Exemplar Chronic Obstructive Pulmonary Disease

Diagnostic Tests:

1. Pulmonary Function Testing [Performed to establish the diagnosis and extent of COPD. Results based on calculated norms for each person by age, height, sex, and weight. COPD clients will have increased total lung capacity and residual volume. FEV1 and FVC are decreased]. 2. Ventilation Perfusion Scanning [determines the extent to which lung tissue is ventilated but not perfused, or perfused but not inadequately ventilated] 3. Serum a1- Antitrypsin levels [Drawn to screen deficiency, normal ranges from 80-260 mg/dL]

Assessment

*Health History [current symptoms, cough, sputum, SOB, dyspnea; frequency of respiratory infections; previous diagnosis of emphysema, bronchitis, asthma; current meds; smoking history; exposure to second hand smoke or other irritants]. *Physical Exam [general appearance, weight, height, mental status; VS; skin color and temperature; chest diameter; use of accessory muscles; nasal flaring; pursed lip breathing; respiratory excursion; percussion tone; breath sounds; neck veins; apical pulse and heart sounds; peripheral pulses; edema]. *If Pt has barrel chest listen to heart sounds at the xiphoid process lowest part of chest to hear heart. *Inspect chest and palpates for symmetry

Safety Alert!

*Hypercapnia (elevated PaCO2) often is chronic in clients with COPD. In these clients, administering O2 can actually increase the PaCO2, leading to somnolence and acute respiratory failure. Close monitoring of O2 administration is necessary!

Planning

*Requires careful planning to meet clients oxygen demands! -client will adapt breathing patterns to meet oxygenation demands adequately. -client will experience ease of respirations with the use of positioning and pursed lip breathing. -client will maintain a patent airway, allowing adequate oxygenation. -client will maintain oxygen saturation levels above 90%. -client will tolerate activity levels, allowing completion of ADLs.

Emphysema

*manifestations (air trapping, possible wheezing, dyspnea, barrel chest, pursed lip breathing, posturing). *therapies (oxygen administration as needed, pursed lip breathing, teach posture changes, low flow oxygen, monitor ABG and O2, mechanical ventilation may be needed, nutritional assessment and increase calories).

Cardia Dysfunction

*manifestations (chest pain, poor perfusion, arrhythmias, hypertension, cardiac hypertrophy, congestive heart failure). *therapies (meds: positive inotropics, calcium blockers, antiarrhythmic meds, diuretics, nitrites, antihypertensives; monitor exercise tolerance, holter monitoring, antiembolism stockings to improve venous return, fluid restrictions).

Bronchitis

*manifestations (chronic cough with mucous, dyspnea, tachycardia, narrowed airway passages, wheezing, air trapping) *therapies (stop smoking, bronchodilators, corticosteriods, fluids to thin secretions, elevate head of bed, low flow oxygen, monitor ABGs and O2, mechanical ventilation may be needed).

Promote Activity

-Assess at each interaction how client is meeting ADLs -Discuss importance of spacing periods of activities with periods of rest. -Design with physician, physical therapist, and client an exercise plan that meets clients current level of performance but helps builds their stamina.

Promote Family Coping

-Assess interactions between clients and family. -Assess the effect of the illness on the family. -Provide info and teaching about COPD. -Help family members recognize behaviors and attitudes that may hinder effective treatment. -Initiate a care conference involving the client, family, and healthcare team members from a variety of disciplines. -Refer the client and family to support groups. -Refer to community agencies or services such as home health.

Promote Balanced Nutrition

-Assess nutritional status including diet history, appropriate weight and height, and skin fold measurements. -Observe and document food intake, including types, amounts, and calorie intake. -Monitor lab values including serum albumin and electrolyte levels. -Consult with dietician to plan meals and nutritional supplements. -Provide frequent small meals help reduce fatigue while eating. -Place client in high fowlers position to expand lung function. -Assist client with choosing preferred foods from the menu. -Keep snacks at the bedside. -Provide mouth care before meals. -If can't maintain oral intake consult with a doctor.

Encourage Smoking Cessation

-Assess the clients knowledge and understanding of the choices involved and the possible consequences of each. Decision to quit is the clients they need to know consequences of continuing or quiting. -Acknowledge concerns, values, and beliefs; listen without judgement. -Spend time with client, encourage expression of feelings. -Help plan a course of action for quitting smoking and adapt. -Demonstrate respect for decisions and the right to choose. -Provide referral to a counselor or groups.

cont..

-Assist with coughing and deep breathing at least every 2 hours. -Provide tissues and paper bag to get rid of expectorated sputum. -Refer to respiratory therapist, and assist with percussion and postural drainage as needed. -Administer expectorant and bronchodilator meds as ordered. Correlate timing with respiratory treatments. -Provide supplemental oxygen as needed. *Promptly report changes in oxygen saturation, skin color, or mental status. A drop in O2, altered LOC, increasing cyanosis indicate hypoxemia and possibly related to obstruction. Provide suctioning to stimulate cough or help clear secretions!

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-Asthma often exists in clients with COPD. People who have moderate to severe asthma can lead to COPD as a result of airway remodeling.

Etiology

-COPD leading cause of death, illness, and disability in the US. -Smoking greatest risk factor -Occupational irritants and air pollution -Use of wood, coal, or animal dung for cooking fires in close quarters.

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-Cardiac dysfunction from prolonged gas exchange, chest pain and hypertension may be the earliest symptoms. Eventually congestive heart failure will result. These clients should be seen every 6 months to make sure treatment is working. -Caloric demand increases as the effort to breath increases, tachypnea makes eating more difficult, can result in weight loss and possibly anemia in later stages of COPD. -Anxiety increases with dyspnea. -Interrupts quality of life!

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-Chronic bronchitis (excessive bronchial mucous secretion), characterized by a productive cough lasting 3 or more months in 2 consecutive years. Causes it smoking & inhaled irritants. Leads to inflammatory process with vasodilation, congestion, and edema of bronchial mucosa glands enlarge and thick tenacious mucous is produced in increased amounts. Changes in cells impair the ability to clear the mucous. Narrowed airways and secretions block airflow; expiration affected first then inspiration. Ciliary function is impaired making it hard to clear the mucous and clear inhaled pathogens. Recurrent infection is common.

Clinical Manifestations

-Clinical presentation varies -Forced expiratory volume in 1 second (FEV1) is the amount of air that can be exhaled in 1 second as measured by a spirometer. Clients FEV1 reading along with symptoms determines the clients level of COPD severity. Pg. 1008 stages! -absent or minor early in the disease -initial symptoms are chronic cough and sputum production -no SOB in early stages -when client finally seeks help chronic productive cough, dyspnea, exercise intolerance often present for 10 years. -cough normally in the mornings

Percussion, Vibration, and Postural Drainage (PVD)

-Dependent nursing functions performed according to a doctors orders. -Percussion (clapping, is forceful striking of the skin with cupped hands, doing this over the lung areas can dislodge secretions from the bronchial walls, cupped hands trap the air against the chest and trapped air sets up vibrations through the chest walls to the secretions, produce a hollow popping sound). -Vibration (series of vigorous quiverings produced by the hands that are placed flat against the clients chest wall, used after percussion to increase the turbulence of the exhaled air and loosen secretions).

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-Emphysema characterized by destruction of the walls of the alveoli, with enlargement of air spaces. Inflammatory cells that collect in distal airway tissues appear to lead to destruction of the walls and alveoli. This destruction causes alveoli and air spaces to enlarge, with loss of pulmonary capillary bed. Affecting gas exchange. Caused by smoking.

Enhance Breathing Patterns

-Monitor VS and lab results. -Assist with ADL's as needed. -Provide periods of rest between scheduled activities and treatments. -Teach and assist with techniques to control breathing patterns pursed lip breathing, abdominal breathing, relaxation techniques. -Administer meds as ordered. *Prepare for intubation and mechanical ventilation if respiratory status deteriorates. Respiratory failure is a possible complication of an acute exacerbation of COPD and requires immediate intervention to preserve life.

PVD..

-Postural Drainage (drainage by gravity of secretions from various lung segments, secretions that stay in lungs allow bacterial growth or cause atelectasis, there are a wide variety of positions to drain the lungs; before drainage client may be given a bronchodilator or nebulizer to loosen secretions; these drainages are scheduled 2-3 times a day the best times include before breakfast, lunch, and late afternoon you don't want to do it after eating because can induce vomiting; assess the patients tolerance of postural drainage by looking at VS, make appropriate adjustments if client isn't tolerating well). *Sequence goes as: positioning, percussion, vibrations, and removal of secretions by coughing or suctioning. Each position assumed for 10-15 minutes. After the treatment listen to lungs and compare with baseline data and document the amount, color, and character of secretions.

Exercise

-Regular exercise program beneficial for improving tolerance, enhancing ADL's, preventing deterioration of condition. -Increasing regular aerobic exercise at least three times a week -Activities strengthen breathing muscles like swimming and golf. -Breathing exercises -Pursed lip breathing -Abdominal breathing

Pathophysiology

-Repeated exposure to respiratory irritants that damage overtime -Damage causes increased mucous production causing arrest in cilia. -Alot of fluid accumulates causing edema. -Edema narrows the airway passages resulting in air trapping (decreased airflow with exhalation) & hyperinflation of lungs. -This leads to bronchitis (inflammation of the mucous membranes of the bronchial tubes).

Home Care For Secretions:

-adequate fluid intake 2-2.5 quarts -avoid respiratory irritants -prevent exposure to infections -pneumonia and flu immunizations -prescribed exercise program -maintain ADL's -balance rest and exercise -maintain nutrient intake -reduce sodium intake -identify early signs of infection -teach about prescribed meds -avoid use of over the counter drugs -teach about oxygen, percussion, postural drainage, nebulizers -describe use, maintenance, cleaning of any equipment -wear id band and carry list of meds always -referral to home health services

Promote Airway Clearance

-assess respiratory status every 1-2 hours; rate and pattern; cough and secretions (color, amount, consistency, odor); and breath sounds. -monitor ABG results, increasing hypoxemia, hypercapnia, and respiratory acidosis can indicate obstruction. -weigh daily; I&O's; and assess mucous membranes and skin turgor. -Encourage fluid intake 2,000-2,500 mL/day -Place in fowlers, high fowlers, orthopneic position; encourage movement.

Complementary & Alternative Therapy

-dietary measures minimizing dairy and salt products help reduce mucous production -hot herbal teas with peppermint to help relieve congestion -acupuncture, hypnotherapy, guided imagery to help quit smoking..

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-dyspnea occurs only on extreme exertion as disease progresses dyspnea becomes more severe and accompanies mild activity. -manifestations of chronic bronchitis and emphysema begin to show. -chronic bronchitis (cough that produces copious amounts of thick sputum, cyanosis, evidence of right sided heart failure, distended neck veins, edema, liver engorged, enlarged heart, loud rhonci or wheezes). -Emphysema (dyspnea first symptom, can be mild at first then occur even at rest, cough minimal or absent, air trapping and hyperinflation increase the chest diameter leading to barrel chest, client thin, tachypneic, use accessory muslces, tripod position which hands on knees leaning forward, breath sounds diminished, client may use pursed lips they prolong expiration to try to get all air out).

Pharmacologic Therapy

-immunizations against pneumonia and influenza -antibiotics if infection suspected -bronchodilators improve airflow and reduce air trapping -corticosteriod -statins may result in significant improvement for the client with COPD.

Diagnosis

-ineffective breathing pattern -ineffective airway clearance -activity intolerance -imbalanced nutrition -compromised family coping -decisional conflict: smoking

Surgery

-lung transplantation both single or bilateral! -lung reduction surgery is an experimental surgical intervention for advanced emphysema and lung hyperinflation.

Hydration

-maintains moisture of mucous membranes if not hydrated secretions can become thick -humidifiers add water vapor to add cool mist to room air helps membranes from drying or becoming irritated -nebulizers give humidity along with meds.

Collaboration

-phsyical therapist, nutritionist, pharmacists, family members, counselors -always be aware of who is taking care of the COPD patient at home!

Risk Factors

-smoking -exposure to smoke -long term exposure to chemical irritants in workplace or a hobby -clients with asthma -short term exposure to high levels of highly irritating substances can result in impairment of lung function

Other Interventions:

-smoking cessation -nictone patches -avoid irritants and allergens -air filtering systems or AC may be useful -pulmonary hygiene measures (hydration, effective coughing, percussion, postural drainage).

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4. Arterial Blood Gas [used to evaluate gas exchange, clients with emphysema have mild hypoxemia and normal low carbon dioxide tension and respiratory alkalosis may be present, chronic bronchitis may have marked hypoxemia and hypercapnia with respiratory acidosis] 5. Pulse Oximetry [monitors oxygen saturation of blood, obstruction and hypoxemia causes saturation levels to be below 95%]. 6. Exhaled Carbon Dioxide [ETCO2 measured to evaluate alveolar ventilation, normal reading is 35-45 mmhg elevated when ventilation is inadequate]

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7. CBC w/ WBC Differential [shows increase RBC and hematocrit as chronic hypoxia stimulates increased erythropoesis to improve oxygen carrying capacity of blood] 8. Chest X-Ray [show white patches indicative of the hyper inflated alveolar sacs filled with secretions common in emphysema]

Safety Alert!

Chronic cough and sputum are not normal occurrences. These symptoms beyond 3-4 days should consult with a doctor, if you have smoking history as well as these symptoms you should have PFT's to determine lung function.

Effective Cough Teaching:

Controlled technique: 1. Following bronchodilator treatment inhale deeply and hold breath briefly. 2. Cough twice (first is to loosen mucous and second to expel it). 3. Inhale by sniffing to prevent mucous from moving back into airways. 4. Rest. Don't do to much from preventing fatigue and hypoxemia. Huff coughing: 1. Inhale deeply while leaning forward 2. Exhale sharply with a huff sound!

COPD

Describes a specific progressive disorder that slowly alters the structures of the respiratory system over time, irreversibly affecting lung function. Periodic exacerbations, with increased symptoms of dyspnea and sputum. Only gets worse each exacerbation. Not curable but can be managed with interventions and lifestyle choices.

Prevention

Don't engage in behaviors that have been linked with the etiology of the disease!

Nursing Process

Focused on promoting oxygenation! Want to reduce the risk of infection and maintain clients safety. Also want to teach the client how to maximize self care while knowing when to notify the health care team.

Culture & Diversity Issue

Hispanic clients with COPD don't receive referral to smoking cessation classes as frequently as clients of other ethnicities. Nurses working with hispanic patients with chronic cough and sputum or diagnosed with COPD should inquire about nicotine and alcohol use and provide client teaching and appropriate referrals in these areas. Materials should be in spanish or get an interpreter.

Oxygen Therapy

Long term O2 therapy is used for severe and progressive hypoxemia. Improves exercise tolerance, mental functioning, and quality of life. Reduces the rate of hospitalization and increases the length of survival. Severe hypoxemia need continuous O2. Close monitoring of LOC and ABG values during O2 therapy is vital.

Evaluation

Observe and record clients breathing and VS, focusing on trends and patterns. Compare from baseline data and what was the goal. -Client consistently maintains oxygen saturation greater than 90%. -Client modifies ADLs to reduce fatigue related to activity intolerance. -Client demonstrates appropriate use of meds.

Overview

Obstructive pulmonary diseases are one that cause obstruction of the airways with bronchoconstriction or inflammation. Three processes normally involved with COPD: -bronchitis (chronic or acute) -emphysema -small airway disease with bronchoconstriction *Although one or the other may dominate, COPD typically includes components of both chronic bronchitis and emphysema. Also small airways disease (narrowing of small bronchiole, resistance to airflow, expiration to be slow or difficult) is apart of COPD. *increases work of breathing, impaired expiration with air trapping, and impaired gas exchange.