COPD - EXAM 3 Flashcards
COPD
An abnormal inflammatory response of the lungs to noxious particles and gases causing obstruction, air trapping in the alveoli and impaired exhalation. COPD impacts work, family, obligations, leisure, and ADLs
Preventable and treatable disease state characterized by chronic and progressive airflow limitation that is not fully reversible.
Precipitating Factors
- Cigarette smoke
- Frequent exposure to air pollutants
- Increased risk for those with asthma, untreated TB, or frequent resp. infection
- Genetics (alpha-1 antitrypsin deficiency)
Emphysema
- Irreversible destruction of alveolar walls leads to rupture of alveoli which leads to decreased number of alveoli and enlargement of remaining alveoli which leads to decreased elasticity and overinflation of the lungs
- 3 types
- centriacinar
- panacinar
- distal acinar
- 3 classfications
- compensatory
- type A (dry)
- type B (wet)
Chronic Bronchitis
- Increased site and number of goblet cells and mucus production
- Leads to damaged cells
- Leads to muscle hyperplasia
- Leads to inflammation and bronchial wall thickening
- Leads to muscle hyperplasia
- Leads to damaged cells
The presence of a chronic cough for three months in each of two succesive years. Excessive mucus in the airways causes scarring and decreased airflow.
Similiarities between Emphysema and Chronic Bronchitis
- There is restricted airflow requiring increased pressures to force air out of alveoli. This leads to bronchial collapse and air trapping.
- Prognosis is affected by age, smoking status, resting HR, airway responsiveness, and concurrent medical conditions (such as hypoxemia, pulmonary HTN, corpulmonale, or CHF)
Emphysema Symptoms
- Barrel chest due to hyperinflation
- Prolonged expiration
- Wheezing or decreased breath sounds
- Distant heart sounds
- Hyper-resonance on percussion
Later in disease process:
- Increased RR (proportional to degree of disease severity)
- Use of accessory muscles
- Cyanosis
- Peripheral edema
Chronic Bronchitis Symptoms
- Associated with frequent respiratory infections (such as acute bronchitis or pneumonia)
- Rhonchi or wheezing on auscultation
- Concurrent cor pulmonale with signs of cyanosis
- Edema associated with right sided heart failure
Diagnostics
- Pulmonary function tests (PFTs)
- Chest X-Ray
- small heart and flat diaphragm in emphysema
- increased bronchial markings in chronic bronchitis
- EKG to rule out right ventricular hypertrophy
- Blood Samples
- ABGs
- HgB/Hct to evaluate polycythemia
Emphysema
Abnornal permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis
COPD Pathophysiology
- Inflammation of central airways due to noxious particles and gases
- Increase in the number of mucus-producing goblet cells
- Structural remodeling of airways walls due to repeated cycles of injury and repair
- Increase in scar tissue formation in airway walls causing fibrosis and loss of elastic recoil
- Air is trapped in the distal alveoli
- Loss of alveolar walls and capillary destruction
- End result is a decrease in the surface area for the diffusion of oxygen, also known as Impaired Gas Exchange
T or F: Cigarette smoking is the most preventable cause of premature death in the US
True
T or F: Of the 4,000 chemicals and gases inahled into the lungs with cigarettes, none of them are proven carcinogens
False
T or F: Breathing in another person’s smoke can cause many breathing problems in children as well as cancer and heart disease in adults
True
T or F: A person’s sense of taste and smell are affected by tobacco smoke
True
T or F: It is not harmful to smoke cigarettes while using nicotine replacement therapy
False
T or F: Patients have a better chance of quitting tobacco use if they use more than one method for cessation
True
T or F: Support and encouragement from family and friends are key factors in improving the success of smoking cessation
True
T or F: The nurse who smokes or uses tobacco should have no difficulty in helping a patient change tobacco use habits
False
T of F: Strong evidence suggests that nursing interventions are effective in reducing smoking
True
T or F: Only patients who express a desire to quit tobacco should be offered treatment
False
The five As in Smoking/Tobacco Cessation Intervention
- ASK every patient whether he/she uses tobacco (include type and amount)
- ADVISE users about the risks of tobacco use and benefits of a tobacco-free lifestlye
- ASSESS their willingness to make a quit attempt (stage of change)
- ASSIST them in quitting (use of community services, pharmacotherapy, etc)
- ARRANGE for follow-up (phone calls, referrals)
Pursed-Lip Breathing
The patient is taught to inhale slowly through the nose and then to exhale slowly through pursed lips, almost as if whistling.
Purpose: To prolong exhalation and thereby prevent bronchiolar collapse and air trapping (keeps alveoli open)
Desired Outcome: Exhalation should be at least 3 times as long as exhalation
Intrustions to patient:
- Blow as though through a straw in a glass of water to form small bubbles
- Blow as if at a lit candle to bend flame, not blow it out
- Steadily blow a table-tennis ball across the table
- Blow a tissue held in the hand until it gently flaps
How often: 8-10 repitiions, 3-4 times/day
Postural Drainage and Cupping (Percussion) AKA PD&C
Uses the principle of gravity
Purpose: to assist bronchial drainage, percussion, vibration and postural drainage may assist in bringing secretions into larger, more central airways
When to perform: 1 hour before meals or 1-3 hours after meals: individualized schedule, position should be maintained for 5-15 minutes to mobilize secretions VIA gravity, administer bronchodilator 15 minutes before procedure, often ordered 2-4 times/day
Equipment: hands, pillows, blocks, blankets, chair, tissues, emesis basin
Assessment of patient: tolerance of procedure, lung sounds pre and post procedure, effectiveness of cough, sputum production and quality
Explanation to patient: procedure, goal, report any discomfort
Contraindications to treatment: should not percuss over kidneys, sternum, spinal cord, or any painful or tender area. CPT is contraindicated for patients with hemoptysis, PTX, right sided heart failure or bronchospasms
Procedure: After each drainage position change, the patient should be given time to cough and deep breathe. Some postural drainage positions should not be performed with patients expeirencing chest trauma, hemoptysis, heart disease, or head injury
Evaluation of outcomes: relief of symptoms of dyspnea, sensation of “fullness”
vibration vests can also be used to loosen secretions
Flutter Mucus Clearance Device
The flutter mucus clearance device is a hand-held device that provides positive expiratory pressure (PEP) treatment for patients with mucus-producing conditions
How does it work?: Used on exhalation to vibrate the airways and loosen mucus. Helps to move mucus up through the airways to the mouth for expectoration
Who should use the flutter valve?: Those patients with cystic fibrosis, those with excessive secretions in COPD and bronchiectasis. Also beneficial for those patients who cannot stolerate CPT or for patients in which CPT is contraindicated
Augmented Coughing
Place palm of hand on abdomen below the xiphoid process, move hands forcefully downward as patient ends deep inspiration and begins expiration to increase abdominal pressure and facilitate cough
Huff Coughing
Series of coughs while saying the word “huff.” This technique prevents the glottis from closing during the cough.
Staged Coughing
Sit up in a chair and breathe 3 or 4 times in and out through the mouth. Cough while bending forward and pressing a pillow inward against the diaphram.
Impaired Gas Exchange
Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane
Related Factors: Alveolar-capillary membrane changes, Ventilation-perfusion imbalance
Defining Characteristics: Abnormal ABG, abnormal resp. status including resp. rate, depth, color, and effot, abnormal skin color, hypoexmia and hypercapnia, mental status changes, including confusion, restlessness, and somnolence
Nursing Interventions:
- Assess resp status frequently, including RR, depth, effort, breath sounds, skin color, and oxygen saturation
- Monitor patient’s behavior and mental status
- Position patients in semi-fowler’s position for optimal chest expansion
- Assist the patient in deep breathing and controlled coughing
- Schedule nursing care to provide rest and minimize fatigue
- Administer humidified oxygen through an appropriate device. Aim for oxygen saturation level of 90%. Watch for onset of hypoventilation as evidenced by increased somnolence
- Assess nutritional status. Help the patient eat small, frequent meals and use dietary supplements as necessary
- Watch for signs of psychological distress, including anxiety, agitation, and insomnia
Respiratory Acidosis
pH LOW (less than 7.35)
PaCO2 HIGH(more than 45…carbonic excess)
HCO3 NORMAL
What would cause excess of carbonic acid? Shallow respiration.
What causes shallow respirations? Pain, narcotic, atelectasis, pneumonia, COPD, asthma
Assessment: shallow respirations, hypoia, disorientation, drowsiness, dizziness, flushing, and warm skin, weakness
Nursing Diagnosis: Imparied Gas Exchange, Disturbed Thought Processes, Activity Intolerance, Risk for Injury
Interventions: Assess, treat underlying cause of shallow respirations, TCDB, ambulate, treat pain, reduce narcotic dose, O2 as indicated, protect from injury
Respiratory Alkalosis
pH HIGH (greater than 7.45)
PaCO2 LOW (Less than 35)
HCO3 NORMAL
What would cause a lot of CO2 to be blown off? Fast respirations
What causes fast respirations? Anxiety, fever, respiratory infections, pain
Assessment: Lightheadedness, confusion, tetany (muscle twitching/spasms…hypocalemia), numbness and tingling of extremities, SOB, anxiety
Nursing Diagnosis: Ineffective Breathing Pattern, Anxiety, Disturbed Through Processes, Risk for Injury
Interventions: Assess, treat underlying cause of hyperventilation, provide oxygen if hypoxemic, slow breathing or paper bag breathing, sedatives, protect from injury
Metabolic Acidosis
pH LOW (less than 7.35)
PaCO2 NORMAL
HCO3 LOW (less than 24)
Loss intestinal contents (lose bicarb) diabetic ketoacidosis, renal failure
Assessment: deep, rapid respirations (kussmaul), weakness, N/V, abdominal pain, flushing of skin. CNS: H/A, confusion, lethargy, drowsiness
Nursing Diagnosis: Deficient Fluid Volume, Risk for Injury, Imbalance nutrition: less than body requirements
Interventions: Assess, treat underlying problem, IV Na HCO3, protect from injury
Metabolic Alkalosis
pH HIGH (more than 7.45)
PaCO2 NORMAL
HCO3 HIGH (more than 30)
Loss acid gastric contents (vomiting, NG sx), Diuretic Tx (loss of H+)
Assessment: tetany, tingling of fingers and toes, tachycardia, hypoventilation, CNS symptoms: dizziness, confusion irrirtable
Nursing Diagnosis: Deficient Fluid Volume, Risk for Injury, Imbalanced Nutrition: less than body requirements
Interventions: Assess, treat underlying problem, IVF replacement, protect from injury
Teaching Smoking Cessation
Encourage use of nicotine replacement therapy; get support and encouragement, schedule follow up visits
Teaching to avoid infections
Stress importance of handwashing, obtaining pneumonia and influenza vaccinations, avoid those that are ill
Teaching Medication Therapy
Difference between rescuer and controller medications, have an adequate supply at all times, carry a list at all times
Teaching Exercise
Strengthen chest muscles, increase stamina to do daily activities, recondition the body to feel less short of breath
Teaching Good Nutrition
Eat small, frequent meals, nutrition supplements, adequate hydration, rest before meals
Teach Energy Conservation
Move slowly, sit for as many tasks as possible, use assistive devices, rest when needed
Teaching Breathing and Airway Clearance Exercises
Teach pursed lip breathing, huff coughing, use of flutter mucus clearance device
Teaching to Control Stress and Anxiety
Includes discusssion of feelings, relaxation techniques, medicaiton, music thearpy, and support groups
Teaching Oxygen Therapy
Use as prescirbed, no smoking, is portable and should improve energy, breathing, and quality of life
Teaching Proper Use of Medication Delivery Devices
Teach slow or rapid inspiration, use of spacer, cleaning of equipment after use, how to administer
Teaching Management of an Exacerbation
Note signs and symptoms of changes or worsening in respiratory status, recognize early symptoms and seek medical attention
Why might heart sounds be distant? What can the RN do to hear the heart sounds better?
Change in the anterior posterior proportions of the chest move the heart further from the chest wall. Heart sounds could be heard better by positioning the patient on the left side or sitting up, leaning slightly forward
Discharge Planning for a patient with COPD
- Home oxygen therapy
- Medication therapy
- Energy conservation techniques
- Breathing retraining
- Effective coughing
- Smoking cessation
- Identify and reduce risk of infection (vaccinations, adequate nutrition, and hydration)
- Psychosocial/Emotional support
- CHN and MD follow-up
- Support groups (American Lung Society)
Ineffective Breathing Pattern
r/t: alveolar hypoventilation, anxiety, chest wall alterations and hyperventilation as evidence by assumption of three point position, dyspnea, increased anterior-posterior diamter, nasal flaring, orthopnea, prolonged expiration, pursed lip breathing, and use of accessory muscles to breathe
Ventilation Assistance:
- Monitor resp. and O2 status
- Auscultate BS, noting areas of decreased or absent ventilation, and presence of adventitious breath sounds
- Encourage slow, deep breathing, turning, and coughing
- Administer medicaitons that promote airway patency and gas exchange
- Position to minimize resp. effort (HOB elevated, use of bedside table to lean on)
- Monitor for resp. muscle fatigue
- Initiate a program of resp. muscle strength and/or endurance training
Ineffective Airway Clearance
r/t: expiratory airflow obstruction, ineffective cough, decreased airway humidity, and tenascious secretions as evidenced by ineffective or absent cough, presence of abnormal breath sounds, or absence of breath sounds
Cough Enhancement:
- Assist patient to sitting position with head slightly flexed, shoulders relaxed, and knees flexed for adequate chest expansion
- Instruct patient to inhale deeply, bend forward slightly, and perform 3 or 4 huggs (against an open flottis)
- Instruct patient to inhale deeply several times, exhale slowly, and cough at the end of exhalation
- Instruct patient to follow coughing with several maximal inhalation breaths
Airway Management:
- Encourage slow, deep breathing, turning, and coughing
- Position patient to maximize ventilation potential
- Regulate fluid intake to optimize fluid balance to liquefy secretions for easier expectoration
- Perform endotracheal or nasotracheal suctioning as appropriate to clear the airway
- Administer bronchodilators and use airway clearance devices to facilitate clearance of retained secretions and increase ease of breathing
Impaired Gas Exchange r/t
R/t: alveolar hypoventilation as evidenced by headache on awakening, PaCO2 greater than 45 mm Hg, PaO2 less than 60 mm Hg, or SaO2 less than 90% at rest
Oxygen Therapy:
- Administer supplemental oxygen as ordered
- Administer oxygen through a humidified system
- Periodically check oxygen delivery device
- Monitor the effectiveness of O2 therapy VIa pulse oximetry or ABGs
- Observe for signs of oxygen induced hypoventilation as this occurs with CO2 narcosis
- Instruct patient and family about home oxygen use
Anxiety
r/t: fear of breathlessness and suffocation as evidenced by shallow breathing, worsening SOB, muscle tension, and lack of energy
How to break the anxiety-breathlessness cycle:
- Teach patient to stay active - go at their own pace
- Teach patients to recognize and plan for situations that cause SOB
- Encourage patients to take time for pleasant activities
- Promote expression of feelings to others
- Teach relaxation techniques such as positive thinking and visualization, music, progressive muscle relaxation, and the use of humor
Clinical Manifestations COPD
- Cough: initially intermittent with small amounts of sticky mucus; later occurs faily
- Dyspnea: initially with exertion; later occurs at rest
- Barrel chest
- Wheezing and chest tightness
- Weight loss and anorexia
- Fatigue
- Hypoxemia
- Hypercapnia and respiratory acidosis later in disease
- Polycythemia and cyanosis
Complications of COPD
- Cor Pulmonale
- Alveolar hypoxia
- Pulmonary hypertension
- Right ventricular hypertrophy as right ventricle tries to overcome the resistance in the pulmonary vessels
- Patient symptoms may include JVD, edema, ascites, or hepatomegaly
- Treatment is aimed at the underlying cause of alveolar hypoxia or pulmonary hypertension
- Secondary Polycythemia
- Compensatory response
- Chronic hypoxia casuses increased erythropoietin production from the kidneys
- More RBCs become available to reansport the less available oxygen
- Causes a ruddy complexion caused plethora
- Acute exacerbations
- An acute worsening of COPD symptoms associated with poorer outcomes primarily caused by infection and pollution
- Acute Respiratory Failure
- Depression/Anxiety
- Worsening anxiety and breathlessness can become a vicious cycle
Diagnostic studies for COPD
- Pulmonary function tests/spirometry
- ABGs
- Exercise tolerance test with oximetry
- EKG
- Echocardiogram (corpulmonale)
Collaborative Care for COPD
- Smoking Cessation
- Medications
- Oxygen thearpy
- Surgical therapy
- Lung transplant
- Lung volume reduction surgery
- Bullectomy
- Respiratory care
- Nutritional therapy
- Exercise therapy
Smoking Cessation for COPD
- Single most effective and cost-effective intervention to reduce risk of devleoping COPD and stopping disease progression
- Provide patients with thier lung age
Medicaitons for COPD
- Bronchodilators and inhaled corticosteriods
- Long-acting
- Short-acting
- Recue and maintenance
- MDI, DPI, nebulization
- Systemic Corticosteriods
- Controversial, but sometimes a necessity
Oxygen Therapy for COPD
Goal: Reduce WOB and maintain SpO2 greater than 90% during rest, sleep, or exertion
- Want LOWEST EFFECTIVE dose of oxygen (typically between 1-3 liters/minute)
- What is the risk of oxygen specific to the COPD patient?
- Concept of hypoxic drive
- COPD patients O2 drive to breathe is hypoxemia due to a tolerance for high CO2 levels
- Pervasive myth but still seen in practice
- Benefits of high flow oxygen outweight risks with respiratory distress or impending respiratory failure
- Home oxygen issues
- Note on door notifying all who enter
- No smoking
- Insurance reimbursement
Respiratory Care for COPD
- Breathing retraining
- Effective coughing
- Chest physiotherapy
- Percussion/Vibreation
- Postural Drainage
- Flutter mucus clearance device
Imbalanced Nutrition: Less than body requirements
r/t: lowered energy level for food acquisition, preparation, ingestion, and digestion, poor appetite, SOB, sputum production, gastric distention, depression
Interventions:
- Rest before meals
- Small, frequent meals
- Eat high calorie foods first
- Reduce prepartion time/energy expenditure
- Liquid or blenderized foods
- High calorie, high protein diet with supplements
- Bronchodilator before meals
- O2 NC during meals - assess for tolerance of changes in delivery methods
- Modified carbohydrates to avoid further increased CO2 levels
- Oral care before meals
- Sodium restriction if heart failure present
- Weight checks, lab values (prealbumin), and calorie counts
