NURSING CARE OF CLIENTS WITH RESPIRATORY PROBLEMS

M.C. a 65 year old man is admitted to your medical unit for exacerbation of his emphysema
(COPD). He has a history of hypertension which has been well controlled by Enalopril for the last
6 years. He presents as a poorly mourished man who is experiencing difficulty breathing. He
complains of coughing spells productive of thick yellow sputum. M.C. seems irritable and anxious
when he tells you that he has been a two-pack-a-day smoker for 38 years. He tells you he has
been sleeping poorly and lately feels very tired most of the time even when he has not done any
physical activity. His VS are 162/84, PR 84, RR 36, T 102F, SaO2 88%. His admitting diagnosis is
chronic emphysema with an acute exacerbation.
His admitting orders are as follows:
Diet as tolerated
Out of bed with assistance
O2 at 2L/nasal cannula
IV D5W at 50 ml/hr
Sputum C&S
ABGs in AM
CBC with WBC differential
CXR in AM
Prednisone 40mg TID
Cefuroxime 1gm/IV Piggy back q 8 hours
Azithromycin 2gm/IV Piggy back q 8 hours
Theo-Dur 300 mg/p.o. BID
Albuterol 2.5 mg(0.5 ml) in 3 ml NS
Ipatropium 500 mcg q 6 hours by oral nebulization
Enalapril 10 mg p.o. q AM
1. What are the significant data that you have gathered?
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65 year old man

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on exacerbation of his emphysema (COPD)

with history of Hypertension well controlled by Enalapril
poorly nourished man
is experiencing difficulty of breathing
complaints of coughing spells productive of thick yellow sputum
seems irritable and anxious
two-pack-a-day smoker for 38 years
sleeping poorly
easy fatigability
VS : BP 162/84, PR 124, RR 36, Temp 102F
SaO2 88%

What other relevant questions do you need to ask M.C.?

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other family history of disease/s

any history of depression, traumatic family history
environment and lifestyle
previous work/job
any history or present problems of finances
dietary lifestyle and modifications done
patients compliance of the antihypertensive meds(Enalapril)
regular and annual check-up with the doctor
since when he is experiencing difficulty of breathing and easy fatigability
level of consciousness upon admission and assessment
2. What is the most common cause of emphysema?

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long term smoking ( two-pack-a-day for 38 years)

Air pollution
Occupational exposure to respiratory irritants
Allergies
Autoimmunity
Infection
Aging - prevalence and severity are greatest in the elderly persons
Genetic Predisposition - deficiency in enzyme alpha1 antitrypsin (this inhibits the
proteases of elastase and collagenase) without their inhibition, the destruction or digestion of
pulmonary tissue occurs more at the bases than at the apices of the lungs.
Based on this information, what question will you ask about his health behaviours?

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During his free time, what does he usually do?

Does he have a regular exercise? For how long?
What dietary regimen does he take?
Does he take his medications regularly?
Does he experience pain? If yes, for how long?

Does he experience dizziness or faint episodes?

3. Describe how you would go about with the respiratory physical assessment of M.C.
What specific changes in the respiratory system do you expect to find indicative of
emphysema?
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Bronchiolar obstruction greatly increases airway resistance and results in greatly

increased work of breathing.

The marked loss of alveolar walls greatly decreases the diffusing capacity of the

lung, which reduces the ability of the lungs to oxygenate the blood and remove carbon dioxide.
Some portions of the lungs are well ventilated, whereas other portions are poorly
ventilated.

Loss of large portions of the alveolar walls also decreases the number of
pulmonary capillaries through which blood can pass, thus the pulmonary resistance increases
markedly causing pulmonary hypertension.
4. What significant findings in the diagnostic procedures will point to an exacerbation of
M.Cs emphysema?

In diseases with airway obstruction, it is usually much more difficult to expire than
to inspire because the closing tendency of the airways is greatly increased by the positive
pressure in the chest during expiration.

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5. Is the CBC with differential and the sputum exam of any diagnostic significance to M.Cs
emphysema? Explain your answer.
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Yes, there is a significance. If there are changes in the CBC it may be indicative
of compensation of the body to the abnormal changes and may also indicate infection which
should be treated immediately.

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6. Are M.Cs VS and SaO2 appropriate? If not, explain why.
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Yes, it is appropriate because the body will compensate for the changes and
significant changes will be noted easily.

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7. Why is the O2 inhalation at 2 LPM inspite of the SaO2 at 88%?
What is the rationale for immediately starting M.C. on oxygen inhalation?
How do we explain the hypoxic drive in a pt. with emphysema?

What important considerations do you have to remember regarding O2 administration in a pt.

with COPD like M.C.?
8. Given M.Cs history and your knowledge of pathophysiologic processes, explain the
pathophysiologic basis of the assessment findings in M.C.
9. What are the possible complications of Emphysema and their manifestations?
10. How does emphysema relate to the other conditions attributed as COPD?
11. Based on the assessment findings, identify five priority problems that M.C. may be
experiencing. Give five nursing interventions for each.
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Tissue perfusion in the lungs
i.
ii.

Altered tissue perfusion

Altered tissue functioning
Obstructive airway

i.

Inadequate Oxygen and Carbon dioxide exchange

Ineffective gas exchange

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ii.

Pain

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Inadequate oxygen supply in the tissues

Carbon dioxide excess
Pain related to inadequate oxygen status
Decreased Oxygen in the body

12. While ausculatating M.Cs breath sounds, you detect the odor of Vicks vaporub. When
you question M.C. about the use of Vicks, he tells you that he started to apply it in and
around his nose to prevent his nose from becoming dry and sore. What important health
teaching is needed by M.C. and his wife regarding the use of vicks while on O2
inhalation?
- Vick Vaporub is an oil based cream. Basically oil supports combustion, if the cream is applied on
the nose and oxygen is applied which supports combustion on it will dry the skin due to its
combustive effect on the skin.
13. Explain the pharmacologic effect of each of the drugs that were given to M.C.
14. What important guidelines do you have to remember regarding the administration of
steroids and bronchodilators especially in a hypertensive pt like M.C.?
15. The laboratory sends the ff. report several hours after admission: RBC 3.8 cu/mm, WBC
13,000/cumm, Hgb 12 g/dl, ABGs pH 7.28, pO2 80mmHg, pCO2 65 mmHg, HCO3 22.
Interpret the above results. How do the results relate to the pathophysiologic changes of
emphysema?
16. With the ABG result, can you say that M.C. is in respiratory failure or
insufficiency? Explain the scientific basis of your answer.
17. What are the major hallmarks of respiratory failure? What do you believe are the principal
causes of this problem in M.C.?
18. You deliver M.C.s tray and he comments how hungry he is. As you leave the room, he is
rapidly consuming the mashed potatoes. When you pick up the tray, you noticed he has
not touched anything else. When you question him, he states I dont understand it. I can

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be so hungry but when I start to eat, I have trouble breathing and I have to stop. Explain
this phenomenon based on your knowledge of the breakdown of carbohydrates.
Seeing him with a major nutritional need, how can you improve his caloric intake?
You noticed M.C.s fondness of milk. You explain that milk causes an increased
production of thick mucus. But he tells you that it can be a good source of protein for
him. How should you respond?
Five days after admission, M.C.s condition has remarkably improved. The MD wants all
medications continued and has shifted the antibiotics to oral preparations. What made
the MD say M.C.s condition has improved? Give the assessment findings that supports
the MDs observation.
M.C. is prepared for discharge after a week in the hospital. He is to continue all
medications except the antibiotics. The cost of medication is a critical issue for elderly
individuals on a fixed income. To help you develop a sensitivity to the cost of
prescriptions, compute for the cost of a week supply of his medications using the drug
receipts of your patient. Compare the cost if generic drugs were used. You may need to
discuss this with the doctor who alone can decide on the drugs to be taken by the patient.
You prepare for your health teaching program for M.C. What will be the basic
components of your teaching plan? What would be the best way of teaching the use of
inhalers and breathing techniques? How would you go about it? How will you ensure the
compliance by M.C. to prevent another exacerbation of his emphysema?

Mr. M.C. was walking with his wife at the mall one day when he suddenly grabbed his right side
and gasped, Oh, I feel something just popped. I cant get any air. His wife immediately yells for
assistance and he was brought immediately by an ambulance to the nearest hospital facility.
On arrival in the Emergency department, the MD auscultates muffled heart tones, no breath
sounds on the right and faint breath sounds on the left. M.C. becomes stupurous, tachcardic and
cyanotic. A stat portable CXR and ABGs are obtained revealing the ff: 70% pneumothorax on the
right. His ABGs on 100% oxygen are pH 7.25, PaCO2 32 mmHg, HCO3 27 mmol/L, BE
+5mmol/L, SaO2 53%.
24. Given the diagnosis of Pneumothorax, explain how the underlying pathophysiology give
rise to the presenting signs and symptoms?
25. Interpret M.C.s ABGs.
26. The MD needs to insert a chest tube. What is the reason for this? What are your
responsibilities as a nurse for this procedure?
27. The MD inserts a size 32 chest tube in the second intercostals space, midclavicular
line. Many chest tubes are inserted in the 5th and 6th ICS, midaxillary line. What
determines the site of chest tube insertion?
28. The chest tubes are connected to a water-sealed chest drainage. Draw the set-up of a 3bottle water-sealed chest drainage system.
29. Would you expect M.C.s lung to reexpand immediately after the chest tube insertion and
connection to water-sealed drainage? Explain your answer.
30. Discuss your specific nursing management of M.C. while having a chest tube connected
to water-sealed chest drainage.

After 4 days, M.C. is discharged much improved. His wife tells you this is the third time he had a
chest tube inserted for a collapsed lung.
31. His wife asks whether this trend will continue. How would you respond to her query?
M.C. develops several more spontaneous pneumothoraces on the right and eventually has
Bleomycin instilled over the right lung to induce scarring.
32. What is this procedure called? What is its specific action and why is it needed by M.C.?