Identify at least four signs and symptoms described in the physician's history and physical that are consistent with Mrs. Hoffman's diagnosis. Then describe the pathophysiology that may be responsible for each symptom

Question

What will be an ideal response?

Answer 1

Shortness of breath (dyspnea)
• Emphysema results from irreversible destruction of lung tissue that causes a loss of elasticity in the alveoli.
• Healthy alveoli provide a rigid structure to bronchioles that normally allow the airways to remain open.
• With emphysema, alveolus tissue loses its elasticity and collapses when air is exhaled.
• As alveoli are destroyed, the lungs are able to transfer less and less oxygen to the bloodstream.
• Therefore, shortness of breath results.
Early morning confusion (hypercapnia)
• If the patient is retaining CO2 (hypercapnia), it is common to see the effects of carbon dioxide toxicity in the a.m.
• Overnight, respiratory rate decreases. Therefore, less CO2 is released.
• With the pathology of the disease, the patient with emphysema experiences CO2 retention due to the collapse of bronchioles that affects not only inspiration of oxygen but also expiration of CO2
• CO2 retention may also increase with loss of muscle mass that allows for support of expiration.
Increased production of brownish-green sputum
• Sputum production is common with COPD.
• When a patient experiences an increase in production and/or a change in the type of sputum (i.e., color), it is generally one of the first signs of either an exacerbation of the condition (due to chronic bronchitis) and/or an underlying infection.
Fatigue
• Fatigue in respiratory muscles occurs because length-tension relationships within respiratory muscles are less than optimal, promoting respiratory muscle inefficiency and fatigue.
• Adequate oxygen supports all activity. Without adequate perfusion, the patient experiences fatigue.
• As dyspnea worsens, so does fatigue.
• Malnutrition contributes to fatigue.
Early satiety
• Early satiety occurs when the patient reaches a full or satiated state after only a small ingestion of food.
• Patients with COPD most probably experience this symptom due to dyspnea.
• Eating also increases pressure on the diaphragm, which contributes to increased dyspnea and consequently early satiety.
• Aerophagia (swallowing of air) with gastric retention may also contribute.
Anorexia
• Loss of appetite is common in patients with COPD.
• Fatigue, dyspnea, and side-effects of medication all may contribute.
Dysgeusia
• Taste changes or altered taste may be a result of medications or changes in saliva.
• Acid-base imbalances or ketosis may also contribute.
• Cigarette smoking may also result in dysgeusia.

Increased blood pressure
• Multifactorial
• As oxygen saturation drops, the message to the CNS is that circulating blood volume is decreasing.
• The sympathetic nervous system is stimulated, resulting in release of norepinephrine.
• This causes generalized arterial and venous vasoconstriction and an increase in blood pressure.
Increased respiratory rate
• Emphysema damages the elasticity of airway and there is destruction of the alveolar wall.
• Thus, airways collapse during expiration, which causes air to become trapped.
• The lungs and chest wall hyperexpand, attempting to compensate.
• This increases the overall work of breathing.
Jugular distention: Due to the decreased amount of oxygen available, there is widespread vasoconstriction and increased pulmonary artery pressure.
Pedal edema
• When the heart (R ventricle) has to work harder in response to the decreased overall oxygen saturation, the increased pressures are transmitted to the venous circulation over time.
• This results in peripheral edema.
Decreased breath sounds: This is due to the trapping of air and the prolonged expiration.
Prolonged expiration
• Emphysema damages the elasticity of the airway and partially destroys the alveolar wall.
• Thus, airways collapse during expiration, which causes air to become trapped.
• The lungs and chest wall hyperexpand, attempting to compensate.
• This increases the overall work of breathing.
Rhonchi
• Rhonchi are added sounds that occur during either inspiration or expiration.
• They are caused by air passing through bronchi that are narrowed.
• This narrowing could be a result of inflammation or the presence of mucus from the infectious process of her pneumonia.
Wheezing
• Occurs due to narrowed airways.
• When this occurs, a high-pitched whistling sound is produced.
Use of accessory muscles: It is typical for a patient with emphysema to develop use of the accessory muscles in order to assist with the expiration of air.