Week 4 Chapter 20 Management of Patients with COPD Flashcards
What is COPD?
Slowly progressive respiratory disease of airflow obstruction
What does COPD include?
- Chronic Bronchitis
- Preventable and treatable but not fully irreversible
- Involving the airways, pulmonary parenchyma, or both
- 4th leading cause of death of all ages
Name other chronic pulmonary diseases
Bronchiectasis, asthma, cystic fibrosis
Pathophysiology of COPD
- Airflow limitation is progressive, associated with abnormal inflammatory response to noxious particles or gases
- Chronic inflammation damages tissue
- Scar tissue in airways results in narrowing
- Scar tissue in the parenchyma decreases elastic recoil (compliance)
- Scar tissue in pulmonary vasculature causes thickened vessel lining and hypertrophy of smooth muscle (Pulmonary HTN)
- Body tries to self repair which increases the number of goblet cell and hypersecretion of mucus
A preventable and treatable disease with some significant extrapulmonary effects
COPD
Disease state characterized by airflow limitation that is not fully reversible
COPD
COPD is currently what?
4th leading cause of death and 12t leading cause of disability
The incidences of COPD increases with?
Age
- Symptoms begin in “middle adult” years
COPD includes diseases that cause airflow obstruction
- Emphysema
- Chronic Bronchitis
COPD is overfunded. T/F
False most underfunded
Name the 3 primary symptoms of COPD
- Chronic cough
- Sputum production
- Dyspnea on exertion (as disease progresses dyspnea occur at rest)
Other symptoms of COPD
- Weight loss
- Accessory muscles
- Resp. insufficiency and resp. infections
- Polycythemia
Assessment and Diagnosis of COPD
Health History
PFT
Spirometry
ABG
Chest Xray
Name the risk factors of COPD
Exposure to tobacco smoke
Older adults
Occupational exposure
Pollution
Genetic abnormalities
What causes most of COPD?
80-90 % pf COPD cases
Risk factors of COPD
Passive smoking
Occupational exposure
Ambient and outdoor air pollution
Genetic abnormalities: Alpha 1- antitrypsin deficiency (A1AD)
- 25 M carriers of this genetic defect
- Lethal disease, develop emphysema by 30s and 40s
- Affects 100,000 Whites
- Tx: Alpha protease inhibitor replacement therapy
Common adverse effects of tobacco smoking
- Larynx cancer/ Oral cavity cancer
- MI
- Systemic atherosclerosis
-Bladder cancer - Pancreas Cancer
-Peptic ulcer - Emphysema
- Lung cancer
- Chronic Bronchitis
Name the complications of COPD
- Resp. insufficiency and failure
- Pneumonia
- Chronic Atelectasis
- Pneumothorax
- Cor pulmonale
Name the medical management of COPD
-Promote smoking cessation
- Reducing risk factors
- Managing exacerbations
- Providing supplemental oxygen therapy
- Pneumococcal vaccine
- Influenza vaccine
- Pulmonary rehabilitation
- Managing exacerbations
Medications to treat COPD
Bronchodilators/ MDIs
Corticosteroids
ABX
Mucolytics
Antitussives
Bronchodilators/MDIs include
- Beta- adrenergic agonist
- Muscarinic antagonists(anticholinergics)
- Combination agents
Tx:
Rx/ Management in COPD
Chronic COPD
- C- Cessation smoking, steroids IF PFTs reversible
- O2 if hypoxic
- PFTs + pnemo vac, flu vac, pulmonary rehab
- Dilators (bronchodilators: B@ agonist, anticholinergic)
Acute COPD
- ABX if indicated by fever and CXR
- Corticosteroids to reduce hospital stay
- O2
- P- phlegm control- mucolytics
- Dilators
Name the surgical management of COPD
-Bullectomy
- Lung volume reduction
- Lung transplant
What is the nursing management of COPD?
Assessing the pt: obtain hx, review dx tests
- Achieving airway clearance
- Improving breathing patterns
- Improving activity tolerance
- MDI pt education
Nursing care of Pt with COPD
- Evaluate exposure to resp. irritants
- Nursing interventions to promote oxygenation
–Incentive spirometry
– Postural Drainage
— Chest percussion and vibration
– Breathing exercises
-Administer medications to promote gas exchange and oxygenation
-Oxygen
- Bronchodilators
Education plan for Pt with COPD
Pt education for
- Smoking cessation
- Medication administration
- Breathing exercises
- Regular exercise
- Realistic goals
- Emergency management
Types of breathing to help COPD includes
Pursed Lip breathing
Diaphragmatic Breathing
Name the clinical manifestations of COPD with Emphysema
Chronic hyperinflation of the alveolar sacs with trapped air leads to barrel chest
-Fix position of the ribs
- Loss of lung elasticity
- Retraction of the supraclavicular fossae on inspiration
- Shoulders heave upward
Advanced stages
- Use of abdominal muscles to inspire
Pressures in the lungs include
Negative pressures-(inspiration)
-Moves air into the lungs =6L
Positive pressures (expiration)
- Moves air out of the lungs
With Emphysema, expiration/ exhalation is …
NOT PASSIVE
What is the passive phase of respiration?
Exhalation
Patients with advanced lung disease such as COPD will often assume what?
Tripod positioning
When breathing difficulties occur
Why tripod psoitioning?
Provides a position that optimizes respiratory mechanics
Nursing Assessment of COPD includes
Health Hx
Inspection and examination findings
Review diagnostic tests
Assessment of COPD
H and P
Review of Dx tests
S/S of infection
- URI (changes in sputum color, consistency and amount)
S/S of hypoxemia
- Cognitive changes - memory impairment, Increase of HR and RR
- Personality and behavior changes
Nursing planning of COPD patients
Smoking cessation
Improved activity tolerance
Maximal self management
Improved coping ability
Adherence to therapeutic regimen and home care
Absence of complications
Ways to Improve Gas Exchange
-Proper administration of bronchodilators and corticosteroids
- Reduction of pulmonary irritants
- Directed coughing, huff coughing
- Breathing exercises to reduce air trapping
- Diaphragmatic breathing
- Pursed Lip breathing
-Use of supplemental O2
Ways to improve activity tolerance
- Focus on rehab activities to improve ADLs and promote independence
- Pacing of activities (AM care)
- Exercise training
- Walking aides
- Utilization of a collaborative approach
What is the priority nursing care for COPD patients?
-Semi Fowlers and monitor RR and tx w/ O2 and wean off O2
- Begin O2 (Pa O2 60-65%)
(O2 sat 90-92% goal)
- Drive to breath is based on low O2
- High paO2 results in low resp. drive
- Hypercapnic drive Increased CO2= Increased RR readjusted CO2 to 50
- When CO2 is 70-80 this is Increased RR
- Assess VS -careful with pulse ox
-Determine the cause of hypoxia
-Preventive URI
—-Pneumonia vaccine, HFLU vaccine, early warning signs
Patient teaching for COPD includes
-Disease process
-Medications
-Procedures
- When and how to seek help
- Prevention of infection hand washing
- Avoidance of irritants and pollutants
-Lifestyle changes
- Pursed lip and diaphragmatic breathing
What are other interventions for COPD?
-Set realistic goals
- Avoid extreme temperatures
- Enhancement of coping strategies
- Monitor for and management of potential complications
Nursing interventions for COPD include
ADLs
- AM challenging
- Heavy secretions in AM
-Increase participation with improved tolerance
Walking aids with periods of rest
Portable O2
-Teaching is tailored to the stage of the disease
-Environmental factors
-Continue home care/ community resources
Retrained breathing includes
Pursed Lip - slow, deep, diaphragmatic breathing)
The key and most important nursing activity is
Smoking cessation
All teaching should be followed by?
Return demonstration of techniques and/ or verbalization
- Aggressive care tx options
- End of life care decisions
What is the single most important intervention to reducing COPD?
Smoking Cessation
Also patient education on which shot?
H. Flu
Nurses must provide a ___________ ____________ then look for multiple strategies
strong warnings
Important to obtain a quit date
Goals and pt outcomes/ evaluation for COPD
Airway clearance
Improve breathing patterns
Improved activity tolerance
Avoidance of complications, resp. failure, atelectasis, URI infections
Adequate coping mech.
Environmental Exposures
Smoking cessation achieved
Knowledge regarding complications/ pneumothorax
Name the medical management of COPD
-ABGs obtain- need O2 baseline in advance stages
- CXR for exclusion
- CT- differential diagnosis must be done to r/o asthma
-A1AT 1% if younger than 45 with strong fam hx
A1AT is produced where?
Liver
and one of its function is to protect the lungs from neutrophil elastase associated with liver disease
Medical management of COPD
-Promote smoking cessation
- Reducing risk factors
- Managing exacerbations
- Providing supplemental O2
- Pneumococcal Vaccine
-Influenza vaccine
- Pulmonary rehab.
- Managing exacerbations
First line therapy of COPD includes
Nicotine replacement
- Gum, nasal spray, transdermal patch
Medical management of COPD includes
Antianxiety agents
Antidepressant- Wellbutrin SR, nortriptyline)
-Hypertensive agents :Clonodine
- Bronchodilators: via MDIs
- Corticosteroids -Improve pulmonary functions
- ABX, mucolytics, antitussives, vaccines (H flu vacs 50% deaths)
- Possible vent . support
- End of life decisions
Pharm therapy of COPD includes
-Bronchodilators- Beta 2 adrenergic agonists
-Albuterol and levalbuterol
-Inhaled - short acting
-Orla- long acting : albuterol
-Therapeutic uses
- Prevention of asthma episode ( exercise induced)
- Long term control of asthma
Formoterol and Salmeterol are
Long acting control of asthma
- Inhaled, long acting
Terbutaline
Oral and long acting
- Long term control of asthma
Complications of bronchos include
Tachycardia and angina
Tremors
Name inhaled Anti- Cholinergic Agents (Muscarinic Agents)
-Ipratropium and Tiotropium (Atrovent and Spreva)
Name the purpose of Muscarinic Agents
Blocks muscarinic receptors of bronchi leading to bronchodilation
Therapeutic uses of Muscarinic Agents include
Relieve bronchospasm with COPD
-Complications -Dry mouth/ hoarseness
This medication causes relaxation of bronchial smooth muscle; bronchodilation
Theophylline
- Therapeutic use -Long term control of chronic asthma or COPD
- Complications- GI Distress, restlessness
This medication class prevents inflammation, suppress airway mucous production and promote responsiveness B2 receptors in bronchial tree
- Reduction in airway mucosa edema
Glucocorticoids
Name the therapeutic uses for glucocorticoids
Short term IV- status asthmaticus
-Inhaled- long term prophylaxis of asthma
- Effects less dramatic for COPD, long term oral not recommended
Medication Regime for COPD
Grade 1-mild- short acting bronchodilator
Grade 2 or 3- short acting bronchodilator and regular treatment with one or more long acting bronchodilators
Grade 3 or 4- Severe or very severe
— One or more bronchodilators and/ or inhaled corticosteroids
— Combination long term B2 agonist plus corticosteroids in one inhaler may be appropriate
Physiologic dead space=
Anatomical+ alveolar
-Anatomical- person’s wt in ml
- 1/3 of the resting Tidal volume
ex: 150 ilbs man has 150 ml of dead space - Mouth and trachea
Alveolar- air in contact w/ alveolar without blood flow in adjacent pulmonary capillaries
- Small amt in healthy individuals
Collaborative Problems
-Resp. insufficiency or failure
- Pneumonia
-Pneumothorax
- Pulmonary HTN
- Cor pulmonale
- Chronic Atelectasis
What is Emphysema?
-Slow, progressive, “ end stage process”
- Overdistended of the alveoli walls beyond the terminal bronchioles resulting in decrease elastic recoil of alveoli
- Impairs O2 and CO2 exchange (CO2 retention)
As there are repeated resp. infections that accelerates the disease what happens
Decrease in elastic “recoil” of the alveoli
This over-distention decreases the pulmonary capillary bed which causes what?
Increase in dead space
- No gas exchange takes place- Hypoxemia
The dilated sacs trap air and increase resistance to blood flow in lungs… this forces what
Increase in PAP may cause right sided HF
What is chronic bronchitis?
Cough and sputum production for at least 3 months in each of 2 consecutive years
Ciliary function is reduced, bronchial walls thicken, bronchial airways narrow, and mucous may plug airways
Chronic Bronchitis
Alveoli may become damaged, fibrosed, and alveolar macrophage function diminishes
Chronic Bronchitis
The patient is more susceptible to what with chronic bronchitis
Infections
Resp. infections
Normal chronic bronchitis has
Inflammation
Increased number of mucous glands
Excess mucus causing chronic cough
In 1 year of smoking cessation
Carbon monoxide level back to normal
After 10 yr smoking cessation
Risk from dying of lung cancer is about half that of smoker
5-15 yrs
Risk of stroke same as non smoker
After 15 years
Risk of coronary heart disease same as nonsmoker
E Cigarettes
-Juul- Delivers higher concentrations of nicotine than other e cigs
5% to 2.4%
Amount of nicotine in one juul pod is equivalent to a pack of cig
Many of the flavoring of e cigs have not been studied
True
Agency deferred its authority to regulate e cig companies pre market application until 2022.
Nicotine is
-Highly addictive
- Toxic to fetuses
- Impairs brain and lung development in adolescence
Emphysema is
Abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli
Results in impaired O2/ CO2 exchange
Decreased alveolar surface in emphysema increases what?
Dead Space
Impaired oxygen diffusion
Hypoxemia results
In emphysema increased pulmonary artery pressure may cause what?
Cor pulmonale
Right sided heart failure
What are the clinical manifestations of Emphysema?
-Congestion
- Dependent edema
- Distended neck veins
- Active, effortful respirations
- Pain in liver (with cardiac feature)
- Hypoxia/ Hypoxemia
- Hypercapnia (later stage)
-Polycythemia
Episodic RV failure (cor pulmonale)
In barrel chest the A-P diameter and transverse diameter is
1:1
Changes in alveolar structure in emphysema includes
Pan lobular emphysema
Centrilobular Emphysema
PLE includes
Enlarged lobes
Hyperinflated chest
Severe dyspnea on exertion
weight loss
CLE includes
Chronic hypoxemia
Hypercapnia
Polycythemia
Overinflated sacs compressed adjacent blood vessels
Decrease in arterial oxygen tension in blood
Hypoxemia
Decrease in oxygen supply to the tissues and cells that can also be caused by problems outside the resp. system
Hypoxia
Severe Hypoxia can be life threatening
Cylinder piped in concentrator
Classified as low flow to high
Oxygen Administration
Devices of O2 administration include
- Nasal cannula
- Oropharyngeal catheter
- Masks
- Transtracheal Catheter
On home oxygen the nurse does what?
Safe methods to administer in home
- Available in gas, liquid, concentrated
- Portable devices
- Humidity must be provided
- Community resources
Oxygen toxicity
May occur when too high a concentration of oxygen greater than 50% is administered for an extended period
Symptoms of Oxygen toxicity include
Substernal discomfort, parathesias, dyspnea, restlessness, fatigue, malaise, progressive, resp. difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates on x ray
Prevention of oxygen toxicity
Use lowest effective concentrations of oxygen
PEEP or CPAP prevent or reverse atelectasis and allow lower O2 percentages to be used
