Interstitial Lung Disease – Diagnosis Presentation & Care Plan for the Case Study

QUESTION

History of Present Illness: A 33-year-old white female presents after admission to the general medical/surgical hospital ward with a chief complaint of shortness of breath on exertion. She reports that she was seen for similar symptoms previously at her primary care physician’s office six months ago. At that time, she was diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short course oral steroid taper. This management did not improve her symptoms, and she has gradually worsened over six months. She reports a 20-pound (9 kg) intentional weight loss over the past year. She denies camping, spelunking, or hunting activities. She denies any sick contacts. A brief review of systems is negative for fever, night sweats, palpitations, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, neural sensation changes, muscular changes, and increased bruising or bleeding. She admits a cough, shortness of breath, and shortness of breath on exertion.

Social History: Her tobacco use is 33 pack-years; however, she quit smoking shortly prior to the onset of symptoms, six months ago. She denies alcohol and illicit drug use. She is in a married, monogamous relationship and has three children aged 15 months to 5 years. She is employed in a cookie bakery. She has two pet doves. She traveled to Mexico for a one-week vacation one year ago.

Allergies: No known medicine, food, or environmental allergies.

Past Medical History: Hypertension

Past Surgical History: Cholecystectomy

Medications: Lisinopril 10 mg by mouth every day

Physical Exam:

Vitals: Temperature, 97.8 F; heart rate 88; respiratory rate, 22; blood pressure 130/86; body mass index, 28, O2 sat 87% on room air

General: She is well appearing but anxious, a pleasant female lying on a hospital stretcher. She is conversing freely, with respiratory distress causing her to stop mid-sentence.

Respiratory: She has diffuse rales and mild wheezing; tachypneic.

Cardiovascular: She has a regular rate and rhythm with no murmurs, rubs, or gallops.

Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass.

Chest X-ray

Impression: Interstitial lung disease

Part I: Research Interstitial lung disease and write a detailed presentation on the diagnosis.

(

, signs and symptoms, diagnostics, treatment)

Part II: Care plan for the case study

(5 nursing diagnosis, 10 goals and 10 interventions – 2 goals and 2 interventions for each diagnosis)

ANSWER

Part I: Interstitial Lung Disease – Diagnosis Presentation

Introduction

Interstitial lung disease (ILD) refers to a group of disorders characterized by inflammation and scarring of the interstitial tissues of the lungs. It encompasses a wide range of conditions that can result in progressive lung fibrosis and impaired gas exchange. This presentation aims to provide an overview of the pathophysiology, signs and symptoms, diagnostics, and treatment options for interstitial lung disease.

Pathophysiology

ILD involves injury and inflammation of the alveolar epithelium and the interstitium, leading to an abnormal wound healing response. The key processes involved in the pathophysiology of ILD include:

Inflammatory Response: Chronic inflammation triggers the release of pro-inflammatory cytokines and growth factors, leading to the recruitment of immune cells and the activation of fibroblasts.

Fibroblast Activation and Fibrosis: Activated fibroblasts produce excessive extracellular matrix components, including collagen, leading to the formation of fibrotic tissue in the interstitium.

Alveolar Epithelial Dysfunction: Damage to the alveolar epithelial cells disrupts the integrity of the alveolar-capillary barrier, impairing gas exchange.

Signs and Symptoms

The signs and symptoms of ILD can vary depending on the specific subtype and the extent of lung involvement. Common manifestations include:

Progressive Dyspnea: Shortness of breath, initially on exertion but may progress to occur at rest.

Dry Cough: Persistent cough that may be nonproductive or accompanied by minimal sputum production.

Fine Velcro-like Crackles: Abnormal lung sounds heard on auscultation, indicating the presence of fibrosis and lung involvement.

Fatigue and Exercise Intolerance: Reduced exercise capacity and generalized fatigue due to impaired lung function.

Diagnostics

To establish a diagnosis of ILD and determine the underlying subtype, various diagnostic tests and procedures are employed, including:

Chest X-ray: Initial imaging modality to assess for the presence of interstitial lung abnormalities, such as reticular or nodular opacities.

High-Resolution Computed Tomography (HRCT): Provides detailed images of lung parenchyma, aiding in the identification of characteristic patterns and distribution of fibrosis.

Pulmonary Function Tests (PFTs): Measures lung volumes, airflow rates, and gas exchange parameters to assess lung function and determine the severity of impairment.

Bronchoscopy and Lung Biopsy: In select cases, bronchoscopy with bronchoalveolar lavage and transbronchial biopsy may be performed to obtain lung tissue samples for histopathological evaluation.

Treatment

The management of ILD aims to slow disease progression, alleviate symptoms, and improve quality of life. Treatment strategies may include:

Pharmacotherapy
Corticosteroids: Systemic or inhaled corticosteroids may be used to reduce inflammation and suppress the immune response.
Immunosuppressive Agents: Medications such as azathioprine, mycophenolate, or cyclophosphamide may be prescribed to modulate the immune system and prevent further lung damage.
Antifibrotic Agents: Nintedanib and pirfenidone are FDA-approved drugs that can slow the progression of fibrosis in certain ILD subtypes.

Oxygen Therapy: Supplemental oxygen may be provided to maintain adequate oxygen saturation levels and alleviate hypoxemia.

Pulmonary Rehabilitation: A multidisciplinary approach involving exercise training, breathing exercises, and education to optimize lung function, enhance physical capacity, and improve quality of life.

Lung Transplantation: In severe cases of ILD, lung transplantation may be considered as a treatment option for eligible patients.

Conclusion

Interstitial lung disease encompasses a diverse group of disorders characterized by lung inflammation and fibrosis. Understanding the pathophysiology, recognizing the signs and symptoms, and employing appropriate diagnostic and treatment strategies are essential in managing ILD. Early detection, prompt intervention, and ongoing monitoring can improve outcomes and enhance the quality of life for individuals affected by this condition.

Part II: Care Plan for the Case Study

Nursing Diagnosis

Impaired Gas Exchange related to interstitial lung disease as evidenced by decreased oxygen saturation and shortness of breath.
Ineffective Airway Clearance related to cough and increased production of sputum.
Anxiety related to dyspnea and hospitalization.
Imbalanced Nutrition: Less than Body Requirements related to difficulty eating due to dyspnea and decreased appetite.
Risk for Impaired Skin Integrity related to immobility and limited mobility.

Goals and Interventions

Impaired Gas Exchange
Goal: Maintain adequate oxygenation with oxygen saturation >92%.
Intervention: Administer supplemental oxygen as prescribed and monitor oxygen saturation regularly.
Goal: Improve lung function and reduce dyspnea.
Intervention: Encourage and assist with deep breathing exercises and provide a calm and supportive environment.

 Ineffective Airway Clearance
Goal: Promote effective coughing and clearance of respiratory secretions.
Intervention: Encourage the patient to perform deep coughing and teach effective coughing techniques. Assist with postural drainage and suctioning if necessary.
Goal: Enhance lung ventilation and gas exchange.
Intervention: Encourage the patient to use incentive spirometry regularly to promote lung expansion and prevent atelectasis.

 Anxiety
Goal: Reduce anxiety levels and promote relaxation.
Intervention: Use therapeutic communication techniques to provide emotional support. Teach stress management techniques, such as deep breathing and guided imagery.

Imbalanced Nutrition: Less than Body Requirements
Goal: Promote adequate nutritional intake.
Intervention: Collaborate with the dietitian to develop a modified diet plan that includes small, frequent meals. Offer assistance and encourage the patient to eat in a comfortable and relaxed environment.

Risk for Impaired Skin Integrity
Goal: Prevent skin breakdown and pressure ulcers.
Intervention: Implement a regular repositioning schedule and provide skin care, paying particular attention to bony prominences. Educate the patient and caregivers on the importance of maintaining good skin hygiene.

Evaluation of Interventions

Regular assessment and documentation should be conducted to evaluate the effectiveness of the interventions in achieving the desired outcomes. This includes monitoring oxygen saturation levels, observing changes in respiratory status, assessing anxiety levels, evaluating nutritional intake, and assessing the skin for signs of breakdown.

Conclusion

A comprehensive care plan for a patient with interstitial lung disease should address the specific nursing diagnoses and goals based on the individual’s needs. By implementing appropriate interventions and evaluating their effectiveness, nurses can optimize patient outcomes, enhance comfort, and improve overall quality of life.