ch 30 COPD, CHRONIC BRONCHITIS, EMPHYSEMA, & COR PULMONALE
Cardiac changes occur as a result of the anatomic changes associated with COPD.
Assess the patient's heart rate and rhythm. Check for swelling of the feet and ankles (dependent edema) or other signs of right-sided heart failure. Examine nail beds and oral mucous membranes. In late-stage emphysema the patient may have pallor or cyanosis and is usually underweight.
Reduced breath sounds are common with...
Emphysema
GOLD 3: Severe
FEV1 30% to 49% of predicted
GOLD 2: Moderate
FEV1 50% to 79% of predicted
GOLD 4: Very severe
FEV1 <30% of predicted
GOLD 1: Mild
FEV1 ≥80% of predicted
What causes cardiac dysrhythmias in patients with COPD?
Hypoxemia (from decreased oxygen to the heart muscle) Other cardiac diseases Drug effects Acidosis
The patient with emphysema has...
Limited diaphragmatic movement (excursion) because the diaphragm is flattened and below its usual resting state. Chest vibration (fremitus) is often decreased, and the chest sounds hyperresonant on percussion because of trapped air.
Respiratory changes occur as a result of?
Obstruction, changes in chest size, and fatigue.
The patient with respiratory muscle fatigue breathes with?
Rapid, shallow respirations and may have an abnormal breathing pattern in which the abdominal wall is sucked in during inspiration or may use accessory muscles in the abdomen or neck.
During an acute exacerbation...
Respiratory rate could be as high as 40 to 50 breaths/min and requires immediate medical attention. As respiratory muscles become fatigued, respiratory movement is jerky and appears uncoordinated.
Respiratory infection risk increases because of?
The increased mucus and poor GAS EXCHANGE. Bacterial infections are common and make COPD symptoms worse by increasing inflammation and mucus production and inducing more bronchospasm. Airflow becomes even more limited, the work of breathing increases, and dyspnea results.
What is indicated in the presence of a "barrel chest"?
The ratio between the anteroposterior (AP) diameter of the chest and its lateral diameter is 1 : 1 rather than the normal ratio of 1 : 1.5, as a result of lung overinflation and diaphragm flattening
The priority collaborative problems for patients with chronic obstructive pulmonary disease (COPD) include:
1. Decreased GAS EXCHANGE due to alveolar-capillary membrane changes, reduced airway size, ventilatory muscle fatigue, excessive mucus production, airway obstruction, diaphragm flattening, fatigue, and decreased energy 2. Weight loss due to dyspnea, excessive secretions, anorexia, and fatigue 3. Anxiety due to a change in health status, and situational crisis 4. Decreased endurance due to fatigue, dyspnea, and an imbalance between oxygen supply and demand 5. Potential for pneumonia or other respiratory infections due to presence of thick secretions and the immunosuppressive effects of some drugs
How can you assess the degree of dyspnea?
Using a visual analog dyspnea scale (VADS). It is a straight line with verbal anchors at the beginning and end of a 100-mm line. Ask the patient to place a mark on the line to indicate his or her breathing difficulty. Document and use this scale to determine the therapy effectiveness and pace the patient's activities.
Gold Classification of COPD Severity is an
8-item test requires the patient to rate his or her specific symptoms on a 0 (no symptom) to a 5 (worst symptom) scale. Scores can range from 0 to 40, with lower scores indicating less severe problems.
"D" designation indicates
a high risk for exacerbation (and need for hospitalization)
Suctioning. Nasotracheal suction is used only for patients with
a weak cough, weak pulmonary muscles, and inability to expectorate effectively. Assess for dyspnea, tachycardia, and dysrhythmias during the procedure. Assess for improved breath sounds after suctioning.
a. The two major changes that occur with emphysema are... b.These changes result in...
a. loss of lung elasticity and hyperinflation of the lung b.dyspnea, reduced GAS EXCHANGE, and the need for an increased respiratory rate.
a. Hypoxemia and acidosis occur because ... b.These problems...
a. the patient with COPD has reduced gas exchange, leading to decreased oxygenation and increased carbon dioxide levels. b. reduce cellular function.
Chronic obstructive pulmonary diseases (COPD) interfere with
airflow and GAS EXCHANGE.
Nursing management for patients with COPD focuses on
airway maintenance, monitoring, breathing techniques, positioning, effective coughing, oxygen therapy, exercise conditioning, suctioning, hydration, and use of a vibratory positive-pressure device. A nursing priority is to teach the patient how to be a partner in COPD management by participating in therapies to improve GAS EXCHANGE and by adhering to prescribed drug therapy.
The patient with chronic bronchitis often has a
cyanotic, or blue-tinged, dusky appearance and has excessive sputum production. Assess for cyanosis, delayed capillary refill, and finger clubbing, which indicate chronically decreased arterial oxygen levels and poor GAS EXCHANGE.
Complications of COPD include
hypoxemia acidosis respiratory infection cardiac failure dysrhythmias respiratory failure.
Wheezes and other abnormal sounds often occur on...
inspiration and expiration
"A" designation indicates
low risk for exacerbation
Emphysema is classified as
panlobular, centrilobular, or paraseptal
A silent chest may indicate...
serious airflow obstruction or pneumothorax.
In diaphragmatic breathing,
the patient consciously increases movement of the diaphragm.
Peak expiratory flow meters are
used to monitor the effectiveness of drug therapy to relieve obstruction. Peak flow rates increase as obstruction resolves.
Evaluation: Reflecting Evaluate the care of the patient with COPD based on the identified priority patient problems. The expected outcomes of care are that the patient will:
• Attain and maintain GAS EXCHANGE at a level within his or her chronic baseline values • Achieve an effective breathing pattern that decreases the work of breathing • Maintain a patent airway • Achieve and maintain a body weight within 10% of his or her ideal weight • Have decreased anxiety • Increase activity to a level acceptable to him or her • Avoid serious respiratory infections
Pursed-Lip Breathing
• Close your mouth and breathe in through your nose. • Purse your lips as you would to whistle. Breathe out slowly through your mouth, without puffing your cheeks. Spend at least twice the amount of time it took you to breathe in. • Use your abdominal muscles to squeeze out every bit of air you can. • Remember to use pursed-lip breathing during any physical activity. -Always inhale before beginning the activity and exhale while performing it. Never hold your breath.
Key Features Cor Pulmonale
• Hypoxia and hypoxemia • Increasing dyspnea • Fatigue • Enlarged and tender liver • Warm, cyanotic hands & feet, w bounding pulses • Cyanotic lips • Distended neck veins • Right ventricular enlargement (hypertrophy) • Visible pulsations below the sternum • GI disturbances such as nausea or anorexia • Dependent edema • Metabolic and respiratory acidosis • Pulmonary hypertension
Diaphragmatic or Abdominal Breathing
• Lie on your back with your knees bent. If you cannot lie comfortably, perform this exercise while sitting in a chair. • Place your hands or a book on your abdomen to create resistance. • Begin breathing from your abdomen while keeping your chest still. -You can tell if you are breathing correctly if your hands or the book rises and falls accordingly.
The patient with COPD is expected to attain and maintain GAS EXCHANGE at his or her usual baseline level. Indicators include that the patient:
• Maintains SpO2 of at least 88% • Remains free from cyanosis • Maintains cognitive orientation • Coughs and clears secretions effectively • Maintains a respiratory rate and rhythm appropriate to his or her activity level
Causes of air trapping are
-loss of elastic recoil in the alveolar walls -overstretching and enlargement of the alveoli into air-filled spaces called bullae -and collapse of small bronchioles.