Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible, sometimes referred to as chronic airway obstruction or chronic obstructive lung disease. The airflow limitation is generally progressive and is normally associated with an inflammatory response of the lungs due to irritants. COPD includes chronic bronchitis and pulmonary emphysema. Chronic bronchitis is a chronic inflammation of the lower respiratory tract characterized by excessive mucous secretion, cough, and Dyspnea associated with recurring infections of the lower respiratory tract. Pulmonary emphysema is a complex lung disease characterized by destruction of the alveoli, enlargement of distal airspaces, and a breakdown of alveolar walls. There is a slowly progressive deterioration of lung function for many years before the development of illness.
Clinical Manifestations Chronic Obstructive Pulmonary Disease (COPD)
Chronic Bronchitis (usually insidious, developing over a period of years) :
- Presence of a productive cough lasting at least 3 months a year for 2 successive years.
- Production of thick, gelatinous sputum; greater amounts produced during superimposed infections.
- Wheezing and dyspnea as disease progresses
Emphysema (Gradual in onset and steadily progressive):
- Dyspnea, decreased exercise tolerance.
- Cough may be minimal, except with respiratory infection.
- Sputum expectoration mild.
- Increased anteroposterior diameter of chest (barrel chest) due to air trapping with diaphragmatic flattening.
Causes for Chronic Obstructive Pulmonary Disease (COPD)
The etiology of Chronic Obstructive Pulmonary Disease COPD includes:
- Cigarette smoking.
- Air pollution, occupational exposure.
- Allergy, autoimmunity.
- Genetic predisposition, aging.
Etiology of emphysema includes:
- Exposure to tobacco smoke due to smoking preventable cause
- Secondhand smoke or passive smoking: nitric oxide, component of smoke, is a potent bronchodilator
- Ambient air pollution
- Alpha 1 -antitrypsin deficiency: genetic abnormality accounts for less than 1% of Chronic Obstructive Pulmonary Disease (COPD)
Etiology of chronic bronchitis includes:
- Exposure to tobacco smoke due to cigarette smoking
- Secondhand smoke or passive smoking
- Ambient air pollution and occupational irritants
- Sex, race, and socioeconomic status: higher prevalence of respiratory symptoms in men, higher mortality rates in whites, and higher morbidity and mortality in blue-collar workers.
- Occupational dusts and chemicals: vapors, irritants and fumes, particulate matter, organic dust
Complications for Chronic Obstructive Pulmonary Disease (COPD)
- Cor pulmonale
- Respiratory failure
- Bronchiectasis: recurrent bouts of bronchitis
- Decreased quality of life and functional status
- Decreased independence due to difficulty breathing and increased oxygen demands resulting in fatigue
- Assistance with activities of daily living (ADLs) as disease progresses
- Pneumonia, overwhelming respiratory infection.
- Right-sided heart failure, Dysrhythmias
- Skeletal muscle dysfunction
Stages of COPD Based on the Global Initiative for Chronic Obstructive Lung Disease
|Stage||Degree of COPD||Status of Airflow Post bronchodilator FEV1(forced expiratory volume in 1 second)|
|0||At Risk||normal spirometrychronic symptoms cough and sputum production|
|I||Mild COPD||FEV 1/ FVC < 70%,FEV1 ≥ 80% predicted with or without chronic symptoms|
|II||Moderate COPD||FEV 1/ FVC < 70%,50% ≤ FEV1 < 80% predicted with or without chronic symptoms|
|III||Severe COPD||FEV 1 / FVC < 70%,30% ≤ FEV 1 or < 50% predicted plus respiratory failure or right heart failure|
|IV||Very Severe COPD||FEV 1 / FVC < 70%FEV1 < 30% predicted orFEV1 < 50% predicted plus chronic respiratory failure|
Treatment for Chronic Obstructive Pulmonary Disease (COPD)
Treatment for Chronic Obstructive Pulmonary Disease (COPD) is designed to relieve symptoms and prevent complications. Because most COPD patients receive outpatient treatment, they need comprehensive patient teaching to help them comply with therapy and understand the nature of this chronic, progressive disease. If programs in pulmonary rehabilitation are available, encourage the patient to enroll.
If the patient is to continue oxygen therapy at home, teach the patient how to use the equipment correctly. Patients with COPD rarely require more than 3 L/minute to maintain adequate oxygenation. Higher flow rates will further increase the partial pressure of arterial oxygen, but patients whose ventilatory drive is largely based on hypoxemia commonly develop a markedly increased partial pressure of arterial carbon dioxide. In such patients, chemoreceptors in the brain are relatively insensitive to the increase in carbon dioxide.
Treatment for Chronic Obstructive Pulmonary Disease (COPD) includes:
- Smoking cessation.
- Inhaled bronchodilators reduce Dyspnea and bronchospasm; delivered by metered dose inhalers (MDI) or handheld or mask nebulizer devices.
- Methylxanthines, such as theophylline (Theo-Dur), given orally as sustained-release formulation for chronic maintenance therapy (less commonly used).
- Inhaled corticosteroids are recommended for patients with symptomatic COPD with documented spirometric improvement from glucocorticosteroids, or in those with an FEV1 that is less than 50% of the predicted value and repeated exacerbations requiring treatment with antibiotics and/or oral glucocorticosteroids.
- Antibiotics help treat respiratory tract infections. Pneumococcal vaccination and annual influenza vaccinations are important preventive measures.
- Oral corticosteroids are used in acute exacerbations for anti-inflammatory effect; may also be given I.V. in severe cases.
- Chest physical therapy, including postural drainage for secretion clearance and breathing retraining for improved ventilation and control of dyspnea.
- Supplemental oxygen therapy for patients with hypoxemia. CO2 must be monitored to determine increased CO2 retention.
- Pulmonary rehabilitation to improve function, strength, symptom control, disease self-management techniques, independence, and quality of life.
- Antimicrobial agents for episodes of respiratory infection.
- Lung volume reduction surgery is under investigation for treatment of heterogeneous emphysema.
- Treatment for alpha1-antitrypsin deficiency:
- Prevent damage to lungs by quitting smoking.
- Lung transplantation may be considered for people with severely disabling alphaantitrypsin disease.
Nursing Diagnosis Chronic Obstructive Pulmonary Disease (COPD)
Nursing diagnosis Nursing Care Plans Chronic Obstructive Pulmonary Disease (COPD) determine with the data that we collect in nursing assessment
Nursing Assessment Chronic Obstructive Pulmonary Disease (COPD)
The typical patient with Chronic Obstructive Pulmonary Disease (COPD), have a long-term cigarette smoker, remains asymptomatic until middle age. His ability to exercise or do strenuous work gradually starts to decline, and he begins to develop a productive cough. These signs are subtle at first, but become more pronounced as the patient gets older and the disease progresses. Eventually the patient may develop Dyspnea on minimal exertion, frequent respiratory infections, intermittent or continuous hypoxemia, and grossly abnormal pulmonary function studies.
- Exposure to risk factors
- Past medical history including asthma, allergy sinusitis, or nasal polyps
- Family history of COPD or other chronic respiratory disease
- Chronic cough: length of time, daily or intermittent, seldom noc turnal
- Chronic sputum production: characteristics of sputum, change with the season amount produced
- Dyspnea that is progressive, persistent, worse with exercise, worse during respiratory infections
- History of exposure to tobacco smoke, occupational dusts and chemicals, smoke from home cooking and heating fuels
- Smoking history: pack years (number of packs per day multiplied by number of years smoking)
- Age when fi rst noticed symptoms
- Current functional status and ability to perform ADLs
- Limitation of activities
- Pneumonia and other respiratory illnesses
- Use of oxygen: liter flow and years of usage
- Weight loss or weight gain
- Sleep pattern and position during sleep: number of pillows used
Potential abnormal physical exam findings (will vary based on severity of illness):
- Assessment of severity based on level of symptoms
- Severity of spirometric abnormalities
- Characteristics of respiratory pattern: rate, depth, symmetry, and synchrony; breathlessness due to airway narrowing and bronchoconstriction
- Use of pursed lip breathing
- Breath sounds: normal and adventitious: crackles, rhonchi and wheezes; hyperresonant lung fields; may be distant due to hyperinflation
- Cough due to increased sputum production: usually worse in the morning
- Sputum production: color, amount; usually increased with chronic bronchitis
- Shortness of breath with speech: two or three words per breath
- Dyspnea on exertion
- Barrel chest as a result of increased RV
- Use of accessory muscles
- Resting pulse oximetry with potential drop with activity
- Presence of complications such as respiratory failure and right heart failure
- Cor pulmonale: right-sided heart failure to include edema, heart rate, blood pressure, jugular venous pressure (JVP)
- Check for presence of murmurs, gallops, rubs, lifts, heaves, and/or thrills
- Fluid retention and edema
- Overall appearance: thin with muscle wasting and barrel chest or overweight with barrel chest
- Enlarged abdominal girth or cachetic appearance
- Enlarged liver with right-sided heart failure
- Posture: hunched over with rolled shoulders
- Pallor skin color
- Generalized edema
Diagnostic Test Chronic Obstructive Pulmonary Disease (COPD)
- Chest X-ray: air trapping; hyperinfl ation; increased A-P diameter; flattened diaphragms
- Postbronchodilator FEV 1
- Pulmonary function test: show decreased FEV 1 (up to 50% loss) and decreased FEF 25%–75%; increased functional residual capacity (FRC) due to air trapping and hyperinflation
- Arterial blood gases: may show increased CO 2 due to inability to expel all of the air (air trapping) and low O 2 levels due to ventilation/ perfusion mismatch
- Assess Dyspnea using a valid tool such as the Modified Borg scale or the Visual Analog Scale
- Oxygen saturation at rest and with activity
- Quality-of-life measure: baseline measurement
- Six-minute walk distance: baseline measurement
Nursing Diagnosis That Could Be Found In Patient with COPD
Common nursing diagnosis found in Nursing care plans for Chronic Obstructive Pulmonary Disease (COPD):
- Ineffective Airway Clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection
- Impaired Gas Exchange related to chronic pulmonary obstruction, abnormalities due to destruction of alveolar capillary membrane
- Imbalanced Nutrition: Less Than Body Requirements related to increased work of breathing, air swallowing, drug effects with resultant wasting of respiratory and skeletal muscles
- Deficient Knowledge [Learning Need] regarding condition, treatment, self-care, and discharge needs related to lack of information or unfamiliarity with information resources, Information misinterpretation, Lack of recall or cognitive limitation
Common nursing diagnosis found in Nursing care plans Chronic Obstructive Pulmonary Disease (COPD): Ineffective Airway Clearance, Impaired Gas Exchange, Imbalanced Nutrition: Less Than Body Requirements, Deficient Knowledge.
Ineffective Airway Clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection
Respiratory Status: Airway Patency Effective
Nursing interventions NCP COPD:
- Auscultate breath sounds. Note adventitious breath sounds such as wheezes, crackles, or rhonchi.
- Assess and monitor respiratory rate. Note inspiratory-toexpiratory ratio.
- Note presence and degree of dyspnea, for example, reports of “air hunger,” restlessness, anxiety, respiratory distress, and use of accessory muscles. Use a 0 to 10 scale or American Thoracic Society’s Grade of Breathlessness Scale to rate breathing difficulty. Ascertain precipitating factors when possible. Differentiate acute episode from exacerbation of chronic dyspnea.
- Assist client to maintain a comfortable position to facilitate breathing by elevating the head of bed, leaning on or over bed table, or sitting on edge of bed.
- Keep environmental pollution from sources such as dust, smoke, and feather pillows to a minimum according to individual situation.
- Encourage and assist with abdominal or pursed-lip breathing exercises.
- Observe for persistent, hacking, or moist cough. Assist with measures to improve effectiveness of cough effort.
- Increase fluid intake to 3,000 mL/day within cardiac tolerance.
- Provide warm or tepid liquids. Recommend intake of fluids between, instead of during, meals.
- Administer medications, as indicated indicated, for example: Beta-agonists.
- Provide supplemental humidification, such as ultrasonic nebulizer and aerosol room humidifier.
- Assist with respiratory treatments, such as spirometry and chest physiotherapy.
- Monitor and graph serial ABGs, pulse oximetry, and chest x-ray.
Sample Nursing care plans Chronic Obstructive Pulmonary Disease (COPD)
Most Chronic Obstructive Pulmonary Disease COPD patients receive outpatient treatment, so provide comprehensive patient teaching to help them comply with therapy and understand the nature of this chronic, progressive disease.
- Teach the patient and his family how to recognize early signs of infection; warn the patient to avoid contact with people with respiratory infections. Encourage good oral hygiene to help prevent infection. Pneumococcal vaccination and annual influenza vaccinations are important preventive measures
- Help the patient and his family adjust their lifestyles to accommodate the limitations imposed by this debilitating chronic disease. Instruct the patient to allow for daily rest periods and to exercise daily as directed.
- Teach good habits of well-balanced, nutritious intake.
- Encourage high-protein diet with adequate mineral, vitamin, and fluid intake.
- Advise against excessive hot or cold fluids and foods, which may provoke an irritating cough.
- Advise to avoid hard-to-chew foods (causes tiring) and gas-forming foods, which cause distention and restrict diaphragmatic movement.
- Encourage five to six small meals daily to ease shortness of breath during and after meals.
- Suggest rest periods before and after meals if eating produces shortness of breath. Warn against potassium depletion. Patients with COPD tend to have low potassium levels; also, patient may be taking diuretics; Watch for weakness, numbness, tingling of fingers, leg cramps, Encourage foods high in potassium include bananas, dried fruits, dates, figs, orange juice, grape juice, milk, peaches, potatoes, tomatoes.
- Advise patient on restricting sodium as directed.
- Limit carbohydrates if CO2 is retained by patient, because they increase CO2.
- Use community resources, such as Meals On Wheels or a home care aide if energy level is low.
Avoid Exposure to Respiratory Irritants
- Advise patient to stop smoking and avoid exposure to second-hand smoke.
- Advise patient to avoid sweeping, dusting, and exposure to paint, aerosols, bleaches, ammonia, and other respiratory irritants.
- Advise patient to keep entire house well-ventilated.
- Warn patient to stay out of extremely hot/cold weather to avoid bronchospasm and dyspnea.
- Instruct patient to humidify indoor air in winter; maintain 30% to 50% humidity for optimal mucociliary function.
- Suggest the use of a HEPA air cleaner to remove dust, pollen, and other particulates; this is controversial as to the benefit to the patient.
- Explain that goal is to strengthen and coordinate muscles of breathing to lessen work of breathing and help lung empty more completely.
- To promote ventilation and reduce air trapping, teach the patient to breathe slowly, prolong expirations to two to three times the duration of inspiration, and to exhale through pursed lips.
- Stress the importance of controlled breathing.
- Teach diaphragmatic breathing and pursed-lip breathing for episodes of dyspnea and stress.
- To help mobilize secretions, teach the patient how to cough effectively. If the patient with copious secretions has difficulty mobilizing secretions, teach his family how to perform postural drainage and chest physiotherapy. If secretions are thick, encourage the patient to drink 12 to 15 glasses of fluid per day.
- Encourage muscle toning by regular exercise.
- If the patient use oxygen therapy at home, teach him how to use the equipment correctly.
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