Case Study 28 Emphysema

u Scenario C.E., a 73-year-old married man and retired railroad engineer, visited his internist, complaining, “Whenever I try to do anything, I get so out of breath I can't go on. I think I'm just getting older, but my wife told me I had to come see you about it.” His resting SpO2 registered 83%. He was sent to the local hospital for a chest x-ray examination and arterial blood gases (ABGs) after resting 20 minutes on room air. C.E. returned to the office. After evaluating the results, the physician told C.E. he had severe emphysema and must start on continuous oxygen (O2) therapy at a 2 L flow rate. The physician completed a prescription for the oxygen therapy, including on the prescription C.E.'s pulse oximetry and ABG results. 2 Respiratory Disorders Case Study 28 Emphysema 1. What is the rationale for starting C.E. on oxygen at a 2 L flow rate? Patients with COPD / emphysema should be on low oxygen therapy unless higher levels of supplemental O2 are needed to maintain a SpO2 of 85% and above. In theory, COPD patients have chronically elevated levels of CO2 in the chemo receptors becoming tolerant of these high levels and therefore the CO2 ceases to be that person's drive to breathe. In theory emphysema, patients could stop breathing if high levels of supplemental O2 provided suddently thus having a hypercapnic drive or rive hypoxic drive to breath. 2. What criteria need to be fulfilled for Medicare to pay for C.E.'s home oxygen therapy? For Medicare to cover the cost of continues O2 therapy, the pt must have severe hypoxemia, which is defined as a PaO2 level of less than 55mm Hg or an arterial O2 saturation of less than 88% on room air and at rest. The criteria vary when hypoxemia is caused by cardiac disease or when O2 is needed at night only. 3. Based on the most common cause of emphysema, what assessment regarding health behaviors is needed? Ask whether the pt smokes; also ask what, how much, and how long he has smoked. Asked if he was exposed to second hand smoke. Ask about lung toxin and occupational exposure. If the pt worked with asbestos, solvents, aerosolized pesticides or herbicides, ask if he used the recommended PPE CaSE StuDy ProGrESS C.E. affirmed he has been a half-pack-per-day smoker for 50years. The physician counseled C.E. on smoking cessation and C.E. agreed to stop smoking. The physician told C.E. his office would have a home equipment company call him to arrange delivery of the oxygen equipment and educate him on its use. As a registered nurse (RN) working for the company, you are assigned to be C.E's case manager. 4. How would you prepare for the initial home visit? - Check with CMS and C.E.;s supplmental insurane compnay if any to see what is cover - Call to make appoinment when both the pt and the pt's wife are there - Collect pt education material about emohysena abd the use of O2 - Pack the O2 unit's O2 adaptors, 50-100 feet of tubing, several nasal canulas 5. What would you address with C.E. and his wife at the first visit? - Using simple terms, explain why C.E. needs O2 - Show them the O2 equipment, demonstrate the operation of equipment and ask for return demo - Using the pt education material review the (do's and don'ts), how to travel and when to seek medical care - Give instructions on 24 hours service - Assess the pt at rest and during activity to ensure his SpO3 levels is over 88% at the current flow rate Rx of 2LPM 6. What assessment do you need to do at each follow-up visit with C.E.? SpO2 levels with and without activity Full set of vitals Equipment function / set up Skin integrity around the ears in the nose Cardiac and Respiratory Assessment CaSE StuDy ProGrESS The next time you visit, C.E. complains of sores behind his ears. He explains, “That long oxygen tubing seems to take on a life of its own. It twists around and gets caught under doors, chairs, everything. It darn near rips the ears off my head." 7. What can you tell him that could help? - Cushion the superoposterior side of the ears so the O2 tubing does rub (E-Z Wrap Soft Foam Ear Protectors for NC) - Examine and clean the sores using normal saline, educate on prevention and signs of infection - Explain COPD increases his nutritional needs for protein and this will assist in the prevention of skin breakdown - Instruct on environmental modifications, educate on how to make a loose lope and place line on belt or pocket to prevent unexpected jerking of tubing / ears. 8. You auscultate C.E.'s breath sounds and detect the odor of Vicks VapoRub. When you question C.E. 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 specific teaching do you need to reinforce with C.E. and his wife? - Educate C.E. of the dangers to use vapor rubs or petroleum-based products around O2. Petroleum supports combustion and melts. All it would take is a spark to start a fire. - Educate the pt on water base moisturizing gels - Provide a checklist for O2 safety including no smoking within 10 feet of O2 and O2 storage -Therapeutic communication, provide education about the risk and benefit of smoking cessations -Refer and help find a support group -Call the provider and suggest a nicotine patch prescription -Abstain from getting involved or provide opinions in family dynamics CaSE StuDy ProGrESS At your next visit 2weeks later, C.E. tells you that he has not smoked since your previous visit. He is upset, though, over an episode a week ago. He says he walked to the kitchen for a snack and became increasingly short of breath. Per your instructions, C.E. removed the nasal cannula (NC), tested the flow against his check, and felt no O2 flowing from the catheter. He lacked the force and volume required to yell for help and was too short of breath to return to the living room to check his O2 tank. He bent forward with his elbows on the countertop and struggled to breathe. He became more frightened with each passing second, and his breathing became increasingly more difficult. A minute later, C.E.'s wife found him and reconnected his O2 tubing. C.E. sat at the table for 20 minutes before he could walk back to the living room. 2 Respiratory Disorders 9. After you have finished, his wife seems upset and tells you that C.E. is still '"smoking a couple of cigarettes” a day. How do you handle this situation? 10. Why did C.E. assume the peculiar position at the countertop? C.E. assumed the tripod position. It has been thought that the tripod position optimizes the mechanics of respiration by taking advantage of the accessory muscles of the neck and upper chest to get more air into the lungs. With the position of the arms secure, contraction of the pectoralis results in elevation of the anterior wall of the chest. 11. C.E.'s wife states that since the incident, C.E. “doesn't want her out of his sight.” She asks you to “talk some sense into him.” She further elaborates, saying that since then “All he does is sit in a chair all day. He won't even get up to get himself a glass of water. I've got a bad hip and this is all very hard on me.” What will you do to help C.E. and his wife cope with his condition? Establish which activities C.E. is experiencing particular difficulty performing. Have C.E and his wife negotiate a plan of ADLs and function only as a neutral 3rd party. 2 Respiratory Disorders 12. What referrals could you consider at this time and why? - Occupational therapy OT referral for energy conservation and to maximize participation in ADLs and IADLs - Pulmonary Rehabilitation Program CaSE StuDy ProGrESS The next few visits are uneventful. C.E. has continued to not smoke and is doing better with managing episodes of dyspnea. At your next visit, you greet C.E., immediately note that he sounds congested, and comment that he sounds like he has a cold. He replies, “Oh, our great-grandchildren were over to visit several days ago and they all had snotty noses." 13. What is your immediate concern and why? - Infection - Pneumonia 14. What assessment do you need to perform? - Physical exam with emphasis on respiratory - Vitsls (checking for fever) SpO2 levels - Look at the sputum collect sample as indicated or as ordered by provider 15. You do not find any signs of an infection. What information would you want to review with C.E. and his wife about the signs and symptoms of infection and when to seek treatment? - Signs of infection include a change in color or consistency of sputum, a cough or increase in coughing - Symptoms are fever, aching, chest tightness, fatigue, and weakness. Note that infections do not always cause a fever in older adults - He should seek Tx as soon as he experiences symptoms 16. What basic hygiene measures would you include in a teaching plan for C.E. and his wife to prevent his developing an infection? Select all that apply. a. Practice good hand washing technique, and wash hands often. b. Avoid people with cold and flu infections, and screen visitors. c. Avoid enclosed, public areas at all times. d. Get pneumonia and flu vaccines every year. e. Use the dishwasher to wash eating utensils, glasses, and plates. f. Use antibacterial wipes daily to clean frequently touched surfaces. 17. C.E.'s wife says she would like to read more about emphysema on the Internet. List two credible resources to which you could direct her. - American Lung Association (https://www.lung.org/) - National Heart, Lung, and Blood Institute (https://www.nhlbi.nih.gov/)