NSG 470: COPD & COLD
Normal PaO2
> 80 mmHg
Before prescribing a patient Chantix for smoking cessation, what should you first determine?
A potential side effect of Chantix is suicidal thoughts, so you should first assess the patient's mental status and suicide potential, and determine if they have a history of any mental disorders.
Bullectomy
A procedure to remove bullae from the lungs. Bullae are air pockets in the lungs that form from tissue destruction as a result of COPD, emphysema, etc.
Directed Coughing aka Huffing
A technique that is used to clear or mobilize secretions from a patient's airway, when spontaneous coughing is inadequate.
The pathophysiology of COPD is characterized by progressive airflow limitation that, once it has become advanced enough, is associated with an inflammatory response of lung tissue to noxious particles & gases. Where do these inflammatory response occur?
- Proximal and peripheral airways (scar tissue → narrowing) - Lung parenchyma (scar tissue → decreased elastic recoil) - Pulmonary vasculature (scar tissue → thickening & hypertrophy → pulmonary hypertension)
How do you determine a "pack year history"?
#PPD (packs per day) X # Years smoked
All of the following clinical manifestations of COPD are considered objective data, except for: a) Activity intolerance (DOE) b) Use of accessory muscles for breathing c) Increased AP:T diameter (Barrel Chest) d) Hypoxemia (< 95%) e) Adventitious breath sounds upon auscultation
(a) - DOE, or dyspnea on exertion, is considered a subjective finding because only the patient can tell you how or when they are feeling SOB. All other clinical manifestations can be seen, heard, or measured by the nurse → objective data
A patient, who has just been diagnosed with COPD, asks the nurse about how he can avoid any further respiratory complications. The nurse should encourage this patient to take each of the following preventative measures, except: a) Receiving a flu vaccine every five years b) Avoiding persons with respiratory infections c) Receiving a Pneumovax vaccine d) Cessation of smoking and other tobacco products
(a) - all people, especially those who have an underlying respiratory illness, should receive a flu vaccine annually.
Which of the following patients has a greater risk for developing COPD? Select all that apply. a) A 12 year-old boy who lives with his parents, who each smoke about 1 pack of cigarettes a day. b) A 48 year-old who lives in a densely populated area with high air pollution. c) A patient whos genetic screening results show that she has the Alpha-1-antitrypsin (AAT) protein. d) A young male who works for a chemical manufacturing company.
(a), (b), and (d) are at greater risk for developing COPD. Patient (c) would not be at risk, because the Alpha-1-antitrypsin (AAT) protein normally protects the lungs from injury. Those who are deficient in this protein would be at a greater risk → Alpha-1-antitrypsin deficiency
A nurse is providing discharge education to a patient with COPD. As part of your teaching plan, you want to encourage all of the following interventions, except: a) Smoking cessation b) Avoiding daily exercise c) Symptom recognition & management d) Adherence to their medication regimen e) Diaphragmatic breathing exercises & pursed-lip breathing
(b) - as part of your discharge instructions, you should encourage patients with COPD to incorporate an exercise regimen into their daily routine, which will improve endurance and activity tolerance; by avoiding exercise altogether, the patient's tolerance to activity will only get worse.
A discharge nurse is referring a number of COPD patients to an outpatient pulmonary rehabilitation service, which will help them improve their physical health and overall quality of life. Of the following patients, which one would not need to be referred to pulmonary rehabilitation? a) An overweight 62 year-old male who states that he cannot get off the couch without feeling short of breath. b) A 71 year-old female who lives alone and has a history of alcohol abuse, anxiety and depression. c) A 50 year-old male who lives with his wife and is looking forward to taking his grandkids to the zoo next week. d) A 63 year-old female with Stage II COPD who is a chronic smoker and refuses to believe the severity of her illness.
(c) Psychologically, this patient is in the right state of mind. Socially, he has a good support system at home. Physically, he is still able to take his grandkids to the zoo, which means that he can tolerate exercise and has few limitations in performing ADL's.
Which of the following accurately characterizes COPD? a) COPD is preventable, treatable, and progresses quickly. b) COPD results in airflow limitation & obstruction that can be fully reversed with treatment. c) COPD is a disease that progresses slowly and can be prevented and treated, but once airflow obstruction occurs, this cannot fully be reversed. d) COPD cannot be prevented, as we do not have control over the air we breathe.
(c) is true - COPD is preventable, treatable, slowly progressive, and results in airflow limitation & obstruction that is NOT FULLY REVERSIBLE.
Diaphragmatic breathing is a type of a breathing exercise used to promote gas exchange in patients with COPD. All of the following are advantages of diaphragmatic breathing, except: a) Helps strengthen your diaphragm & inspiratory muscles b) Improve alveolar ventilation c) Lowers heart rate and blood pressure d) Stress reduction e) Increases respiratory rate
(e) - diaphragmatic breathing decreases your respiratory rate.
Pursed lip breathing technique is often described as "smell the roses, blow out the candles." All of the following are advantages of pursed-lip breathing, except: a) Slow expiration prevents small airway collapse b) Promotes relaxation c) Helps patients gain control of their dyspnea d) ↓ feeling of panic e) Strengthens the diaphragm
(e) - this is an advantage of diaphragmatic breathing.
What is the #1 risk factor for COPD?
**Smoking - tobacco smoke causes 80-90% of COPD cases.
Pathophysiology of COPD
- Airflow limitation is progressive, associated with abnormal inflammatory response to noxious particles or gases - Chronic inflammation damages tissue - Scar tissue in airways results in narrowing - Scar tissue in the parenchyma decreases elastic recoil (compliance) - Scar tissue in pulmonary vasculature causes thickened vessel lining and hypertrophy of smooth muscle (pulmonary hypertension)
What medications can be used to to improve gas exchange in patients with COPD?
- MDI (meter dose inhaler) - Short-acting beta-agonists i.e. Albuterol, Terbutaline - Long-acting beta-agents i.e. Salmeterol, Formoterol - Anticholinergics i.e. Ipratropium (block the action of Acetylcholine → inhibition of the PNS → airway expansion = ease of breathing) - Oral meds: corticosteroids - Theophylline (nonselective phosphodiesterase enzyme inhibitor)
In order to be eligible for a lung volume reduction surgery, what criteria must a patient meet?
- They must be in the early stages of disease with a limited degree of illness - They must be a non-smoker - They must have some degree of functional impairment in their early stages of disease - They cannot have any significant comorbidities that could increase the risk for complications - They must first be referred to pulmonary rehabilitation and have an appropriate exercise evaluation performed
People with COPD live in a chronic state of respiratory acidosis. How are each of the following blood values effected in these patients? 1. pH 2. PaO2 3. PaCO2 4. HCO3
1. decreased blood pH (→ becoming more acidic) due to hypoventilation, which leads to... 2. decreased concentration of O2, and... 3. increased concentration of CO2 (retention), which leads to... 4. bicarbonate level is normal [if uncompensated]; increased [if compensated]
In diagnosing COPD, a number of pulmonary function tests are performed, including the use of a spirometer in measuring FEV (forced expiratory volume) and FVC (forced vital capacity). The comparison of these two measurements is called the "FEV:FVC Ratio," which decreases as the disease progresses. The normal ratio is _____%. The ratio decreases to _____% in those with mild COPD. Patients who have moderate to severe COPD have a ratio of less than _____%.
100, 70, 50
Lung transplants are indicated if the prognosis for survival is less than _____ years (end-stage).
2-3
People with COPD should increase their fluid intake _____ Liters per day to thin mucous secretions.
2-3
Normal HCO3 (bicarbonate)
23-30 mEq/L
Challenges in quitting smoking peak ________ hrs. after the last nicotine use, and are heightened during ________ days after the quit date.
24-48, 7-21
Chronic Bronchitis is defined as a disease of the airways characterized by cough & sputum production for ≥ _____ months, for _____ consecutive years.
3, 2
Normal PaCO2
35-45 mmHg
Normal blood pH
7.35-7.45
Which of the following medications are used in COPD pharmacotherapy? Select all that apply. a) Beta-2 agonists b) Anticholinergics c) Steroids d) Antibiotics e) Methylxanthines
ALL of the above are used to manage COPD
What clinical characteristics would make a patient eligible to receive a lung transplant? Select all that apply. a) An FEV1 < 25% b) Significant hypoxemia, hypercapnia, and/or pulmonary HTN. c) Frequent COPD exacerbations. d) A rapid decline in lung function. e) A prognosis for survival less than 2-3 years.
ALL of the above meet lung transplant eligibility criteria
A nurse is educating a group of students on the role of smoking tobacco in causing respiratory illnesses. Which statements should the nurse include in her teaching to help the students better understand? a) Tobacco decreases the activity of scavenger cells, which are responsible for removing mutagens and debris from the lungs. b) Nicotine causes ciliary paralysis, which decreases the ciliary cleansing mechanism. c) Tobacco causes irritation of our Goblet cells, leading to an increase in mucous production. d) As mucous production increases, people may experience airway irritation, infection, and possibly lung damage. e) Hemoglobin + CO, which is present in cigarettes, creates a compound that cannot effectively carry oxygen, thus leading to decreased perfusion and shortness of breath.
ALL of the above*
Clinical Manifestations of COPD
Activity intolerance → dyspnea on exertion (DOE) Productive cough (sputum) Hypoxemia (decrease Pox < 95%) Rapid, shallow respirations (hyperventilation) Irregular breathing patterns Use of accessory muscles for breathing Barrel chest (increased AP:T diameter) Adventitious breath sounds upon auscultation Weight loss/emaciated/thin (advanced disease) Distended neck veins (R sided heart failure/advanced disease) Pale/cyanotic nail beds & clubbed fingers (advanced disease)
Clinical Manifestations of Emphysema
Adventitious breath sounds (wheezes/crackles) on expiration **Dyspnea/SOB: both on exertion AND at rest Cough + sputum production (variable) Activity intolerance Pursed-lip breathing Weight loss: thin, cachectic (nutritional deficits) Posturing: tri-pod / orthopneic Use of accessory muscles Distended neck veins (JVD) → R. sided HF (Cor Pulmonale) Barrel Chest
Which of the following is true regarding the medication Bupropion? a) Bupropion is an antidepressant used to help people quit smoking. b) This medication may cause substantial weight gain. c) Bupropion is contraindicated in those with seizure disorders, anorexia nervosa, and bulimia. d) Patients should be assessed for any signs of suicidality before starting this medication. e) Side effects of this medication include sleep problems (weird dreams), and dry mouth.
All are true, except (b) - Bupropion may limit weight gain associated with smoking cessation.
Oxygen therapy is commonly used in managing the symptoms associated with COPD. Which of the following statements are true regarding oxygen therapy? Select all that apply. a) To qualify for in-home O2 therapy, you must have a "room air", post-ambulation O2 sat < 88%. b) Patients should not use O2 therapy for more than 15 hours a day because they will become dependent on it. c) O2 therapy has been shown to improve survival and control/prevent dyspnea. d) O2 therapy can be used intermittently for those who de-sat during exercise or sleep.
All are true, except (b) - for maximum benefits, oxygen therapy should be used at least 15 hrs./day.
Which of the following signs and symptoms would only be seen in patients with advanced COPD? Select all that apply. a) Weight loss → thin, emaciated appearance b) Irregular breathing patterns c) Distended neck veins (JVD) d) Clubbed fingernails e) Pale/cyanotic nail beds
All options, except (b), would indicate advanced COPD. Irregular breathing patterns can manifest early on in the development of lung diseases.
These medications, also known as cough suppressants, are used as pharmacotherapy to provide COPD symptom relief.
Antitussive agents
This surgical intervention for people with COPD involves the excision of non-functioning, enlarged air spaces. It helps to decrease dyspnea and improve lung function.
Bullectomy
This medication, used to help patients quit smoking, reduces the intensity of nicotine cravings, and signs/symptoms of withdrawal. It may also limit weight gain associated with smoking cessation.
Bupropion (antidepressant)
Varenicline
Chantix
This medication, used to help patients quit smoking, targets nicotine receptors in the brain, attaching to them and preventing nicotine from reaching them. It helps to alleviate nicotine cravings, reduces the signs and symptoms of nicotine withdrawal, and limits the sense of pleasure normally felt when smoking.
Chantix (Varenicline)
This respiratory disease is characterized by airway inflammation leading to the hypersecretion of mucous. This inflammation results in increased Goblet cell formation & mucous-secreting glands, which create mucous plugs (→ loss of cilia protection). Because of this build-up of mucous, the bronchial airways become thickened, narrowed, and irritated, which causes even more mucous to be secreted. With disease progression, alveolar macrophage function decreases and ultimately increases a patient's susceptibility to respiratory infections.
Chronic Bronchitis
In Emphysema, as the alveolar walls continue to break down, there is a decrease in pulmonary capillary bed perfusion, so the body signals more blood flow to the area. Because of this, there is an increase in pulmonary arterial pressure (pulmonary hypertension) that backs up into the RV, causing right ventricular hypertrophy and right-sided heart failure, also known as:
Cor Pulmonale
What is the classic symptom of Emphysema?
Dyspnea
Disease diagnoses under the COPD umbrella
Emphysema Chronic bronchitis
True or False: Pulse Oximetry measures O2 & CO2 concentration and is the most accurate measure of respiratory status in patients with COPD.
False - A pulse oximeter measures your oxygen saturation level (determines the % of hemoglobin in the blood that is saturated with oxygen). - It does NOT give any information about the concentration of CO2 in the blood, which is the major issue in COPD (elevated CO2 → hypercapnia) - ABG's are the most accurate assessment of respiratory status
True or False: COPD/COLD are slow progressing diseases of the lungs that can be treated, but not prevented.
False - these diseases are preventable
FEV1
Forced Expiratory Volume - The volume of air that a patient can forcibly exhale in 1 second - Decreased FEV1 may indicate COPD
FVC
Forced Vital Capacity - The maximum volume of air that can be forcibly exhaled from the point of maximum inhalation - Decreased FVC may indicate COPD
What is the treatment for Alpha-1-antitrypsin deficiency?
Genetic counseling Infusion of specific alpha-1 protease inhibitor replacement therapy
Side Effects of Chantix (Varenicline)
Hostility Agitation Depression Sleep problems (vivid dreams) Suicidal thoughts
Emphysema
Hyperinflation of air sacs with destruction of alveolar walls
Pathophysiology of Chronic Bronchitis
Hyperplasia of mucous-secreting glands & Goblet cells Formation of mucous plugs Disappearance of cilia Chronic inflammation, narrowing, and scaring of bronchial airways Altered function of alveolar macrophages Increased susceptibility to respiratory infection
What is the goal of exercise therapy and re-conditioning?
Improving respiratory status by strengthening the condition of the lungs through exercise Increasing activity tolerance
This surgical intervention for patients with COPD involves removing the diseased portion of the lung(s), which decreases dyspnea and improves lung function by allowing the functional tissue to expand.
Lung volume (reduction) surgery
These medications are used as pharmacotherapy to provide COPD symptom relief. They decrease viscosity & promote expectoration of airway secretions.
Mucolytics
What pharmacological strategies can be implemented to help people quit smoking?
Nicotine Replacement Bupropion Varenicline (Chantix)
In Emphysema, infection or injury to the lung parenchyma causes the release of inflammatory mediators that attract neutrophils, which release the enzyme elastase. This leads to a destruction of the alveolar walls, causing the air sacs to become overdistended and increase in surface area, which leads to a great amount of dead space. Because there is no gas exchange in areas of dead space, this results in decreased _____ diffusion and _____ elimination.
O2 → hypoxemia CO2 → hypercapnia (respiratory acidosis)
PaCO2
Partial pressure of carbon dioxide in the blood 35-45 mm Hg Elevated → Hypercapnia (seen in COPD)
Pneumovax
Pneumococcal vaccine - protects against serious infections caused by the bacteria Streptococcus pneumoniae.
What potential ("collaborative") problems are patients with COPD at greater risk for?
Pneumothorax: large bullae can rupture either spontaneously or after severe coughing Pulmonary HTN: secondary to chronic hypoxemia, which leads to pulmonary artery constriction (prevent this with adequate oxygenation) Cor Pulmonale: R. sided heart failure Acute Respiratory failure (ARF): can occur with infection; may need temporary ventilator support
Lung parenchyma
Portion of the lung involved in gas exchange—the alveoli, alveolar ducts and respiratory bronchioles.
Describe the role of the PPMP model in nursing management of patients with COPD.
Predict: early symptom recognition Prevent: disease progression and complications Manage: w/ medications, surgery, oxygen, diet, & exercise Promote: risk reduction and health promotion
What are the four characteristics (in order) of COPD/COLD?
Progressive airflow restriction (not completely reversible*) Obstruction Inflammation Destruction
How do bronchodilators (beta-2 agonists), anticholinergics, and methylxanthines provide symptom relief in those with COPD?
Relieve bronchospasms Reduce airway obstruction → increased O2 distribution and alveolar ventilation
Scavenger cells
Remove foreign objects & mutagens from the lungs
What potential complications are associated with COPD?
Respiratory insufficiency or failure Atelectasis Respiratory infections (i.e. Pneumonia) Cor Pulmonale Pneumothorax Pulmonary HTN
Cor Pulmonale
Right-sided ventricular hypertrophy & heart failure
What diagnostic tests are used to determine if a patient has COPD?
Spirometry: decreased FEV1/FVC Pulse Oximetry ABG's (Arterial Blood Gases) CXR (Chest X-ray) Genetic testing
Why do patients with emphysema sit in a "tripod" position?
They are leaning forward in an attempt to expand their lungs and bring the lung tissue closer to their rib cage/chest wall
True or False: Healthy people should receive the Pneumococcal vaccine once before the age of 65; those with COPD, Asthma, or a history of tobacco use should repeat the vaccine once again after the age of 65.
True
True or False: People should receive an annual influenza immunization to protect themselves from respiratory illnesses.
True
True or False: COPD-related mortality is higher in women than it is in men.
True - Since 2005, more women died from COPD than men.
In Emphysema, the alveoli are over-_____ and under-______.
distended, perfused
COLD
chronic obstructive lung disease
COPD
chronic obstructive pulmonary disease
If a patient has COPD, what will their chest x-ray show? What would these findings suggest?
hyper-inflated lungs & barrel structure of rib cage hyperinflation of the alveoli and a flattened diaphragm (advanced disease)
Patients with COPD have ________ VD (Dead Space ventilation), ________ AV (Alveolar ventilation), and ________ PaCO2 (CO2 in the blood).
increased, decreased, increased
When creating a therapeutic plan of care, the nursing (and patient) goals should be realistic, objective, and ________.
measurable
What does an ABG (arterial blood gas analysis) measure?
pH - blood acidity PaO2 - partial pressure of oxygen in the blood PaCO2 - partial pressure of carbon dioxide in the blood HCO3 - bicarbonate level SaO2 - oxygen saturation
Progressive airflow limitation → inflammatory response of the ________ lung tissue → inflammatory response of the ________ airways.
proximal i.e. lung parenchyma distal (peripheral) i.e. pulmonary vasculature
Patients with COPD survive in ________ ________.
respiratory acidosis (inc. CO2)
What lung structures come after the terminal bronchioles?
respiratory bronchioles + alveoli
How does environmental temperature and altitude affect those with lung diseases?
↑ temp = ↑ O2 requirements Cold weather promotes bronchospasm High altitude aggravates hypoxemia
