Oedema and Cyanosis Assessment: Skin
The first nursing assessment is based on the nursing diagnosis of impaired gas exchange with a focus on the skin. The reason why the measure needs to be conducted is that the patient has alveolar-capillary membrane alterations. The evidence includes oedema and cyanosis, and the key outcomes involve observations of swelling and skin discoloration (Virsilas et al., 2019). The changes need to take place without any respiratory distress factors with an emphasis on avoidance of their clinical manifestations. The assessment focuses on evaluating the patient’s skin to determine the presence of cyanosis and oedema since it is a strong indicator of oxygen depletion in the blood. The comprehensive description of anticipated abnormal findings from the focused assessment is skin discoloration, which is the result of low oxygen levels. Its clinical manifestation is blue skin, which is likely to be observed during the assessment. The prioritization is due to the accessibility of the assessment since the indicators are visual.
Hypoxia Assessment: Cardiovascular System
The next step is to observe the patient’s mental state because restlessness and agitation correspond to hypoxia since sluggish capillaries and cool peripheries can translate to a lower supply of oxygen to the brain as well. It is stated that these mental health symptoms and anxiety can be strong signs of low oxygen supply to the brain (Lari et al., 2020). The assessment additionally involves analyzing the level of consciousness, which is likely to decrease due to hypoxia (Lari et al., 2020). The arterial gas values lead to depressed levels of blood oxygen, which causes cerebral hypo perfusion. It is critical to observe the patient’s consciousness level as well as mental state, especially for the signs of anxiety, restlessness, and agitation. The comprehensive description of anticipated abnormal findings from the focused assessment is likely to involve the presence of these mental status indicators, and the patient will probably exhibit lower levels of consciousness. The assessment can be done in parallel with other assessments, where the patient’s behavioral responses to questions and procedures can be noted.
Ineffective Breathing Pattern: Respiratory System
The patient breath sounds are additionally critical to assess since decreased airflow in the lungs is likely to lead to wheezes and other abnormal sounds. It is important to note that wheezing and other abnormal breathing sounds are strong indicators of emphysema due to lung tissue consolidation (Rao et al., 2021). These metrics can be interpreted as part of vital signs since the patient shows crackles heard bilaterally in both bases of the lungs. The prioritization is essential since the identified emphysema is primarily a respiratory issue, which manifests most strongly in the lungs (Jaitovich & Barreiro, 2018). The comprehensive description of anticipated abnormal findings from the focused assessment is likely to involve wheezes, crackles, and other sounds considered abnormal.
Pathophysiology
Firstly, it is worth noting that the patient had hypertension before, which may also be one of the causes of emphysema. Reduction of the capillary network in the lungs entails the development of pulmonary hypertension and an increase in the load on the right parts of the heart (Leap et al., 2021). Edema of the lower extremities, ascites, and hepatomegaly occur (Perticone et al., 2021). The pathophysiology of hypertension and exacerbation of emphysema is indicative of the case-specific data, which is the blood pressure of 162/102mmHg. In other words, low levels of oxygen in the blood combined with high blood pressure lead to pathophysiological pulmonary artery remodeling due to vasoconstriction. It exacerbates the condition since the oxygenation is already hindered within alveoli, but the narrowing of blood vessels leads to even more reduction of blood passing through the lungs, further reducing oxygen exchange.
Secondly, the patient’s peripheral vascular disease or PVD is evidenced by cool peripheries when touched. The pathophysiology of PVD is atherosclerosis and ischemia of the peripheral blood vessels. The pathophysiological manifestation of PVD in conjunction with emphysema lead to already poorly oxygenated blood being unable to reach the peripheries due to highly reduced throughput of the arteries. A strong manifestation of the PVD and emphysema is the body’s inability to ensure even thermoregulation in the peripheries, such as hands and feet (Perticone et al., 2021). Therefore, the pathophysiology of such as condition is a result of the buildup of plaque in the inner sides of the arterial linings, which reduces the blood vessel diameter leading to lower blood flow. Since the patient already struggles with blood oxygenation, PVD exacerbates the cardiovascular system’s state even more.
Thirdly, the development of emphysema in the lungs of smokers is due to the fact that tobacco smoke causes the migration of neutrophils into the respiratory zone of the lungs. It produces a large number of proteolytic enzymes — elastase and cathepsin (Leap et al., 2021). In addition, tobacco smoke resin accumulates in the patient’s alveolar macrophages, which leads to inhibition of the formation of α1-antitrypsin. Prolonged and intensive tobacco smoking causes an imbalance in the oxidants/antioxidants system, with a predominance of oxidants that cause damage to biological membranes and alveolar walls (Leap et al., 2021). With emphysema of the lungs, peripheral vascular disease and reduction of the capillary network of the lungs cause an increase in pressure in the pulmonary artery (Celli et al., 2018). Hypoxic pulmonary vasoconstriction contributes to the progression of pulmonary hypertension.
In addition, since the heart’s right ventricle in these conditions must develop more pressure to overcome the increased pressure in the pulmonary artery, it hypertrophies and expands (Perticone et al., 2021). In addition, chronic hypoxemia causes an increase in erythrocytosis, causing an increase in blood viscosity. Deterioration of the rheological characteristics of blood further increases pulmonary vascular resistance and the insufficiency of the heart’s right ventricle.
Nursing Care Interventions
Supplemental Oxygen
The first nursing care intervention is administering supplemental oxygen to the patient as prescribed. The case provides information on the patient’s paleness and demonstrates the poor oxygenation of the blood. The exacerbation of emphysema provides a rationale to administer supplemental oxygen if prescribed by the medical professional. Thus, the nursing intervention of administering supplemental oxygen is relevant and focused on the patient’s core conditional metrics. The administration requires a nurse to ensure that the arterial oxygen pressure does not decrease below 60 mmHg and the oxygen saturation does not decline below 89% (Nolan & Rochester, 2019). These procedures require a nursing professional to check the metric of importance frequently, such as every 30 minutes (de Lima et al., 2019). The evaluation technique is based on observing the patient’s vital signs, specifically blood oxygenation and blood pressure. During the exacerbation of the condition among patients with emphysema, it is necessary to integrate the administering of supplemental oxygen under the supervision of a nurse. It requires an individual approach and depends on the initial condition of the patient, the severity of the disease and concomitant diseases, as well as vital signs.
Suction
The second nursing intervention is the suction of secretions, where a nursing professional assists the patient with a clearing of the phlegm whenever there is difficulty in expectorating. The case provides information on the patient’s wet cough with yellow sputum expectorated and crackles heard bilaterally in both bases of the lungs. These are strong indicators of excessive phlegm buildup, and the patient has a high chance of being unable to fully expectorate on his own due to exacerbation of emphysema. Thus, the nursing intervention of the suction of secretions is relevant and focused on the patient’s core conditional metrics. The suction assistance requires a nurse to ensure that the process is not done for more than 15 seconds since the patient will be unable to inhale (Alharbi et al., 2021). The frequency can vary depending on the patient, but checking the phlegm buildup every 20 minutes is reasonable (Blervaque et al., 2021). The evaluation technique is based on observing the patient’s vital signs, breathing sounds, breathing frequency, and phlegm buildup.
Education
Patient education is an effective means of achieving specific goals, including smoking cessation, understanding a number of issues related to terminal events, and improving the outcomes of exacerbations. Multidisciplinary educational programs may be useful for elderly patients (Sandelowsky et al., 2019). It is necessary to make sure that the patient is aware of the importance of quitting smoking. This will reduce the likelihood of developing progressive signs of the disease. The nurse should make it clear that the improvement of the patient’s condition and the relief of painful sensations is possible only with joint work. Attention should also be paid to the patient’s family, even though they do not have a permanent opportunity to support the patient (Sauriasari et al., 2021). They should be provided with instructions on additional patient care to prevent neglect of recommendations for reducing smoking. It is necessary to make a plan for attending training sessions and additional meetings in order to be able to make sure that the state of health improves.
Interprofessional Team
For the most favorable discharge of Mr. Coates, it is necessary to work together with a physiotherapist. Due to the irreversible nature of structural changes in the lungs, physiotherapy is designed to combat chronic infection, bronchospasm, and hypersecretion and improve respiration’s functional reserves (Gao et al., 2019). The main methods are thermal, aerosol, and climatological procedures, regularly combined with respiratory gymnastics (DeGaris & Osadnik, 2020). There is an increased need for medical rehabilitation carried out by special exercises of respiratory gymnastics, controlled breathing with physical effort, diaphragmatic breathing, and expansion of the lateral parts of the chest.
The relevance of physical rehabilitation in emphysema is associated with a relatively high incidence rate, as well as with the high effectiveness of this method for improving the quality of life and slowing the progression of the disease. Under the influence of exercises, the elasticity of the lung tissue and the mobility of the lung improves, the mobility of the chest increases and the excursion of the diaphragm increase, the respiratory muscles strengthen, the mechanism of breathing, coordination of breathing, and movements are improved (Solomen, 2019). Thus, the patient’s health condition will significantly improve when working with a physiotherapist, facilitating further discharge.
References
Alharbi, M. G., Kalra, H. S., Suri, M., Soni, N., Okpaleke, N., Yadav, S., Shah, S., Iqbal, Z., & Hamid, P. (2021). Pulmonary Rehabilitation in Management of Chronic Obstructive Pulmonary Disease.Cureus. Web.
Celli, B. R., Locantore, N., Tal-Singer, R., Riley, J., Miller, B., Vestbo, J., Yates, J. C., Silverman, E. K., Owen, C. A., Divo, M., Pinto-Plata, V., Wouters, E. F., Faner, R., & Agusti, A. (2018). Emphysema and extrapulmonary tissue loss in COPD: a multi-organ loss of tissue phenotype.European Respiratory Journal, 51(2), 1702146. Web.
de Lima, F. F., Camillo, C. A., Grigoletto, I., Uzeloto, J. S., Vanderlei, F. M., Ramos, D., & Ramos, E. M. C. (2019). Effects of combining functional exercises with exercise training on daily physical activities and functionality in patients with COPD: A protocol for a randomized clinical trial.Trials, 20(1). Web.
DeGaris, J. S., & Osadnik, C. R. (2020, January 1). Physical exercise during acute exacerbations of chronic obstructive pulmonary disease: Australian physiotherapy practice. Chronic Respiratory Disease, 17, 147997312091282.
Gao, H., Gao, Y., Sun, P., Shen, J., Yao, H. J., Fu, S. D., & Meng, C. (2019). Effect of physical therapy for chronic obstructive pulmonary disease. Medicine, 98(38), e17241.
Jaitovich, A., & Barreiro, E. (2018). Skeletal muscle dysfunction in chronic obstructive pulmonary disease. What we know and can do for our patients.American Journal of Respiratory and Critical Care Medicine, 198(2), 175–186. Web.
Lari, A., Alherz, M., Nouri, A., Botras, L., & Taqi, S. (2020). Caution against precaution: A case report on silent hypoxia in COVID-19. Annals of Medicine and Surgery, 60, 301-303.
Leap, J., Arshad, O., Cheema, T., & Balaan, M. (2021). Pathophysiology of COPD.Critical Care Nursing Quarterly, 44(1), 2–8. Web.
Nolan, C. M., & Rochester, C. L. (2019). Exercise training modalities for people with chronic obstructive pulmonary disease. COPD: Journal of Chronic Obstructive Pulmonary Disease, 16(5–6), 378–389.
Perticone, M., Maio, R., Caroleo, B., Suraci, E., Corrao, S., Sesti, G., & Perticone, F. (2021). COPD significantly increases cerebral and cardiovascular events in hypertensives. Scientific Reports, 11(1).
Rao, C. M., Singh, P., Maikap, D., & Padhan, P. (2021). Musculoskeletal disorders in chronic obstructive airway diseases: A neglected clinical entity.Mediterranean Journal of Rheumatology, 32(2), 118. Web.
Sandelowsky, H., Krakau, I., Modin, S., Ställberg, B., & Nager, A. (2019). COPD patients need more information about self-management: a cross-sectional study in Swedish primary care.Scandinavian Journal of Primary Health Care, 37(4), 459–467. Web.
Sauriasari, R., Madani, R. A., Rozaliyani, A., & Sudiana, D. (2021). The effect of repeated education using live demonstrations and videos of how to use inhalation drugs on quality of life for COPD patients.Heliyon, 7(9), e07870. Web.
Solomen, S. (2019). Guidelines for the physiotherapy management of chronic obstructive pulmonary disease. Physiotherapy – the Journal of Indian Association of Physiotherapists, 13(2), 66.
Virsilas, E., Timukiene, L., & Liubsys, A. (2019). Congenital methemoglobinemia: Rare presentation of cyanosis in newborns. Clinics and Practice, 9(4), 1188.