COPD Flashcards
1
Q
Chronic Obstructive Pulmonary Disease (COPD)?
A
refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis.
2
Q
Emphysema
A
destruction of the alveoli
3
Q
Chronic bronchitis
A
presence of chronic productive cough for 3 months in 2 successive years
4
Q
Do people w COPD only show emphysema or chronic bronchitis?
A
People with COPD often display characteristics of both chronic bronchitis and emphysema.
5
Q
How common is COPD in Canada?
A
prevalence of COPD among the population aged 35 years and older was 9.4% (2 million Canadians).
6
Q
What causes COPD ?
A
- exposure to irritants that damage your lungs and airways
- Tobacco smoking
7
Q
Pathophysiology of COPD
A
Noxious particles and Gases causes:
inflammation of central airways/ peripheral airway remodelling/ parenchymal destruction/ pulmonary vascular changes
Causes:
COPD- mucus hypersecretion/ cilia dysfunction/ airflow limitation/ hyperinflation of lungs/ alveolar destruction/ loss of elastic recoil/ gas exchange abnormalities/ pulmonary hypertension/ cor pulmonale/ systemic effects
8
Q
Bullae
A
cystic space >1cm in diameter
9
Q
Bleb
A
cystic space <1cm in diameter
10
Q
Why do people w COPD have pulmonary hypertension?
A
hypoxia leads to pulmonary vasoconstriction leading to an increase in pressure, therefore leading to pulmonary hypertension
11
Q
What systemic (extrapulmonary) changes can result from COPD?
A
unintentional weight loss, skeletal muscle dysfunction, an increased risk of cardiovascular disease, osteoporosis, and depression, among others.
12
Q
What are the clinical manifestations (signs and symptoms) of COPD?
A
- dyspnea
- intermittent cough in the morning
- productive cough during winter
- Barrel Chest
13
Q
What position to patients sit in to relieve symptoms of COPD?
A
Leaning forward
14
Q
Why might polycythemia develop later in the development of COPD?
A
Polycythemia develops as a result of increased production of red blood cells secondary to the body’s attempt to compensate for chronic hypoxemia.
15
Q
Usual COPD age at onset
A
> 40 yrs
16
Q
Usual Asthma age at onset
A
<40 yrs
17
Q
Smoking history, COPD vs Asthma
A
COPD: usually >10 packs/ year
Asthma: Not casual but could become trigger
18
Q
Which produces sputum, Asthma or COPD?
A
COPD frequently
Asthma infrequently
19
Q
Do asthma spirometer findings improve or normalize? What about COPD?
A
Asthma: Findings often normalize
COPD: Findings sometimes improve but never normalize
20
Q
Is asthma progressive?
A
Usually stable with exerbations
21
Q
is COPD progressive?
A
Progressive worsening with exacerbations
22
Q
How are PFT’s conducted?
A
conducted to measure lung volumes and airflow. -
In PFTs, a spirometer is used. The patient’s age, sex, height, and weight are entered into the PFT computer to calculate predicted values.
The patient inserts a mouthpiece, takes as deep a breath as possible, and exhales as hard, fast, and long as possible.
The computer determines the actual value achieved, predicted (normal) value, and percentage of the predicted value for each test.
23
Q
Normal PFT
A
A normal actual value is 80 to 120% of the predicted value
24
Q
Forced vital capacity (FVC)?
A
Amount of air that can be quickly and forcefully exhaled after maximum inspiration. Normal: >80% of predicted
25
Forced expiratory volume in the first second of expiration (FEV1)?
Amount of air exhaled in first second of FVC; valuable clue to severity of airway obstruction. Normal: >80% of predicted
26
FEV1/FVC?
Ratio of value for FEV1 to value for FVC; useful in differentiating obstructive and restrictive pulmonary dysfunction. Normal: <80% of predicted
27
Peak expiratory flow rate (PEFR)?
Maximum airflow rate during forced expiration; aids in monitoring bronchoconstriction in asthma. Normal: <600L/min
28
What is cor pulmonale, and how can it result from COPD?
Cor pulmonale is hypertrophy of the right side of the heart, with or without heart failure, that results from pulmonary hypertension. In COPD, pulmonary hypertension is caused primarily by constriction of the pulmonary vessels in response to alveolar hypoxia
29
What does acidosis following hypoxia in the pulmonary vessels cause?
Further vasoconstriction leading to Cor Pulmonale
30
How are acute exacerbations of COPD (AECOPD) defined?
An acute exacerbation of COPD (AECOPD) is defined as a sustained worsening of COPD symptoms. The term sustained implies a change from baseline that lasts 48 hours or longer
31
The frequency of AECOPD is related to what?
related to the underlying severity of airflow obstruction, and patients with a history of frequent exacerbations are more likely to continue experiencing frequent exacerbations.
32
Why is it important to identify whether a client has a purulent or non-purulent exacerbation of COPD?
Exacerbations should be characterized as purulent or non-purulent to assist in determining the need for antibiotic therapy; purulent exacerbations necessitate antibiotic therapy.
33
What causes AECOPD?
The cause of AECOPD is often difficult to determine. Noninfectious triggers for exacerbations include exposure to allergens, irritants, cold air, and air pollution.
34
What vaccinations should be recommended for people with COPD?
Annual influenza vaccination and pneumococcal vaccination
35
How can COPD lead to acute respiratory failure?
Frequently, patients with COPD wait too long to contact their health care provider when they develop fever, increased cough and dyspnea, or other symptoms suggestive of AECOPD.
An exacerbation of cor pulmonale may lead to acute respiratory failure.
Discontinuing bronchodilator or corticosteroid medication may also precipitate respiratory failure.
36
How is depression, anxiety, and panic related to COPD?
- Patients with COPD are 85% more likely to experience anxiety disorders. Depression may be related to feelings of hopelessness, social isolation, and grief that accompany the progressive course of the disease, and an overall decrease in quality of life is related to reduced physical functioning and sedentary lifestyle. Anxiety can occur when a person is exceptionally dyspneic, particularly if the condition occurs suddenly, and the person becomes anxious and tries to breathe faster, which affects oxygenation status
37
What assessments should a nurse perform on a client with COPD?
- history including effect of symptoms on patients life
- Vitals
- PFT's
- Chest radiographic imagery to rule out other comorbidities
38
How are “pack-years” calculated for people with a history of cigarette smoking?
Tobacco consumption should be quantified and is typically expressed in pack-years. Pack-years are calculated by multiplying the number of cigarette packs smoked daily by the number of years smoked.
39
How is the MRC Dyspnea Scale used to assess shortness of breath and dyspnea in COPD?
Grade 1: Breathlessness with vigorous exercise
Grade 2: short of breath when hurrying or walking up a slight hill
Grade 3: Walks slower than people of the same age and stops for breath while walking at own pace level
Grade 4: Stops for breath after walking 100 yards
Grade 5: Too breathless to leave the house or breathless when dressing
40
What are the 7 primary COPD management goals?
1. Prevent disease progression (smoking cessation)
2. Reduce the frequency and severity of exacerbations
3. Alleviate breathlessness and other respiratory symptoms
4. Improve exercise tolerance
5. Treat exacerbations and complications of the disease
6. Improve health status and quality of life
7. Reduce associated mortality and mortality
41
what is the most significant factor in slowing the progression of COPD?
Cessation of cigarette smoking
42
Why are bronchodilators the mainstay of treatment for COPD?
Bronchodilator medication therapy relaxes smooth muscles in the airway, reduces airway resistance and dynamic hyperinflation of the lungs, and improves the ventilation of the lungs, thus reducing the degree of breathlessness
43
How do short-acting bronchodilators help in COPD?
improve pulmonary function, symptoms, and exercise function
44
How do long-acting bronchodilators help in COPD?
preventing COPD exacerbation in patients who have higher peripheral eosinophilia counts with previous acute exacerbations
45
Why are inhaled corticosteroids (ICS) and long-acting β2 adrenergic agonists (LABAs) often combined in the treatment of COPD?
ICS monotherapy does not have consistent effects on important outcomes (e.g., pulmonary function, symptoms, exacerbations) and is not a recommended therapy. However, ICS in combination with a LABA has been found to reduce the frequency of exacerbations and to improve lung function and health status in patients who are at high risk of AECOPD.
46
Why would a phosphodiesterase 4 inhibitor (e.g. Roflumilast) be prescribed for a person with COPD?
Those who continue to experience exacerbations despite being on optimized LABD therapy may require the addition of a daily macrolide. The phosphodiesterase 4 inhibitor roflumilast (Daxas) is indicated as add-on therapy for reduction of inflammation with bronchodilators, for the maintenance of COPD in patients with chronic cough and sputum and frequent exacerbations.
47
Why are oral or parenteral corticosteroids used in the treatment of COPD?
Oral or parenteral corticosteroids are used for the treatment of AECOPD. They speed recovery time, reduce relapse rates, reduce the need for hospitalization, and improve FEV1 and partial pressure of oxygen.
48
How does long-term oxygen therapy at home affect the prognosis for clients with COPD?
Long-term oxygen therapy (15 hours per day or more to achieve an oxygen saturation of 90% or greater) prolongs life in patients with hypoxemia.
49
Which three surgical procedures have been used to manage severe COPD? (and how do they help?)
1. Lung volume reduction surgery
2. Bullectomy
3. Lung transplantation
50
Lung volume reduction surgery
The rationale for this surgery is that by reducing the size of the hyperinflated emphysematous lungs, airway obstruction is decreased and room for the remaining normal alveoli to function is increased. The procedure reduces volume by approximately 20 to 35% of the most emphysematous lungs and improves lung and chest wall mechanics.
51
Bullectomy
An older surgical procedure, specific to the patient with bullous emphysema. The surgical removal of the bulla is intended to decompress adjacent lung parenchyma.
52
lung transplantation
lung transplantation for patients with advanced, severe COPD.
53
What are the components of an effective pulmonary rehabilitation program?
- exercise conditioning
- breathing exercises
- energy conservation
- nutrition
- smoking cessation
- environmental factors
- health promotion
- patient education and self management
- psychological support
- psychological counselling
- vocational rehabilitation
Can be 4- over 12 weeks in outpatient, inpatient, or in-home programs
54
How does upper and lower extremity training improve the health of people with COPD?
Lower extremity training focuses on aerobic training and includes walking, treadmill walking, bicycling, and cycling ergometry. Upper extremity training focuses on improving arm strength and endurance. Peripheral muscle wasting and weakness affects approximately 25% of patients with COPD.
55
What vaccinations are recommended to prevent viral pneumonia?
An influenza vaccine is modified annually to reflect the anticipated strains in the upcoming season.
56
Who should get influenza vaccines
The flu vaccine is considered a mainstay of prevention and is recommended annually for individuals considered to be at risk for influenza, including older persons, long-term care residents, patients with COPD or diabetes mellitus, and health care workers
57
What, if any, drug treatment is available for viral pneumonia?
Currently, there is no definitive treatment for viral pneumonia. An antiviral medication, amantadine, is approved for oral use in the treatment of influenza A virus.
58
How is pursed lip breathing helpful?
Pursed-lip breathing is used to prolong exhalation, prevent bronchiolar collapse and air trapping, and assist with dyspnea. Exhalation should be at least three times longer than inhalation.
59
How much fluid should a client with COPD take in daily?
Fluid intake should be at least 2 to 3 L per day unless contraindicated for other medical conditions, such as heart failure. Fluids should be taken between meals (rather than with them) to prevent excess stomach distension and to decrease pressure on the diaphragm.
60
What medications (commonly used to treat disorders in older adults) can worsen COPD symptoms?
- Nonspecific β-blockers should be avoided because they can also block the α2 receptors in the airway and cause bronchoconstriction. Angiotensin-converting enzyme inhibitors may cause a dry cough or worsen a current cough.
- Older persons may not adhere to medication therapies because of cognitive impairment and complexity of the polypharmacy prescribed. - Arthritis in the hands can hinder the patient from using proper technique for MDIs. It is important to review MDI technique during clinic visits and have a DPI or spacers prescribed (if possible) because they are easier to use.
61
How can the nurse promote effective airway clearance in a client with COPD?
* Facilitate deep breathing by sitting patient up to maximize use of diaphragm and prolong expiratory phase.
* Ensure adequate hydration (oral intake approximately 2–3 L/day, humidified ambient air) to liquefy secretions for easier expectoration.
* Teach effective cough techniques to minimize the extent of airway collapse and to enhance airway clearance.
* Assist with inhaled bronchodilator administration to facilitate clearance of retained secretions.
62
How should a nurse support a client with COPD to improve gas exchange?
Monitor respiratory and oxygenation status to assess need for intervention.
* Teach pursed-lip breathing to prolong expiratory phase and slow respiratory rate.
* Assist patient to assume position of comfort (e.g., tripod position, elevated back rest, support of upper extremities to fix shoulder girdle) to maximize respiratory excursion.
* Administer and teach appropriate use of bronchodilators to open the airways.
* Teach signs, symptoms, and consequences of hypercapnia (e.g., confusion, somnolence, headache, irritability, decrease in mental acuity, increase in respiration, facial flush, diaphoresis) to recognize condition early and initiate treatment.
* Teach avoidance of central nervous system depressants because they further depress respirations.
* Administer O2 if appropriate to increase SaO 2 saturation.
* Select O2 supply systems and devices (e.g., nasal cannula, mask) that are appropriate for patient’s ADLs (rest, sleep, exercise) to minimize effect on preferred lifestyle.
63
How can a nurse promote good nutrition in a client with COPD?
* Monitor caloric intake, weight, and serum albumin and protein levels to determine adequacy of intake.
* Provide menu suggestions for high-protein, high-calorie foods to ensure maintenance of weight.
* Give patient high-protein, high-calorie liquid supplements if necessary, to provide adequate calories and protein to prevent weight loss and muscle wasting.
* Plan periods of rest before and after food intake to assist with controlling fatigue and to compensate for blood flow diversion to the gastrointestinal tract for digestion.
* Refer to hospital for financial or nutritional assistance as necessary (e.g., Meals-On-Wheels, home care) to ensure nutritional adequacy after discharge.
* Discuss benefit of five to six small meals throughout the day because this reduces bloating.
64
How can a nurse promote effective sleep in a client with COPD?
* Identify usual sleep habits and elicit reasons for difficulty sleeping to provide baseline data.
* Monitor patient’s sleep pattern, and note physical circumstances (e.g., pain or discomfort and urinary frequency) and psychological circumstances (e.g., fear or anxiety) that interrupt sleep to initiate appropriate interventions.
* Observe for signs and symptoms of sleep apnea such as frequent awakenings at night or excessive daytime sleepiness, or noting a partner who complains of the patient’s snoring or gasping for air to initiate appropriate diagnostic tests and interventions.
* Identify patient-specific methods of relaxation, and teach patient relaxation methods to foster sleep.
* Encourage exercise and activity during daylight hours to ensure improved sleep at night.
* Provide patient with activity that promotes wakefulness to limit daytime sleep.
* Instruct patient in arranging surroundings (e.g., clothing, temperature, position, noise level) to produce an environment conducive to sleep.
* Teach patient to avoid alcoholic beverages, caffeine products, or other stimulants before bedtime to reduce interference with sleep.
65
How can a nurse reduce the risk for respiratory infection in a client with COPD?
* Monitor for systemic and localized signs and symptoms of infection to determine whether an infection is present.
* Teach patient to assess indicators of infection: change in sputum colour, quantity, odour, and viscosity; increase in cough and dyspnea; experience of fever, chills, diaphoresis, excessive fatigue; increase in respiratory rate; and abnormal breath sounds (gurgles, wheezing) to determine whether an infection is present.
* Teach patient to use good handwashing and hygiene techniques and to avoid contact (when possible) with people with respiratory infections to minimize sources of infection.
* Encourage patient to obtain vaccination for influenza and pneumococcal pneumonia to decrease occurrence or severity of influenza or pneumonia.
* Teach proper care and cleaning of home respiratory equipment to eliminate this source of infection.
* Instruct patient to seek medical attention for manifestations of early infection to initiate treatment promptly.
* Teach patient to follow plan of care for managing exacerbations (e.g., increase fluid intake, initiate antibiotics and oral corticosteroid) to initiate appropriate self-care promptly.
66
How can the health of a client with COPD be promoted?
- The best way to prevent COPD is never to smoke, and the next best step is to stop smoking immediately
- Avoiding or controlling exposure to occupational and environmental pollutants and irritants is another preventive measure to maintain healthy lungs.
- Early identification and treatment of respiratory tract infections is important for improving the long-term prognosis of COPD. Avoiding exposure to large crowds in the peak influenza periods may be necessary, especially for older people and patients with a history of respiratory conditions.
- Patients should also be taught good handwashing technique, to avoid sharing food and drinks, and to keep their hands away from their nose, mouth, and ears.
- Influenza and pneumococcal pneumonia vaccinations are recommended.
67
What exercise should be recommended for a client with COPD?
- Walking is by far the best physical exercise for patients with COPD. Coordinated walking with slow, pursed-lip breathing without breath holding is a difficult task that requires conscious effort and frequent reinforcement. During coordinated walking and breathing, the patient is taught to breathe in through the nose while taking one step, then to breathe out through pursed lips while taking two to four steps (the number depends on a patient’s tolerance). Walking should occur at a slow pace with rest periods when necessary.
- Patients should be encouraged to walk 15 to 20 minutes a day and gradually increase this time. Patients can begin at a slower pace by walking for 2 to 5 minutes three times a day and slowly building up to 20 minutes a day, if possible.
68
What strategies can be used to conserve energy in clients with COPD?
- Alternative or modified methods of hair care, shaving, showering, and other activities that necessitate over-the-head reaching must be explored. Assuming a tripod posture (elbows supported on a table, chest in fixed position) and placing a mirror on the table while using an electric razor or hair dryer conserves energy in comparison with standing in front of a mirror to perform these activities.
- Another energy-saving tip is to exhale when pushing, pulling, or exerting effort during an activity and to inhale during rest.
69
What should nurses teach clients with COPD about maintaining a healthy sex life?
- (a) have sexual activity during the part of the day when breathing is best,
- (b) use slow pursed-lip breathing,
- (c) refrain from sexual activity after eating or other strenuous activity,
- (d) do not assume a dominant position, and
- (e) do not prolong foreplay. These aspects of sexual activity require open communication between partners regarding their needs and expectations and the changes that may be necessary as the result of a chronic disease (e.g., changes in body image, role reversal).
70
What are the psychosocial considerations for a client with COPD?
Emotions frequently encountered include guilt, depression, anxiety, social isolation, denial, and dependence. Among patients who still or used to smoke, guilt may result from the knowledge that the disease was caused largely by tobacco smoking. The patient may experience depression as they realize the severity and chronicity of the disease
71
What is pneumonia?
Pneumonia is an acute inflammation of the lung parenchyma caused by a microbial agent
72
What are all of the things that can cause pneumonia?
Pneumonia can be caused by bacteria, viruses, Mycoplasma, fungi, parasites, and chemicals
73
Why is it helpful to classify pneumonia as community-acquired or hospital-acquired?
a clinically effective way to classify pneumonia is as community-acquired or hospital-acquired. Classifying pneumonia is important because of differences in the likely causative organisms and the selection of appropriate antibiotics.
74
What are the characteristics of community-acquired pneumonia (CAP)?
Community-acquired pneumonia (CAP) is defined as a lower respiratory tract infection of the lung parenchyma with onset in the community or during the first 2 days of hospitalization.
75
What is the definition of hospital-acquired pneumonia (HAP)?
Hospital-acquired pneumonia (HAP) is pneumonia occurring 48 hours or longer after hospital admission and not incubating at the time of hospitalization.
76
How many critical care unit infections does pneumonia account for?
HAP accounts for 25% of all critical care unit infections
77
Which factors increase the risk of a person developing aspiration pneumonia?
The person who has aspiration pneumonia usually has a history of loss of consciousness (e.g., as a result of seizure, anaesthesia, head injury, stroke, alcohol intake). With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Another risk factor is tube feedings.
78
What are the 3 types of aspiration pneumonia?
- Mechanical
- Chemical
- Obstructive
79
Which individuals are most at risk for opportunistic pneumonia?
Patients with altered immune response are highly susceptible to respiratory infections. Specific individuals considered at risk include those with severe protein–calorie malnutrition; those with immune deficiencies; those who have received transplants and been treated with immunosuppressive medications; and patients who are being treated with radiation therapy, chemotherapeutic agents, or corticosteroids
80
What are the 4 stages of the disease process in pneumonia (and the characteristics of each stage)?
1. Congestion. After the pneumococcus organisms reach the alveoli via droplets or saliva, there is an outpouring of fluid into the alveoli. The organisms multiply in the serous fluid, and the infection is spread. The pneumococci damage the host by their overwhelming growth and interference with lung function.
2. Red hepatization. There is massive dilation of the capillaries, and alveoli are filled with organisms, neutrophils, red blood cells, and fibrin (Figure 30.1). The lung appears red and granular, similar to the liver, which is why the process is called hepatization.
3. Grey hepatization. Blood flow decreases, and leukocytes and fibrin consolidate in the affected part of the lung.
4. Resolution. Complete resolution and healing occur if there are no complications
81
What are the typical clinical manifestations of pneumonia?
- signs of pulmonary consolidation, such as dullness to percussion, increased fremitus, bronchial breath sounds, and crackles, may be found.
- sudden onset of fever, chills, a cough producing purulent sputum, and pleuritic chest pain
82
What sort of atypical signs and symptoms might manifest with pneumonia?
- more gradual onset, a dry cough, and extrapulmonary manifestations such as headache, myalgias, fatigue, sore throat, nausea, vomiting, and diarrhea. On physical examination, crackles are often heard.
83
What is empirical therapy?
therapy based on observation and experience, implemented when the condition’s exact cause is not known
84
When caring for a client with pneumonia, what should be done first: administer the first dose of antibiotics, or collect a sputum culture?
A sputum culture should be collected before initiating antibiotic therapy as a means to intervene for patients with community- or hospital-acquired pneumonia.
85
What types of pneumonia respond best to antibiotic therapy?
bacterial and mycoplasma pneumonia.
86
How many days does it take for the signs and symptoms of pneumonia to improve after starting antibiotic therapy?
48 to 72 hours. Indications of improvement include decreased temperature, improved breathing, and reduced chest pain. Abnormal physical findings can last for more than 7 days
87
What supportive measures should be used to treat people with pneumonia?
In addition to antibiotic therapy, supportive measures may be used, including oxygen therapy to treat hypoxemia, analgesics to relieve the chest pain for patient comfort, and antipyretics such as acetylsalicylic acid (ASA; Aspirin) or acetaminophen (Tylenol) for significantly elevated temperature. During the acute febrile phase, the patient’s activity should be restricted, and rest should be encouraged and planned.
88
What nutritional therapy should be used in pneumonia?
- min 3L of H20
- min 1500 calories per day
- small, frequent meals are best for dyspnea
