenation, as evidenced by ABGs within normal range.
- Patient will report and demonstrate improved activity tolerance.
- Patient will demonstrate two strategies to improve oxygenation.
Assessment:
1. Assess and monitor the respiratory pattern.
This will provide baseline data, which is useful in evaluating the degree of respiratory distress. Note respiratory rate and depth, the use of accessory muscles, pursed-lip breathing, and the ability to speak or converse.
2. Routinely assess the skin and mucous membrane color.
Peripheral cyanosis may be seen in the nail beds, and central cyanosis around the mucous membranes.
3. Evaluate ABGs.
Closely monitor arterial blood gas results for worsening hypoxemia or hypercapnia.
4. Evaluate the level of activity tolerance.
Dyspnea with minimal exertion is a common characteristic of emphysema. The patient may be unable to perform basic self-care activities because of hypoxemia and dyspnea.
Interventions:
1. Elevate the head of the bed and assist with positioning.
The client may be most comfortable sitting in a tripod position where they rest their arms on their legs or a table.
2. Encourage pursed-lip breathing as tolerated.
Breathing exercises help reduce airway collapse, dyspnea, and work of breathing.
3. Provide supplemental oxygen.
Apply oxygen at the lowest concentration first to maintain Spo2 levels within 88-92%.
4. Administer a bronchodilator.
Short-acting bronchodilators are administered for acute exacerbations to relax the smooth muscles of the airway, reducing bronchoconstriction.
5. Educate on limiting exposure to lung irritants.
Tobacco smoke, dust, pollen, fumes, and air pollution are common causes of emphysema exacerbations. Instruct on avoiding environmental irritants when possible.
6. Refer the patient to pulmonary rehabilitation.
Pulmonary rehabilitation improves dyspnea, health status, and exercise tolerance in stable patients, promoting continued progress after discharge.
Impaired Spontaneous Ventilation
An emphysema exacerbation may deteriorate requiring invasive measures to preserve ventilation.
Nursing Diagnosis: Impaired Spontaneous Ventilation
Related to:
- Respiratory distress
- Respiratory muscle weakness
As evidenced by:
- Abnormal ABGs
- Decreased cooperation
- Worsening dyspnea
- Restlessness
- Tachycardia
- Use of accessory muscles
Expected outcomes:
- Patient will demonstrate ABGs within acceptable limits.
- Patient will be free of signs of respiratory distress such as cyanosis, altered mental status, and dyspnea.
Assessment:
1. Assess the patient’s respiratory rate, depth, and pattern.
Changes in the respiratory pattern may be an early sign of respiratory distress. Intervene promptly if cyanosis, accessory muscle use, or desaturation is observed.
2. Auscultate for adventitious breath sounds.
Adventitious breath sounds such as wheezes or crackles are an indication of breathing difficulties.
3. Monitor ABGs.
Obtain arterial blood gas results immediately and reassess after oxygen implementation to prevent worsening hypoxemia or hypercapnia.
Interventions:
1. Prepare for ventilatory support.
If hypoxemia or hypercapnia becomes severe, consider the use of noninvasive positive-pressure ventilation (NIPPV) first. This strategy has been shown to reduce mortality.
2. Continue to administer medications.
Bronchodilators, steroids, and antibiotics are utilized to treat bronchoconstriction, inflammation, and infections in emphysema.
3. Discuss surgical options.
Surgical procedures such as bullectomy, lung volume reduction surgery, endobronchial valve placement, and lung transplantation may improve symptoms, restore lung function, and improve quality of life.
4. Emphasize the importance of the patient’s involvement even on ventilation.
Keeping the patient involved in activities and their care decisions when applicable will help promote a sense of well-being.
Ineffective Airway Clearance
The damaged air sacs cause shortness of breath and reduce airway clearance.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Damaged alveoli
- Excess sputum production
- Smoking
- Inflammation
As evidenced by:
- Dyspnea
- Wheezing, crackles
- Excessive secretions
- Usage of accessory muscles
- Coughing
Expected outcomes:
- Patient will maintain clear breath sounds and unlabored respirations.
- Patient will demonstrate effective expectoration of excess sputum.
- Patient will develop techniques for maintaining an effective airway.
- Patient will maintain an oxygen saturation over 92%.
Assessment:
1. Frequently assess the patient’s lung sounds and respirations.
Adventitious lung sounds are expected with emphysema. Monitor for rhonchi or crackles that signal an infection, such as pneumonia. Monitor for changes in respiratory patterns for impending respiratory distress.
2. Assess oxygen saturation.
Patients with chronic lung diseases often present with a lower baseline oxygen saturation, sometimes between 88-90%.
Interventions:
1. Encourage expectoration of secretions. Suction if necessary.
If the patient cannot clear secretions on their own, suctioning will aid in clearing thick mucus that they cannot expectorate.
2. Provide supplemental oxygen as prescribed.
Supplemental oxygen will help in increasing SpO2 levels to an acceptable level. Do not over-oxygenate the patient.
3. Assist the patient in assuming a semi-Fowler’s position.
Elevating the patient’s upper body will help improve expansion, allowing the patient to breathe more easily.
4. Instruct on breathing techniques.
Pursed-lip breathing slows the pace of breathing, allows trapped air to be released, and keeps the airways open longer to decrease the work of breathing.
5. Prepare for surgery.
Lung volume reduction surgery removes damaged lung tissue so the remaining lung tissue can expand and work efficiently. Severe cases may require a lung transplant.
References
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