Introduction
A 65-year old Caucasian female presented with a chief complaint of dry cough that had lasted for two weeks and low grade fever that that she had experienced for two days. The X-ray examination showed hyperinflation of both lungs with an increased AP diameter. This pointed to evidence of emphysema. Thus, the following paper is a case evaluation of the emphysema and a care plan synthesis.
Pathophysiology
The pathological implications of emphysema include the enlargement of airspaces distal to the terminal bronchioles. The enlargement is accompanied by the distraction of the alveolar walls. However there is no obvious fibrosis as is the case with other chronic obstructive pulmonary disease (COPD) (Nici & Zuwallack, 2012). Emphysema is caused by the destruction of the epithelial barriers of the lungs. The destruction is normally caused by the infiltration of the mucociliary and epithelial cells by foreign antigens such as cigarette ingredients and macrophages. The foreign antigens release neutrophilic chemotactic factors. For example, the macrophages release metalloproteinases which destroy the epithelia barriers. The chemotactic factors promote the structural change such as the inflammation of lungs that interferes with the airflow (Nici & Zuwallack, 2012).
Signs/symptoms
The common manifestation of emphysema is cough and dyspnea. Dyspnea refers to shortness of breath (Rice et al., 2010). Sometimes the patient can complain of sore throat. In the early states the dyspnea occurs during activity. However, as the condition progresses, the attacks of dyspnea happen more often. Eventually, the patient experiences dyspnea at rest.
Progression trajectory
Emphysema develops in stages. In order to determine the progression, staging of emphysema is applied to identify the extent of damage to the lungs. The stages include mild, moderate, severe and very severe. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) uses forced expiratory volume in first second (FEVI) to identify the stages. However, the most sensitive estimates of the emphysema are the application of the chest CT scans.
Diagnostic testing
The diagnosis of emphysema normally starts with the taking the history of the patient. The history is used to learn about the possible lung condition and the breathing symptoms. The next stage is oximetry. According to Rice et al. (2010), this is a non invasive test. The health professional uses a sensor that is clipped onto a finger to evaluate the amount of red blood cells carrying oxygen. The other diagnosis is the use of radiology. This entails the use of plain chest X-ray. The emphysema can be indicated by inflated lungs without normal markings and, also, by signs of destruction of lung tissue and alveoli. More details of the lung destruction can be established by a CT scan of the chest (Rice et al., 2010).
Treatment options
The treatment options include lifestyle changes, pharmacological and surgery. Lifestyle change is commonly for patients who smoke tobacco. The pharmacological treatment entails the use of bronchodilators which relax the muscles that surround the bronchioles. The medication allows the breathing tubes to dilate; hence, allowing the air to flow more freely. Patients with emphysema have higher risk of getting infected with pneumonia and other bacterial infections. As a result, antibiotics may be prescribed if the patient presents with signs of an infection such a fever and weakness. Use of supplemental oxygen is also a common management option as the disease progresses. The decision to use oxygen supplementation is normally influenced by oximetry tests, blood tests and the general pulmonary function (Rice et al., 2010). The patients with severe emphysema symptoms and who do not respond to pharmacological interventions can be subjected to lung volume reduction surgery.
Differentiation of the disorder from normal development
Healthy human lungs are used to bring oxygen into the body and to remove carbon dioxide. The gas exchange in healthy lungs takes place through the flat endothelial and overlying alveolar epithelial cells layers. The layers adhere tightly to each other in which the basement membrane is fused into a single layer. The lungs provide a large surface area for the gaseous exchange. Coughing is a common event; it is used as a protective measure to remove any irritation by expelling the mucus from the lungs. However, the development of the emphysema is characterized by the destruction of the epithelial lining. This results in difficulties in breathing and abnormal coughing.
Physical and Psychological Demands
The physical and psychological effect on the individual may increase as the disease progresses (Kelly & Lynes, 2008). Patients with severe emphysema cannot perform strenuous exercises. For instance, a patient needs to plan for daily activities carefully to avoid exposure to risk agents such as crowds, stairs and crowds. The psychological effect depends on the individual. Some patients can adopt well, while other experience devastating experiences. Patients living with chronic lung diseases experience stress and anxiety, fear of breathless moments, and sense of worthlessness (Kelly & Lynes, 2008). In addition, there are financial implications that relate to the treatment and management of the condition. These changes are part of gradual transition that alter family dynamics and can lead to development of resentment and tension.
Concepts for Optimal Emphysema Management and Outcomes
The concepts should include psychological and physical interventions. The psychological interventions include relaxation and distraction therapy. For example, Perez et al. (2013) noted that dyspnea can be managed through a multidimensional concept. First, the concept should include emotional experience of breathlessness. The second concept should be the consideration of the causative biological mechanism. The fears arrayed by the patient should be addressed through effective communication in which both the patient and the family are involved. According to Kelly and Lynes (2008), involving the patient and family in the decision making process makes them feel more informed and in control.
Interdisciplinary Team Personnel
Chronic lung disorders have tremendous physical and psychological consequences for the patients and the family (Kelly & Lynes, 2008). As a result, there is need or interdisciplinary team to help the patient gain psychological and physical wellbeing. The interdisciplinary team personnel will include nurses, doctors, social workers, family members, church members, and family members. The nurses and doctors will provide the patient and the family with the relevant information that relates to the management and treatment of the disorder. The social workers will help in linking the patient to support group that are critical in provision of social and psychological care such as the church members and community.
Facilitators and Barriers
The facilitators and barriers to optimal emphysema management and outcomes relate to customized care plans, building relations with patients and involvement of multidisciplinary teams. The customized and personalized care facilitators involve strategies that address the patient’s social and behavioral needs. Perez et al. (2013) noted that personalized care should be flexible in the scheduling of appointments and should incorporate home visits. This helps in identification of environmental barriers. The barriers related with personalized care include limited staff capacity and resources to reach the patients and families.
On the other hand, team based care creates environments that foster cohesiveness of small work groups. The groups are important in enhancing the sense of belonging and dignity which is critical for the patients with chronic diseases. The barriers associated with team based care include lack of team integration. The team may not be prepared to provide holistic care that relate to social determinants of health. Finally, the building of relations entails listening to narratives of the patients and building of social support system among patients and care providers. It includes dynamic care plans with short term attainable goals. The main barrier to the facilitator is the tendency to exclude the input of the patient. This may make the patient fell undermined and thus influence the care process.
Overcoming the barriers
In order to overcome the barriers, there should be enough resources that can impact on one patient at a time. This ensures that care providers can adopt holistic approach by paying attention to specific needs of the patient. Resources are also critical in facilitating the activities of the multidisciplinary teams. In addition, the design of the care plans should focus on the people rather than the infrastructure. According to Kelly and Lynes (2008), people change while the infrastructure supports the change.
Care Plan Synthesis
Comprehensive and Holistic Recognition and Planning
The optimal management of emphysema requires a holistic approach that includes the recognition and treatment of the disease. It entails bringing together the dimensions of the emphysema through the lifetime of the patient and the integration of the medical care by applying patient centered approach. Therefore, for the holistic recognition and management, the six core components include clinical information system, self management support, delivery system, decision support system, and healthcare organization and community resources. Based on the physical and psychological implications of the disorder, the plan will involve a multidisciplinary team and will be stretched in a time frame that will ensure continuous care for the patient.
Socio-cultural Background
Care for patients with COPD should meet the socio-cultural needs of the individual. Socio-cultural influences affect the management of diseases at individual and family levels (Kelly & Lynes, 2008). For instance, the patient goes to church and she has some people she can conduct there. The integration of the patient with the religious leaders and church members will help in alleviation of the stress and depression. The social workers can help the patient to interact with the members on routine basis. This will reduce the depression and day stress that the patient has been facing. In addition, integrated care includes the community and family support. The patient has two grown up daughters who live in nearby community. These family members are important in provision of social support. For instance, the patient noted that she would like the daughters involved in a life. In order to achieve the optimal management health care providers should approach the daughters and provide them with the necessary information and how they can contribute to the care process of their mother
Evidence based management of emphysema
Jiang et al. (2015) carried out a study that sought to assess the outcome of community intervention. The study investigated the changes in quality of life, dyspnea, and quality adjusted life in patients with COPD. This was longitudinal research that started in February 2008 and ended in April 2009. The patients were evaluated on monthly basis. The indexes for assessment included measurement of pulmonary functions (FEVI), the dyspnea scale, frequency of hospitalization and costs associate with the hospitalization. The care included knowledge training, pharmaceutical care, community care, and exercise (Jiang et al., 2015). The study also included community management of a control group. At the end of the study, the data was analyzed using SPSS software. The functions of the lung, the dyspnea scale scores and quality adjusted life were measured using student t-tests. The results pointed to significance difference between the intervention and the control group. There was significant improvement in the pulmonary function, dyspnea scale scores and quality of life (Jiang et al., 2015). This pointed to the fact that the intervention group fared significantly better than the control group.
Customized Care plan for the Patient
The care plan for the patient will entail a pharmacological and non pharmacological care. This plan will be implemented by the multidisciplinary team. Bearing in mind the depression and day stress the patient has been facing, a social support group for patient will be created. This group will include members of the church that she attends. In addition, a behavioral intervention program will be designed. It will entail a counseling session and rehabilitative care for the patient. The main focus for the intervention will be to help the patient to stop smoking. In order to ensure optimal results, the intervention will be designed in a participatory approach. As a result, the intervention will be flexible and tailored to the social-cultural needs of the woman. The daughters will also help the mother in cooking her foods to ensure that the right nutrition is maintained.
The pharmacological care will be based on the progression of the disorder. For instance, the bronchodilators will be prescribed to help in relaxing the muscles that surround the bronchioles. Due to the mild fever reported by the patient, diagnosis for bacterial infections will be carried out and appropriate antibiotics prescribed. A follow up program will be designed in order to monitor the progress of the patient.
References
Jiang, Y., Zhu, Y., Chen, X., Xu, X., Li, F., Fu, H., Zhang, Y., & Shen, C. (2015). Impact of adherence to GOLD guidelines on 6-minute walk distance, MRC dyspnea scale score, lung function decline, quality of life, and quality-adjusted life years in a Shanghai suburb. Journal of Genetics and Molecular Research, 14(3), 8861- 8870.
Kelly, C., & Lynes, D. (2008). Psychological effects of chronic lung disease. Nursing Times, 104(47), 82–85.
Nici, L., & Zuwallack, R. (2012). An Official American Thoracic Society Workshop Report: The Integrated Care of the COPD Patient. Proceedings of the American Thoracic Society, 9(1), 10-17.
Perez, B., Cummings, L., Schrag, J., Mead, H., & Jewers, M. (2013). Facilitators and Barriers to Providing Patient-Centered Chronic Disease Care to Patient Populations at Risk for Health and Health Care Disparities in Safety Net Settings. Modern Healthcare, 42(19), 6-7.
Rice, L., Dewan, N., Bloomfield, H., Grill, J., Schult, T., Nelson, D., Kumar, S., Thomas, M., Geist, L., & Beaner, C. (2010). Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial. American Journal of Respiratory Critical Care Medicine, 182(1), 890-896.