Chronic Obstructive Pulmonary Disease (COPD)



Chronic obstructive pulmonary disease (COPD) is irreversible condition in which airways become obstructed and resistance to air flow is increased during expiration when airways collapse. COPD is usually further subdivided into other diseases such as bronchitis and emphysema, and actually COPD refers to these simultaneous disease entities.

Emphysematous changes include enlarging of the air spaces distally to the terminal bronchioles, and concurrent changes in alveolar walls. Capillary numbers decrease in the remaining walls and may sclerosis. Gas exchange is decreased due to the reduction in available alveolar surfaces as well as decreased perfusion to non-ventilated areas. Ventilation/perfusion mismatching occurs and functional residual capacity is increased. The anteroposterior diameter of the chest is often enlarged due to the loss of elasticity and increased air trapping in the airway supportive structures. These type A patients are often called “pink puffers” because of the increased response to hypoxemia. Symptoms include dyspnea and increase in breathing effort, which result in a well-oxygenated, or pink, patient who displays overt dyspnea, or puffing.

Chronic Obstructive Pulmonary Disease

Bronchitis is usually associated with prolonged exposure to lung irritants, which results in inflammatory changes and thickening of bronchial walls, and increases in mucous production. The patient exhibits a chronic productive cough due in part to the increase in size of mucous glands and decrease in cilia. These type B patients are often called “blue bloaters” because their response to hypoxemia is reduced, with increasing PaC02 levels and cyanosis. These patients frequently have bouts of cor pulmonale, or right-sided heart failure, resulting in peripheral edema.

lung with COPD

The most common precipitating factors for COPD include cigarette smoking, air or environ- mental pollution, allergic response, autoimmunity, and genetic predisposition. Treatment is aimed at avoidance of respiratory allergens and irritants, controlling bronchospasms, and improving airway clearance.
Medical care
Laboratory:
cultures used to identify causative organisms and determine appropriate antimicrobial therapy; CBC used to identify presence of infection with elevated white blood cell count, and to monitor for increases in RBCs and hematocrit as the body tries to compensate for oxygen transport requirements; alpha1-antitrypsin levels used to identify deficiency that may be present if patient has heredity predisposition; theophylline levels used to monitor for therapeutic levels and/or toxicity

COPD EFFECT

Pulmonary function studies:
used to evaluate pulmonary status and function, and to identify airway obstruction, increased residual volume, total lung capacity, compliance, decreased vital capacity, diffusing capacity, and expiratory volumes with emphysema patients; increased residual volume, decreased vital capacity and forced expiratory volumes with normal static compliance and diffusion capacity with bronchitis patients
Chest x-ray:
used to identify hyperinflation of lungs, flattened diaphragm, or pulmonary hypertension; used to identify barotrauma that may occur, increased anteroposterior chest diameter, large retrosternal air spaces, or secondary cardiovascular complications with right-sided heart failure
Electrocardiography:
used to identify dysrhythmias associated with this disease; tall p waves in inferior leads, vertical QRS axis, atrial dysrhythmias, right ventricular hypertrophy, sinus tachycardia, and right axis deviation
Oxygen:
used to improve hypoxemia; liter flow should be low in order to maintain the patient's respiratory drive; PaO2, may be acceptable at 55-60 mmHg to avoid hypoventilation and maintain function
IV fluids:
used to maintain hydration and for administration of medical therapeutics Bronchodilators: xanthines and sympathomimetics are used to relieve bronchospasms and help to promote clearance of mucoid secretions
Antibiotics:
used to treat respiratory infections Arterial blood gases: used to identify acid-base disturbances, presence of hypoxemia and hypercapnia, and to evaluate responses to therapies
Chest physiotherapy:
percussion and postural drainage are used to facilitate mobilization of secretions and promote clearance of airways
Corticosteroids:
used to decrease secretions and reduce inflammation in the lungs; use of steroids is controversial
Psychological treatment:
use of anti-anxiety agents to decrease fear and anxiety related to dyspnea, without sedation to depress the respiratory drive; psychotherapy may be required to enable patients to cope with their ongoing disease process

PATHWAY COPD
Pathway COPD


NURSING CARE PLANS
Ineffective airway clearance
[See Mechanical Ventilation]
Related to: bronchospasm, fatigue, increased work of breathing, increased mucous production, thick secretions, infection
Defining characteristics: dyspnea, tachypnea, bradypnea, bronchospasms, increased work of breathing, use of accessory muscles, increased mucous production, cough with or without productivity, adventitious breath sounds
Ineffective breathing pattern
[See Mechanical Ventilation]
Related to: pain, increased lung compliance, decreased lung expansion, fear, obstruction, decreased elasticity/recoil
Defining characteristics: dyspnea, tachypnea, use of accessory muscles, cough with or without productivity, adventitious breath sounds, prolongation of expiratory time, increased mucous production, abnormal arterial blood gases
Impaired gas exchange
[See Mechanical Ventilation]
Related to: obstruction of airways, bronchospasm, air-trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to move secretions, hypoventilation
Defining characteristics: hypoxemia, hypercapnia, mental changes, confusion, restlessness, dyspnea, vital sign changes, inability to tolerate activity, respiratory acidosis
Anxiety
[See Mechanical Ventilation]
Related to: threat of death, change in health status, life-threatening crises
Defining characteristics: fear, restlessness, muscle tension, helplessness, communication of uncertainty and apprehension, feeling of suffocation
Activity intolerance
Related to: fatigue, weakness, increased effort and work of breathing, inadequate rest, hypoxia, hypoxemia
Defining characteristics: dyspnea, decreased oxygen saturation levels with movement or activity, increased heart rate and blood pressure with movement or activity, feelings of tiredness and weakness
Outcome Criteria
Patient will be able to tolerate minimal activity without respiratory compromise.
INTERVENTIONS
RATIONALES
Monitor for patient’s response to activity changes.
Identifies patient’s ability to compensate for increases in activity and provides baseline date from which to plan care.
Monitor vital signs before, during, and after increased activity levels.
Increases in heart rate greater than 10/minute or respiratory rate greater than 32 may indicate that patient has reached his maximal activity limit and further activity may result in circulatory/respiratory dysfunction.
Plan activities to ensure patient obtains adequate amounts of rest and sleep.
Decreases potential for dyspnea and provides rest to prevent excessive fatigue.
Assist patient with activities as warranted.
Conserves energy and decreases oxygen consumption and dyspnea.
Increase activity gradually and encourage patient participation.
Gradual increases facilitate increased tolerance to activity by balancing oxygen supply and demand, and patient cooperation may facilitate feelings of self-worth and adequacy.
Administer inhalers as ordered prior to activities.
Helps prevent dyspnea by performing activities at peak time of medication effects.
Information, Instruction, Demonstration
INTERVENTIONS
RATIONALES
Instruct on techniques to save energy expenditure: shower stools, arm and leg rests, gathering required articles and placement within reach, etc.
Helps CO decrease energy expenditure and fatigue, which may result in increased dyspnea.

Provide patient with exercise regimen protocol.
Promotes independence and self-worth; increases tolerance to exercises.
Instruct on breathing exercises to be performed with activity.
Promotes effective respiratory patterns during exertion.

Discharge or Maintenance Evaluation
·       Patient will be able to tolerate activity without excessive dyspnea or hemodynamic instability,
·       Patient will be able to perform ADLs within limits of disease process.
·       Patient will be able to recall information accurately, and will be able to utilize relaxation and breathing techniques effectively.
·       Patient will be compliant with prescribed exercise regimens.
Ineffective individual/family coping
[See Mechanical Ventilation]
Related to: changes in lifestyle and health status, sensory overload, fear of death, physical limitations, inadequate support system, inadequate coping mechanisms, continual dyspnea
Defining characteristics: inability to meet role expectations, inability to meet basic needs, constant worry, apprehension, fear, inability to problem-solve, anger, hostility, aggression, inappropriate defense mechanisms, low self-esteem, insomnia, depression, destructive behaviors, vacillation when choices are required, delayed decision-making, muscle tension, fatigue
Risk for infection
Related to: disease process, inability to move secretions, decreased cilia function, immunosuppression, poor nutrition
Defining characteristics: increased temperature, chills, elevated white blood cell count, inability to move secretions
INTERVENTIONS
RATIONALES
Monitor for increased dyspnea, sputum color and character changes, cough, and temperature elevation.
Yellow or green sputum, with increased viscosity usually indicates infection. Prompt recognition facilitates prompt treatment.
Obtain sputum specimen for culture and sensitivity as ordered.
Identifies the causative organism and provides information regarding appropriate antimicrobial agent required.
Administer antibiotics as ordered.
Controls and clears the infection and any secondary infections in the bronchial tree. Improvement should be noted within 24-48 hours after antimicrobial agent has begun.
Monitor for abrupt changes in other body systems; cardiac abnormalities and alteration in heart sounds, increasing pain, changes in mental status, recur- ring temperature elevations.
May indicate presence of secondary infection or resistance to ordered antibiotics. Superinfections, systemic bacteremia, inflammatory cardiac conditions, meningitis or encephalitis may occur.
Provide adequate rest time for patient.
Helps to facilitate healing and natural immunity.

Discharge or Maintenance Evaluation
Patient will exhibit no signs/symptoms of secondary infection.
Altered nutrition: less than body requirements
[See Mechanical Ventilation]
Related to: dyspnea, inability to take in sufficient food, increased metabolism due to disease process, decreased level of consciousness, fatigue, increased sputum, medication side effects
Defining characteristics: actual inadequate food intake, altered taste, altered smell sensation, weight loss, anorexia, absent bowel sounds, decreased peristalsis, muscle mass loss, changes in bowel habits, abdominal distention, nausea, vomiting
Knowledge deficit
Related to: lack of information, lack of recall of information, cognitive limitations
Defining characteristics: request for information, statement of misconception, statement of concerns, development of preventable complications, inaccurate follow-through with instructions
Outcome Criteria
Patient will be able to recall information accurately and will follow through with all instructions.
INTERVENTIONS
RATIONALES
Assess knowledge of COPD disease process, medications, and treatments.
Identifies level of knowledge and provides baseline from which toplan teaching.
Instruct on medication effects, side effects, contraindications, and signs/symptoms to report.
Promotes knowledge and compliance with treatment regimen.
Instruct in proper technique for using and cleaning inhalers.
Proper technique, including appropriate time intervals between puffs, facilitates effective delivery and therapeutic effect.
Instruct on need to avoid smoking and other respiratory irritants.
May initiate and exacerbate bronchial irritation which can result in increased mucous production and airway obstruction.
Instruct on effective coughing techniques; postural drainage, chest physiotherapy, etc.
Effective coughing reduces fatigue and facilitates removal of secretions. Percussion and postural drainage help to mobilize tenacious secretions.
Instruct to drink 10-12 glasses of water per day.
Instruct on use of supplemental oxygen at low flow rates, and reasons to avoid increasing flow indiscriminately.
Maintains hydration and pro- motes easier mobilization of secretions. COPD patients will rarely require more than 2-3 L/min to maintain their optimum oxygenation levels. Increasing flow rates will increase their PaO2 but may decrease their respiratory drive and may result in drowsiness and confusion.
Instruct on oxygen safety: avoiding flammable objects, use of Vaseline or other petroleum products, and ambulation with tubing.
Promotes physical and environ mental safety.

Instruct on avoiding sedative or antianxiety drugs as warranted.
Sedative may result in respiratory depression and impair cough reflexes.
Instruct on avoiding people with infections; encourage patient to obtain influenza and pneumonia vaccinations as warranted.
Prevents exposure to other infections, and decreases potential for incidence of upper respiratory infections.
Instruct on activity limitations, methods to conserve energy and promote rest, pursed-lip breathing, etc.
Helps decrease fatigue, optimizes activity level within range of disease process, and reduces dyspnea and oxygen consumption.
Instruct on signs/symptoms to notify MD: increased temperature, change in sputum color or character, increasing dyspnea.
Provides for prompt recognition of infection to facilitate prompt intervention prior to respiratory failure.
Instruct to continue with follow-up medical care.
Provides for monitoring of progression of disease, presence of complications, or exacerbations, and facilitates changes in medical regimen to concur with current medical condition.
Provide patient/family with information regarding support groups, such as the American Lung Association, etc.
Support groups may be required to provide emotional assistance and respite for caregiver(s).

Assist patient/family to set realistic goals for long-and short-term.
Provides a plan for patient and facilitates self-involvement with realistic goals and methods to meet them. Fosters independence and reduces anxiety.

Discharge or Maintenance Evaluation
Patient will be able to recall information regarding disease process and treatment regimen.
Patient will be able to recall accurately the signs/symptoms for which to notify MD, the effects and side effects of medications, and proper procedure for using inhalers.
Patient will be able to demonstrate accurately proper cough techniques, pursed-lip breathing, and proper positioning to facilitate breathing.
Patient/family will be able to access support systems effectively.


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