NSG 170 - Oxygenation - COPD

capnography

A noninvasive method to quickly and efficiently provide information on a patient's ventilatory status, circulation, and metabolism; effectively measures the concentration of carbon dioxide in expired air over time.

lung parenchyma

portion of the lung involved in gas transfer—the alveoli, alveolar ducts and respiratory bronchioles

Anxiety

Anxiety related to increasing periods of dyspnea occurs with exacerbations in moderate and severe COPD. Severe COPD can result in impairment of other body systems because of insufficient airflow, further restricting quality of life.

Holter monitoring

an ECG device is worn during a 24-hour period to detect cardiac arrhythmias

cardiac hypertrophy

enlargement of the heart by increases in muscle wall thickness or chamber size or both

Air trapping

incomplete emptying of alveoli during expiration due to loss of lung tissue elasticity (emphysema), bronchospasm (asthma), or airway obstruction

COPD etiology

Among the leading causes of death, disability, and illness in the United States. In most cases, the individual with COPD is over age 50, is a current or former smoker, and has a 20 pack-per-year smoking history. Aging COPD pt. experiences worsening lung function Mortality rates are nearly equal for women and men, though rates for women have significantly increased since 1970. COPD is not curable, the symptoms of the disease can be managed. Cigarette smoking accounts for approximately 80% of cases. Other causes that have contributory effects of COPD on the lungs include exposures to occupational respiratory irritants and air pollution (both indoors and outdoors) in industrialized nations. The use of wood, coal, or animal dung for cooking fires in close quarters in less-developed nations increases the risk of COPD in women from those countries. Among individuals with COPD, approximately 1% of cases are linked to a deficiency of alpha-1 antitrypsin (AAt), which is an inherited genetic abnormality Referred to as genetic COPD (Alpha-1 Foundation, n.d.), this disorder is caused by a deficiency of the protein AAt, which is produced by the liver. AAt is necessary for normal lung development and function; therefore, lack of this protein causes pulmonary complications. Because lung damage from smoking is the most common cause of COPD, the majority of individuals with COPD develop the condition during adulthood. In many cases, individuals with COPD first become symptomatic between 35 and 40 years of age However, AAt deficiency can cause liver impairment among adults, children, and infants that leads to COPD even when a long history of smoking is not present

Anna Mercurio, known as "Happy" to all her friends, is an 83-year-old widow who lives with her two adult sons. During the past 15 years, Mrs. Mercurio has become increasingly short of breath while gardening and walking, two of her favorite activities. She also has developed a chronic cough that is particularly bad in the mornings. Ten years ago, her family physician told her that she had emphysema. She is admitted to the hospital with possible pneumonia and acute exacerbation of COPD. ADPIE

Assessment: Mrs. Mercurio reports exposure to her husband's and sons' tobacco smoke, which increases her risk for pulmonary infection. Her recent hospital admission was due to pulmonary infection. Diagnosis: Risk for Infection related to secondhand smoke exposure. Planning: The patient will correctly state the relationship between secondhand smoke exposure and risk for pulmonary infection. The patient will identify two strategies for avoiding secondhand exposure to her husband's and sons' tobacco smoke. In 1 week, the patient will report that she has not been exposed to secondhand tobacco smoke. Implementation: Although Mrs. Mercurio's sons have agreed to smoke only in the garage or outside the home, her husband is not described as having made any such promises. In any event, to account for Mrs. Mercurio's inability to control the behavior of her family members, nursing interventions should address what she is able to accomplish by her own power. (Note: Additional nursing diagnoses should be formulated to include the patient's husband and sons in the plan of care.) The nurse's teaching should include describing the relationship between secondhand smoke exposure and the risk for pulmonary infection. Throughout the teaching, the nurse should encourage Mrs. Mercurio to ask questions. Mrs. Mercurio should also be encouraged to identify strategies for avoiding secondhand smoke exposure; for example, she could ask her husband and sons not to smoke inside her home, and she could facilitate the creation of a comfortable "smoking area" inside her garage. Evaluation: The nurse should review each patient outcome identified during the planning phase. Evaluation of Mrs. Mercurio's exposure to secondhand smoke after 1 week will require a telephone call or collaboration with the home-care nurse to evaluate this outcome. If any outcome is not fully achieved, the nurse should review and revise the nursing plan of care to address the unmet patient outcomes. Next, the nurse should implement nursing interventions related to the new or revised patient outcomes.

Why is it important for the nurse to assess the patient with COPD for risk for injury related to the use of oxygen?

Because oxygen supports combustion, no one should smoke in a room where supplemental oxygen is used.

Breathing requires calories

Caloric demand increases as the effort to breathe increases. Tachypnea makes eating more difficult. Increased caloric demand with decreased caloric intake often occurs in the latter stages of COPD, often resulting in weight loss and possibly anemia.

Home Care Assessment: Oxygenation Family

Caregiver availability, skills, and responses. Ability and willingness to provide care as needed (help with ADLs, providing meals, assisting with transportation and shopping, caring for dependents, and performing treatments, such as percussion and postural drainage) Family role changes and coping. Effect on financial status, parenting and spousal roles, sexuality, and social roles Alternate potential primary or respite caregivers. Other family members, volunteers, church members, paid caregivers or housekeeping services, and available community respite care

Promote Airway Clearance

Chronic bronchitis & emphysema affect the ability to maintain open airways. In chronic bronchitis, copious amounts of thick, tenacious mucus impair ciliary action, making it difficult to clear mucus from the airways. The loss of supporting tissue caused by emphysema increases the risk for airway collapse. In both cases, air is trapped distally, and less oxygen is available to the alveoli for diffusion. Normal respiratory defense mechanisms are impaired, and mucus-plugged airways provide an ideal environment for bacterial growth. Respiratory infection further impairs airway clearance and is often the cause of an acute exacerbation. Encourage a fluid intake of at least 2000-2500 mL/day unless contraindicated to help keep mucus thin. Place in Fowler, high-Fowler, or orthopneic position; encourage movement and activity to tolerance. Assess respiratory status every 1-2 hours or as indicated. Adventitious sounds should decrease with effective intervention. Diminished or absent breath sounds may indicate increasing airway obstruction and possible atelectasis. Monitor ABG results. Increasing hypoxemia, hypercapnia, and respiratory acidosis may indicate increasing airway obstruction. Weigh daily, monitor intake and output, and assess mucous membranes and skin turgor. Dehydration causes respiratory secretions to become thicker, more tenacious, and difficult to expectorate (expel or spit out); fluid overload can further compromise respiratory status. Assist with coughing and deep breathing at least every 2 hours while the patient is awake (see the Patient Teaching feature). Provide tissues and a paper bag to dispose of expectorated sputum. This important infection control measure reduces the spread of respiratory organisms to other people. Refer to a respiratory therapist, and assist with or perform percussion and postural drainage as needed. Percussion helps loosen secretions in airways; postural drainage facilitates movement of these secretions out of the respiratory tract. Administer expectorant and bronchodilator medications as ordered. Coordinate timing with respiratory treatments. Using expectorants and bronchodilators before coughing, percussion, and postural drainage increases their effectiveness in clearing airways. Provide supplemental oxygen as ordered. Supplemental oxygen helps maintain adequate blood and tissue oxygenation.

Safety Consideration

Chronic cough and sputum are not normal occurrences. An individual experiencing chronic cough and sputum beyond 3-4 days should consult with a healthcare professional. Individuals with a smoking history as well as chronic cough and sputum production should have PFTs to determine lung function.

Promote Family Coping

Chronic illness affects the entire family structure. Roles and relationships change; additional demands are placed on the family. Family members may blame the patient for causing the illness or may have distorted perceptions about it, even denying its existence. They may refuse to assist or participate in care. The patient may develop an attitude of helplessness or dependence or may demonstrate anger, hostility, or aggression. Assess the effect of the illness on the family to assist in planning appropriate interventions. Provide information and teaching about COPD to help the family gain an understanding of the patient's condition and needs. Help family members recognize behaviors and attitudes that may hinder effective treatment, such as continuing to smoke in the house. Initiate a care conference involving the patient, family, and healthcare team members from a variety of disciplines. A wide range of perspectives and areas of expertise aids in problem solving and facilitates communication. Refer the patient and family to support groups and pulmonary rehabilitation programs as available.

Emphysema

Clinical Manifestations: Air trapping Possible wheezing Dyspnea Barrel chest Pursed-lip breathing Posturing Clinical Therapies: Oxygen administration as needed Pursed-lip breathing technique Patient education of posture changes to improve ventilation Low-flow oxygen Monitoring of ABGs and oxygen Mechanical ventilation if patient cannot meet oxygen demands Nutritional assessment and increased calorie intake

Cardiac dysfunction

Clinical Manifestations: Chest pain Poor perfusion Arrhythmias, particularly premature ventricular contractions Hypertension Cardiac hypertrophy Congestive heart failure Clinical Therapies: Medications: Positive inotropics Calcium blockers Antiarrhythmic medications Diuretics Nitrites Antihypertensives Monitoring of exercise tolerance Holter monitoring Antiembolism stockings to improve venous return Fluid restrictions if cardiac dysfunction not medically managed

Bronchitis

Clinical Manifestations: Chronic cough with mucus production Dyspnea Tachycardia Narrowed airway passages Wheezing Air trapping Clinical Therapies: Smoking cessation Bronchodilators Corticosteroids Fluids to thin secretions Elevating the head of the bed Low-flow oxygen Monitoring of ABGs and oxygen Mechanical ventilation if patient cannot meet oxygen demands

Why is it important for the patient with COPD to drink sufficient fluids?

Dehydration can cause respiratory secretions to become thicker, more tenacious, and difficult to expectorate. Adequate hydration is essential to help thin and expectorate secretions, as well as to ensure overall fluid volume balance.

Home Care Assessment: Oxygenation Community

Environment. Usual temperature and humidity; presence of air pollutants, such as automobile exhaust, industrial smoke and pollutants, and smoke from field burning Current knowledge of and experience with community resources. Medical and assistive equipment and supply companies, respiratory and physical therapy services, home health agencies, local pharmacies, available financial assistance, and support and educational organizations, such as the local lung association and COPD support groups.

COPD - Nursing Process

Focused on promoting oxygenation. Health promotion activities include smoking cessation, reducing the risk of infection, and maintaining patient safety. d/t chronic nature of this disease process, teaching the patient how to maximize self-care while knowing when to notify the healthcare team is another important role of the nurse.

Patient Teaching - Effective Coughing Techniques

For controlled cough technique, teach the patient as follows: Following prescribed bronchodilator treatment, inhale deeply and hold breath briefly. Cough twice, the first time to loosen mucus and the second to expel secretions. Inhale by sniffing to prevent mucus from moving back into deep airways. Rest. Avoid prolonged coughing to prevent fatigue and hypoxemia. For huff coughing, teach the patient to: Inhale deeply while leaning forward. Exhale sharply with a "huff" sound to help keep airways open while mobilizing secretions.

Classification of COPD by Severity

GOLD 1: Mild. Usually, but not always, chronic cough and sputum production; mild airflow limitation; FEV1/forced vital capacity (FVC) less than 0.70; FEV1 predicted to be greater than 80% GOLD 2: Moderate. Usually worse symptoms, with shortness of breath typically developing on exertion; FEV1/FVC less than 0.70; FEV1 predicted to be 50-80% GOLD 3: Severe. Worse symptoms, with noticeable shortness of breath; FEV1/FVC less than 0.70; FEV1 predicted to be 30-50% GOLD 4: Very severe. Severe symptoms; FEV1/FVC less than 0.70; FEV1 predicted to be less than 30%

Second hand smoke

In infants, secondhand smoke is believed to impair maturation of the respiratory epithelium. Secondhand smoke is associated with an increased risk for sudden infant death syndrome (SIDS). Secondhand smoke causes children's lungs to develop more slowly, and it increases their risk of developing infections. In all individuals, tobacco smoke increases mucus production and impairs motility of the cilia in the respiratory tract.

Asthma - Planning

Nursing care of the patient with COPD, especially in later stages, requires careful planning in order to meet the patient's oxygenation demands. Possible outcomes for this patient may include the following: The patient will adapt breathing patterns to meet oxygenation demands adequately. The patient will experience ease of respirations with the use of positioning and pursed-lip breathing. The patient will maintain a patent airway, allowing adequate oxygenation. The patient will maintain oxygen saturation levels above 90%. The patient will tolerate activity levels, allowing completion of ADLs.

Assessment COPD pt.

Observation and patient interview: Current symptoms, including: cough sputum production shortness of breath or dyspnea activity tolerance frequency of respiratory infections and most recent episode previous diagnosis of emphysema, chronic bronchitis, or asthma; current medications smoking history in pack-years (packs per day times number of years smoked) history of exposure to secondhand smoke and to occupational or other pollutants Physical examination: General appearance weight for height mental status v/s w/ temperature skin color and temperature anteroposterior:lateral chest diameter use of accessory muscles nasal flaring pursed-lip breathing respiratory excursion and diaphragmatic excursion percussion tone breath sounds throughout neck veins apical pulse and heart sounds peripheral pulses edema Auscultation of the chest may yield very little information to aid in establishing the diagnosis of COPD. Often, lung sounds are distant or reduced, although occasionally wheezes or inspiratory crackles may be heard. These sounds, however, are also associated with other diagnoses. Heart sounds may be difficult to hear if the patient has a barrel chest. Auscultation over the xiphoid process (the lowest portion of the sternum) makes it easier to hear heart tones. Inspect and palpate the chest for symmetry. Increased anteroposterior diameter indicates chronic respiratory effort. Assess the use of accessory muscles during breathing and observe the position of the individual. Upright posturing is an effective aid for ease of breathing. Self-posturing may indicate respiratory distress. An individual with COPD may sit upright with support of an overbed table. B/c COPD is a progressive and deteriorating illness, many patients with COPD reach the point at which they can no longer continue to live successfully at home. The nurse working with the patient with COPD at home may want to use a home care assessment for oxygenation for patients with COPD

Asthma - Evaluation

Observe and record the patient's breathing and vital signs, focusing on trends and patterns. Compare the patient's actual respiration and breathing patterns to the outcome goal established. Some interventions may require time before progress is observed. For example, improving the ease of breathing may occur readily with a change in medications, but quitting smoking may take months or years. Potential outcomes to evaluate the effectiveness of care may include: The patient consistently maintains oxygen saturation greater than 90%. The patient modifies ADLs to reduce fatigue related to activity intolerance. The patient demonstrates appropriate use of medications (e.g., inhalers). Because COPD is a chronic condition, patients with COPD will need continual re-evaluation to ensure that medications are providing relief, the patient is maintaining appropriate activity levels, and the patient is adhering to the treatment plan, including any smoking cessation program. Patients with a history of smoking usually require multiple attempts before they successfully quit smoking for the long term, so the nurse should evaluate the patient's success and provide encouragement to the patient at each interaction.

Asthma - Diagnosis

Patients with COPD have multiple nursing care needs. Because of the obstructive nature of the disease, airway clearance is a high priority. Nutritional deficit is common, particularly when emphysema is predominant. Because this chronic disease affects all functional health patterns, psychosocial issues are also of concern in planning nursing care. NANDA-I diagnoses appropriate for the patient with COPD include the following: Breathing Pattern, Ineffective Airway Clearance, Ineffective Activity Intolerance Imbalanced Nutrition: Less Than Body Requirements Coping: Family, Compromised Decisional Conflict: Smoking.

What therapies could be used to decrease the risk of infection in the patient with COPD?

Percussion, vibration, and postural drainage can be performed to help remove secretions from the lungs and airways.

Collaboration

Physical therapists, nutritionists, pharmacists, family members, and sometimes counselors to help patients achieve outcomes and improve their quality of life

Safety Alert

Prepare for intubation and mechanical ventilation if respiratory status deteriorates (increasing hypoxemia and hypercapnia, decreased LOC, cyanosis, or worsening airway obstruction). Respiratory failure is a possible complication of an acute exacerbation of COPD and requires immediate intervention to preserve life.

Why is the patient with COPD at a greater risk for developing respiratory infections?

Secretions that remain in the lungs or respiratory airways promote bacterial growth and subsequent infection.

Home Care Assessment: Oxygenation Patient

Self-care abilities. Ability to ambulate and perform ADLs independently Exercise and activity pattern. Type and regularity of usual exercise, perceived and actual energy for desired and required leisure activities Assistive devices required. Supplemental oxygen, humidifier, nebulizer treatments, or inhalers; walker, cane, or wheelchair; grab bars, shower chair, and other devices to promote safety and minimize energy expenditure; scale to monitor weight on a regular basis Home environment. Factors that impair airway clearance, gas exchange, or activity tolerance; indoor pollutants, such as cigarette smoke, dust, and allergens (e.g., pets); lack of humidity in the air; barriers, such as stairs Current level of knowledge. Importance of avoiding smoking and other pollutants; dietary salt and other restrictions if appropriate; recommended activities; medications; need to limit exposure to respiratory infections; use of prescribed nebulizer, multidose inhaler, powdered dose inhaler, or home oxygen; activity level.

COPD Risk Factors

Smoking is the greatest risk factor. More an individual smokes, the greater the risk of acquiring the disease. Frequent exposure to smoke also increases an individual's risk for COPD. Long-term exposure to chemical irritants in the workplace or through a hobby also increases risk for COPD. Some evidence indicates that patients with asthma are more likely to develop COPD compared with the general population. Although short-term exposure to respiratory irritants normally does not pose a risk for COPD, short-term exposure to high levels of highly irritating substances can result in impairment of lung function, leading to COPD and other respiratory disorders.

Why might a patient with COPD who is confined to bed choose to drink less, and how can the nurse promote hydration in this patient?

Tachypnea makes eating and drinking more difficult. Altered self-care abilities and inability to get out of bed to get water or go to the bathroom may contribute to decreased water intake. The nurse should make sure there is a supply of fresh water within the patient's reach. Assessment of caregiver availability, skills, and responses should be evaluated.

Asthma - Implementation

The highest priorities of nursing implementation are aimed at promoting oxygenation, which includes monitoring and promoting airway clearance and effective breathing patterns. Ongoing reassessment to determine effectiveness of interventions will help guide the nursing plan of care. For patients in the hospital, the nurse should assist with ADLs as necessary to help the patients conserve energy and reduce fatigue. Regardless of setting, the nurse should teach and assist with techniques to control and improve breathing pattern: pursed-lip breathing, abdominal breathing, and relaxation techniques.

What teaching should the nurse provide to a patient who will be discharged with home oxygen therapy for the first time?

The nurse should teach the patient how to use the device properly, checking the oxygen level in the tank, need for portable devices for trips outside the house, and the need to maintain the lines and keep them free of obstruction.

barrel chest

a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema.

COPD Diagnosis

These procedures also are used to assess respiratory status and monitor treatment effectiveness: PFT to diagnose and evaluate the extent and progression of COPD Ventilation and perfusion scanning to determine the extent of V-Q mismatch (i.e., the extent to which the lung tissue is ventilated but not perfused [dead space] or perfused but inadequately ventilated [physiologic shunting]) Serum α1-antitrypsin levels to assist in determining etiology ABGs to evaluate gas exchange and acid-base balance Pulse oximetry to monitor oxygen saturation of the blood Capnography (ETCO2) to evaluate alveolar ventilation (ETCO2 levels above 45 mmHg indicate inadequate ventilation; levels below 35 mmHg indicate impaired perfusion.) CBC with differential to monitor RBCs and hematocrit and to check for the presence of bacterial infection CXR to monitor the extent of secretions in the alveolar sacs and to assess for the presence of pulmonary infection.

Patient Teaching - Home Care for Patients with COPD

When preparing for home care for a patient with COPD, the nurse must teach both the patient and the patient's family and caregivers the following: Maintain adequate fluid intake (at least 2.0-2.5 quarts of fluid daily). Avoid respiratory irritants, including cigarette smoke (both primary and secondary), other smoke sources, dust, aerosol sprays, air pollution, and very cold, dry air. Prevent exposure to infection, especially upper respiratory infections. Receive a pneumococcal vaccine and annual influenza immunization. Follow the prescribed exercise program, maintain ADLs, and balance rest and exercise. Maintain nutrient intake (e.g., eating small, frequent meals and using nutritional supplements to provide adequate calories). Identify early signs of an infection or exacerbation, and seek medical attention for the following: fever, increased sputum production, purulent (green or yellow) sputum, upper respiratory infection, increased shortness of breath or difficulty breathing, decreased activity tolerance or appetite, and increased need for oxygen. Understand prescribed medications, including purpose, proper use, and expected effects. Avoid use of over-the-counter medications unless approved by the physician. Understand other prescribed therapies, such as use of home oxygen, percussion, postural drainage, and nebulizer treatments. Wear an identification band and carry a list of medications at all times in case of an emergency. The nurse should also provide referrals to home care services, such as home health, assistance with ADLs (as needed), home maintenance services, respiratory therapy and home oxygen services, and other agencies such as Meals on Wheels and senior services as indicated.

Promote Balanced Nutrition

With advanced COPD, minimal activity, including eating, can cause fatigue and dyspnea. The patient may be unable to consume a full meal without resting. At the same time, the increased work of breathing increases metabolic demands, and more calories are required. The patient may appear cachectic (thin and wasted). Poor nutritional status further impairs immune function and increases the risk of a complicating infection. Assess nutritional status, including diet history, appropriate weight for height, and anthropometric (skinfold) measurements. It is important to differentiate nutritional status from body type rather than assume a nutritional impairment. Observe and document food intake, including types, amounts, and caloric intake. This information can provide direction for supplementation if needed. Monitor laboratory values, including serum albumin and electrolyte levels. These values provide information about the adequacy of nutritional intake, including protein. Consult with a dietitian to plan meals and nutritional supplements that meet caloric needs. More concentrated sources of high-energy foods may be required to maintain caloric intake without excess fatigue. A diet high in proteins and fats without excess carbohydrates is recommended to minimize carbon dioxide production during metabolism. Provide frequent, small feedings with between-meal supplements to maintain intake and reduce fatigue associated with eating. Place the patient in a seated or high-Fowler position for meals to promote lung expansion and reduce dyspnea. Assist the patient with choosing preferred foods from the menu; encourage family members to bring food from home if allowed. Keep snacks at the bedside to provide additional caloric intake. Provide mouth care before meals to enhance the appetite. If the patient is unable to maintain oral intake, consult with the primary care provider about enteral or parenteral feedings. Maintenance of caloric and nutrient intake is vital to prevent catabolism.

Emphysema

a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness. Characterized by destruction of the walls of the alveoli, with resulting enlargement of abnormal air spaces Deficiency of α1-antitrypsin, an enzyme that normally inhibits the activity of proteolytic enzymes and tissue destruction in the lungs, contributes to the development of emphysema in some individuals, especially when combined with exposure to cigarette smoke. Inflammatory cells that collect in distal airway tissues appear to lead to destruction of elastic fibers in the respiratory bronchioles and alveolar ducts. Alveolar wall destruction causes alveoli and air spaces to enlarge, with loss of corresponding portions of the pulmonary capillary bed. As a result, the surface area for alveolar-capillary diffusion is reduced, affecting gas exchange. Elastic recoil is lost, reducing the volume of air that is passively expired. The loss of support tissue also affects airways, increasing the risk of expiratory collapse and further air trapping. Either respiratory bronchioles or alveoli may be the primary tissue involved anatomically. As in chronic bronchitis, cigarette smoking is strongly implicated as a causative factor in most cases of emphysema. Asthma often exists as a comorbid disease in the patient with COPD. Patients who have lived with moderate to severe persistent asthma for most of their lives may develop COPD as a result of airway remodeling and damage to alveoli over time

chronic bronchitis

a condition in which the bronchi in the lungs are constantly swollen and clogged with mucus disorder of excessive bronchial mucus secretion It is characterized by a productive cough lasting 3 or more months in 2 consecutive years Cigarette smoke is the major factor implicated in the development of chronic bronchitis. Inhaled irritants lead to a chronic inflammatory process with vasodilation, congestion, and edema of the bronchial mucosa. Goblet cells increase in size and number, and mucous glands enlarge. Thick, tenacious mucus is produced in increased amounts. Changes in bronchial squamous cells impair the ability to clear mucus Narrowed airways and excess secretions obstruct airflow; expiration is affected first, then inspiration. Because ciliary function is impaired, normal defense mechanisms are unable to clear the mucus and any inhaled pathogens. Recurrent infection is common in chronic bronchitis.

Pursed-lip breathing (PLB)

a technique of exhaling against pursed lips to prolong exhalation, preventing bronchiolar collapse and air trapping; done to increase expiratory airway pressure, improve oxygenation of the blood, and help prevent early airway closure.

COPD Clinical Manifestations

dyspnea, cough, and sputum in varying degrees depending on progression of disease The clinical presentation of COPD varies from simple chronic bronchitis without disability to chronic respiratory failure and severe disability. Forced expiratory volume in 1 second (FEV1) is the amount of air that can be exhaled in 1 second as measured by a spirometer. A patient's FEV1 reading, combined with symptom manifestations, determines the patient's level of COPD severity. Manifestations are typically absent or minor early in the disease. Initial symptoms are chronic cough and sputum production, which tend to begin long before changes in pulmonary function. No incidence of shortness of breath occurs in the early stages of pulmonary decline as a result of COPD. When the patient finally seeks care, chronic productive cough, dyspnea, and exercise intolerance often have been present for as long as 10 years. The cough typically occurs in the mornings and often is attributed to "smoker's cough." Dyspnea initially occurs only on extreme exertion; as the disease progresses, dyspnea becomes more severe and accompanies mild activity. Manifestations characteristic of chronic bronchitis and emphysema develop. Manifestations of chronic bronchitis include a cough that produces copious amounts of thick, tenacious sputum; cyanosis; and evidence of right-sided heart failure, including distended neck veins, edema, liver engorgement, and an enlarged heart. Adventitious lung sounds, including loud rhonchi, and possible wheezes are prominent on auscultation. Emphysema: Emphysema is insidious in onset. Dyspnea is the first symptom and initially occurs only with exertion but may progress to become severe, even at rest. Cough is minimal or absent. Air trapping and hyperinflation increase the anteroposterior chest diameter, a condition called barrel chest. The patient often is thin, is tachypneic, uses accessory muscles of respiration, and often assumes a tripod position (a position of sitting and leaning forward) On auscultation, breath sounds are diminished, and the percussion tone is hyperresonant. The patient may utilize pursed-lip breathing. Pursed-lip breathing involves exhaling through a narrow opening between the lips to prolong the expiratory phase in an effort to promote more alveolar emptying while maintaining open alveoli. Prolonged impairment of gas exchange as a result of COPD eventually results in cardiac dysfunction. Chest pain and hypertension may be the earliest manifestations, indicating that the heart is having to work harder to provide oxygen through the bloodstream. Congestive heart failure eventually may result. Patients with COPD should be seen by their specialist or primary care provider at least every 6 months in order for their disease progression to be evaluated and therapies to be modified or added.

premature ventricular contractions

extra, abnormal heartbeats that disrupt the regular ventricular rhythm of the heart

chronic obstructive pulmonary disease (COPD)

progressive disorder that slowly alters the structures of the respiratory system over time, irreversibly affecting lung function. The disease is one of periodic exacerbations, often related to respiratory infection, with increased symptoms of dyspnea and sputum (mucus or mucopurulent matter expectorated from the lungs) production. Unlike acute processes in which lung tissues recover, airways and lung parenchyma do not return to normal following an exacerbation; instead, they demonstrate progressive destructive changes. COPD is not curable, but it can be managed (and sometimes prevented) with appropriate medical interventions and lifestyle choices. COPD typically includes components of both chronic bronchitis and emphysema, two distinctly different processes. Small airways disease, narrowing of small bronchioles, is also part of the COPD complex. Through different mechanisms, these processes cause airways to narrow, resistance to airflow to increase, and expiration to become slow or difficult. The result is a mismatch between alveolar ventilation and blood flow or perfusion, leading to impaired gas exchange.

COPD pathophysiology

results from repeated exposure to respiratory irritants that begin to damage the structures of the respiratory system. Damage to the large and small airway passages causes increased mucus production, causing arrest in cilia action. Excessive amounts of fluid accumulate with the lung mucosal cells, causing edema. Edema causes narrowing of airway passages, resulting in airflow limitation, air trapping (decreased airflow with exhalation), and ultimately, hyperinflation of the lungs. This process leads to bronchitis (best defined as inflammation of the mucous membranes of the bronchial tubes). COPD pt stimulated to breath by level of oxygen rather than carbon dioxide...therefore consider during oxygen delivery and their pulse ox baseline

Obstructive pulmonary diseases

those that cause obstruction of the airways, usually through a combination of bronchoconstriction and inflammation. These include bronchitis (chronic or acute) and emphysema

COPD Prevention

•Smoking cessation •Vaccination: pneumococcal & influenza q fall •Pulmonary Rehab is a program of education and exercise that helps you manage your breathing problem, increase your stamina (energy) and decrease your breathlessness. The education part of the program teaches you to be "in charge" of your breathing instead of your breathing being in charge of you •Surgery decrease their exposure to secondhand smoke, occupational respiratory irritants, and air pollutants. This is especially important for Hispanic patients because they have an increased risk of developing COPD, and because tobacco use is the leading preventable cause of death among Hispanics living in the United States. Nurses working with Hispanic patients who exhibit chronic cough and sputum or who are diagnosed with COPD should inquire about nicotine and alcohol use and provide patient teaching and appropriate referrals in these areas.