Transcript Collaborative Care

Chronic Pulmonary Diseases
Asthma and COPD
JSBrinley, RN, MSN/Ed, CNE
Asthma – Definition
• Chronic inflammatory disorder of airways
– Causes airway hyperresponsiveness leading to wheezing,
breathlessness, chest tightness, and cough
– Risk factors
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Genetics
Immune response
Allergens
Exercise
Air pollutants
Occupational factors
Respiratory infections
Nose an sinus problems
Drugs and food additives
GERD
Psychologic
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Triggers of Asthma
Allergens
 May be seasonal or year round depending on
exposure to allergen
– House dust mites
– Cockroaches
– Furry animals
– Fungi
– Molds
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Triggers of Asthma
Exercise
• Induced or exacerbated after exercise
– Pronounced with exposure to cold air
• Breathing through a scarf or mask may ↓ likelihood of
symptoms
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Triggers of Asthma
Air Pollutants
• Can trigger asthma attacks
– Cigarette or wood smoke
– Vehicle exhaust
– Elevated ozone levels
– Sulfur dioxide
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Triggers of Asthma
Occupational Factors
• Most common form of occupational lung
disease
– Exposure to diverse agents
• Arrive at work well, but experience a gradual decline
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Triggers of Asthma
Respiratory Infection
• Major precipitating factor of an acute asthma
attack
– ↑ inflammation hyperresponsiveness of the
tracheobronchial system
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Triggers of Asthma
Nose and Sinus Problems
• Allergic rhinitis and nasal polyps
– Large polyps are removed
– Sinus problems are usually related to
inflammation of the mucous membranes
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Triggers of Asthma
Drugs and Food Additives
• Asthma triad: Nasal polyps, asthma, and
sensitivity to aspirin and NSAIDs
– Wheezing develops in about 2 hours.
– Sensitivity to salicylates
• Found in many foods, beverages, and flavorings
• β-Adrenergic blockers
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Triggers of Asthma
Drugs and Food Additives
• Food allergies may cause asthma symptoms.
– Avoidance diets
– Rare in adults
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Triggers of Asthma
Gastroesophageal Reflux Disease
• Exact mechanism is unknown.
– Reflux of acid could be aspirated into lungs,
causing bronchoconstriction.
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Triggers of Asthma
Emotional Stress
• Psychologic factors can worsen the disease
process.
– Attacks can trigger panic and anxiety.
– Extent of effect is unknown.
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Pathophysiology
Fig. 29-1. Pathophysiology of asthma. IL, Interleukin.
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Pathophysiology
• Primary response is chronic inflammation
from exposure to allergens or irritants.
– Leading to airway hyperresponsiveness and acute
airflow limitations
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Pathophysiology
• Inflammatory mediators cause early-phase
response.
– Vascular congestion
– Edema formation
– Production of thick, tenacious mucus
– Bronchial muscle spasm
– Thickening of airway walls
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Early Phase Response of Asthma
Triggered by Allergen
Fig. 29-2. Allergic asthma is triggered when an allergen cross-links IgE receptors on mast cells, which are then
activated to release histamine and other inflammatory mediators (early-phase response). A late-phase response
may occur due to further inflammation.
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Factors Causing Obstruction
Fig. 29-3. Factors causing obstruction (especially expiratory obstruction) in asthma. A, Cross section of a
bronchiole occluded by muscle spasm, swollen mucosa, and mucus in the lumen. B, Longitudinal section of a
bronchiole.
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Pathophysiology
• Late-phase response
– Occurs within 4 to 10 hours after initial attack
– Occurs in only 30% to 50% of patients
– Can be more severe than early phase and can last
for 24 hours or longer
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Pathophysiology
• Late-phase response
– If airway inflammation is not treated or does not
resolve, it may lead to irreversible lung damage.
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Clinical Manifestations
• Unpredictable and variable
– Recurrent episodes of wheezing, breathlessness,
cough, and tight chest
– May be abrupt or gradual
– Lasts minutes to hours
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Clinical Manifestations
• Expiration may be prolonged.
– Inspiration-expiration ratio of 1:2 to 1:3 or 1:4
– Bronchospasm, edema, and mucus in bronchioles
narrow the airways.
– Air takes longer to move out.
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Clinical Manifestations
• Wheezing is unreliable to gauge severity.
– Severe attacks may have no audible wheezing.
– Usually begins upon exhalation
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Clinical Manifestations
• Cough variant asthma
– Cough is only symptom.
– Bronchospasm is not severe enough to cause
airflow obstruction.
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Clinical Manifestations
• Difficulty with air movement can create a
feeling of suffocation.
– Patient may feel increasingly anxious.
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Clinical Manifestations
• An acute attack usually reveals signs of
hypoxemia.
– Restlessness
– ↑ anxiety
– Inappropriate behavior
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Clinical Manifestations
• More signs of hypoxemia
– ↑ pulse and blood pressure
– Pulsus paradoxus (drop in systolic BP during
inspiratory cycle >10 mm Hg)
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Classification of Asthma
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Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
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Complications
• Severe acute attack
– Respiratory rate >30/min
– Pulse >120/min
– PEFR is 40% at best.
– Usually seen in ED or hospitalized
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Complications
• Life-threatening asthma
 Too dyspneic to speak
 Perspiring profusely
 Drowsy/confused
 Require hospital care and often admitted to ICU
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Diagnostic Studies
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Detailed history and physical exam
Pulmonary function tests
Peak flow monitoring
Chest x-ray
ABGs
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Diagnostic Studies
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Oximetry
Allergy testing
Blood levels of eosinophils
Sputum culture and sensitivity
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Question
• A client is diagnosed with asthma is admitted
to the emergency department with difficulty
breathing. Which diagnostic test will be
ordered to determine the status of the client?
– A.
– B.
– C.
– D.
Complete blood count.
Pulmonary function test.
Allergy skin testing.
Drug cortisol level.
Collaborative Care
• Education
– Start at time of diagnosis.
– Integrate through care.
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Collaborative Care
• Desired therapeutic outcomes
– Control or eliminate symptoms
– Attain normal lung function
– Restore normal activities
– Reduce or eliminate exacerbations and side
effects of medications
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Drug Therapy
Fig. 29-4. Drug therapy: stepwise approach for managing asthma.
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Asthma Control Test
Fig. 29-5.
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Collaborative Care
• Mild intermittent and mild persistent asthma
– Avoid triggers of acute attacks.
– Premedicate before exercising.
• Choice of drug therapy depends on symptom severity.
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Collaborative Care
• Acute asthma episode
– Respiratory distress
– Treatment depends upon severity and response to
therapy.
• Severity measured with flow rates
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Collaborative Care
• Acute asthma episode
– O2 therapy may be started and monitored with
pulse oximetry or ABGs in severe cases.
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Collaborative Care
• Severe exacerbations
– Most therapeutic measures are the same as for
acute episode.
• ↑ in frequency and dose of bronchodilators
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Collaborative Care
 Severe exacerbations
– IV corticosteroids are administered every 4 to 6
hours, then are given orally.
– Continuous monitoring of patient is critical.
– IV magnesium sulfate is given as a bronchodilator.
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Collaborative Care
• Severe exacerbations
– Supplemental O2 is given by mask or nasal cannula
for 90% O2 saturation.
• Arterial catheter may be used to facilitate frequent ABG
monitoring.
– IV fluids are given because of insensible loss of
fluids.
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Question
The nurse anticipates intubation and mechanical
ventilation for the patient with a severe exacerbation of
asthma (status asthmaticus) when:
1. The PaCO2 is 60 mm Hg.
2. The PaO2 decreases to 70 mm Hg.
3. Severe respiratory muscle fatigue occurs.
4. The patient has extreme anxiety and fear of
suffocation.
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Drug Therapy
• Long-term control medications
– Achieve and maintain control of persistent asthma
• Quick-relief medications
– Treat symptoms of exacerbations
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Drug Therapy
• Three types of antiinflammatory drugs
– Corticosteroids
– Leukotriene modifiers
– Monoclonal antibody to IgE
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Drug Therapy
• Corticosteroids (e.g., beclomethasone,
budesonide)
– Suppress inflammatory response
– Inhaled form is used in long-term control.
– Systemic form to control exacerbations and
manage persistent asthma
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Drug Therapy
• Corticosteroids
– Reduce bronchial hyperresponsiveness
– Decrease mucous production
– Are taken on a fixed schedule
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Drug Therapy
• Corticosteroids
– Oropharyngeal candidiasis, hoarseness, and a dry
cough are local side effects of inhaled drug.
• Can be reduced using a spacer or by gargling after each
use
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Spacer
Fig. 29-6. Example of an AeroChamber spacer used with a metered-dose inhaler.
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Drug Therapy
• Leukotriene modifiers or inhibitors (e.g.,
zafirlukast, montelukast, zileuton)
– Block action of leukotrienes—potent
bronchoconstrictors
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Drug Therapy
• Leukotriene modifiers or inhibitors
– Have both bronchodilator and antiinflammatory
effects
– Not indicated for acute attacks
– Used for prophylactic and maintenance therapy
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Drug Therapy
• Anti-IgE (e.g., Xolair)
– ↓ circulating free IgE levels
– Prevents IgE from attaching to mast cells,
preventing release of chemical mediators
– Subcutaneous administration every 2 to 4 weeks
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Drug Therapy
• Three types of bronchodilators
– β2-Adrenergic agonists
– Methylxanthines
– Anticholinergics
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Drug Therapy
• β-Adrenergic agonists (e.g., albuterol,
metaproterenol)
– Effective for relieving acute bronchospasm
– Onset of action in minutes and duration of 4 to 8
hours
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Drug Therapy
• β-Adrenergic agonists
– Prevent release of inflammatory mediators from
mast cells
– Not for long-term use
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Question
• The client is diagnosed with mild intermittent
asthma. Which medication would the nurse
discuss with the client?
– A.
– B.
– C.
– D.
Daily inhaled corticosteroids.
Use of a “rescue inhaler.”
Use of systemic steroids.
Leudotriene agonists.
Drug Therapy
• Methylxanthines (e.g., theophylline)
– Less effective long-term bronchodilator
– Alleviates early phase of attacks but has little
effect on bronchial hyperresponsiveness
– Narrow margin of safety
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Drug Therapy
• Anticholinergic drugs (e.g., ipratropium)
– Block action of acetylcholine
– Usually used in combination with a bronchodilator
– Most common side effect is dry mouth.
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Patient Teaching Related to
Drug Therapy
• Correct administration of drugs is a major
factor in success.
– Inhalation of drugs is preferable to avoid systemic
side effects.
• MDIs, DPIs, and nebulizers are devices used to inhale
medications.
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Patient Teaching Related to
Drug Therapy
• Correct administration of drugs
– Using an MDI with a spacer is easier and improves
inhalation of the drug.
– DPI (dry powder inhaler) requires less manual
dexterity and coordination.
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Example of DPI
Fig. 29-8. Example of a dry powder inhaler (DPI).
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Nursing Management
Nursing Assessment
• Health history
– Especially of precipitating factors and medications
• ABGs
• Lung function tests
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Nursing Management
Nursing Assessment
• Physical examination
– Use of accessory muscles
– Diaphoresis
– Cyanosis
– Lung sounds
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Nursing Management
Nursing Diagnoses
• Ineffective airway clearance
• Anxiety
• Deficient knowledge
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Nursing Management
Planning
• Overall Goals
– Maintain greater than 80% of personal best PEFR
– Have minimal symptoms
– Maintain acceptable activity levels
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Nursing Management
Planning
• Overall Goals
– Few or no adverse effects
– No recurrent exacerbations of asthma or
decreased incidence of asthma attacks
– Adequate knowledge to participate in and carry
out management
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Nursing Management
Health Promotion
• Teach patient to identify and avoid known
triggers.
– Use dust covers
– Use scarves or masks for cold air
– Avoid aspirin or NSAIDs
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Nursing Management
Health Promotion
• Prompt diagnosis and treatment of upper
respiratory infections and sinusitis may
prevent exacerbation.
• Fluid intake of 2 to 3 L every day
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Nursing Management
Nursing Implementation
• Acute intervention
– Monitor respiratory and cardiovascular systems:
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Lung sounds
Respiratory rate
Pulse
BP
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Nursing Management
Nursing Implementation
• An important goal of nursing is to ↓ the
patient’s sense of panic.
– Stay with patient.
– Encourage slow breathing using pursed lips for
prolonged expiration.
– Position comfortably.
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Nursing Management
Nursing Implementation
• Ambulatory and home care
– Must learn about medications and develop selfmanagement strategies
– Patient and health care professional must monitor
responsiveness to medication.
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Nursing Management
Nursing Implementation
• Ambulatory and home care
– Patient must understand importance of continuing
medication when symptoms are not present.
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Question
• The client is diagnosed with exercise-induced
(EIA) is being discharged. Which information
should the nurse include in the discharge
teaching?
– A. Take two (2) puffs on the rescue inhaler and wait
five (% minutes before exercising.
– B. Warm-up exercises will increase the potential for
developing the asthma attacks.
– C. Use the bronchodilator inhaler immediately prior
to beginning to exercise.
– D. Increase dietary intake of food high in
monosodium glutamate (MSG).
Nursing Management
Nursing Implementation
• Important patient teaching
– Seek medical attention for bronchospasm or when
severe side effects occur.
– Maintain good nutrition.
– Exercise within limits of tolerance.
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Nursing Management
Nursing Implementation
• Important patient teaching
– Measure peak flow at least daily.
– Asthmatic individuals frequently do not perceive
changes in their breathing.
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Nursing Management
Nursing Implementation
• Peak flow should be monitored daily and a
written action plan should be followed
according to results of daily PEFR.
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Nursing Management
Nursing Implementation
• Peak flow results
– Green Zone
• Usually 80% to 100% of personal best
• Remain on medications.
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Nursing Management
Nursing Implementation
 Peak flow results
 Yellow Zone
 Usually 50% to 80% of personal best
 Indicates caution
 Something is triggering asthma.
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Nursing Management
Nursing Implementation
• Peak flow results
– Red Zone
• 50% or less of personal best
• Indicates serious problem
• Definitive action must be taken with health care
provider.
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Case Study
• A 30-year-old woman comes to the
emergency department with severe
wheezing, dyspnea, and anxiety.
• She recently had a cold that did not
resolve.
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Case Study
• She had taken a new job at a dry cleaners and
laundromat.
• She has been having regurgitation of food
after eating, which she related to the stress
from her recent divorce.
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Case Study
• She is upset that her children had just brought
home a stray cat.
• She does not know if she was allergic to the
cat.
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Discussion Questions
1. What possible asthma triggers may she
be experiencing?
2. Are there any possible triggers that she
can avoid or manage?
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Discussion Questions
3. What are her priorities of care?
4. What patient teaching topics should you
cover with her?
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COPD
Description
• Airflow limitation not fully reversible
– Generally progressive
– Abnormal inflammatory response of lungs to
noxious particles or gases
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COPD
Description
• Includes
– Chronic bronchitis
– Emphysema
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COPD
Significance
• Fourth leading cause of death in the United
States
• More women die than men
• Death rates in Hispanics are lower than in any
other ethnic group
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COPD
Etiology
• Risk factors
– Cigarette smoking
– Occupational chemicals and dust
– Air pollution
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COPD
Etiology
• Risk factors
– Infection
– Heredity
– Aging
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COPD
Cigarette Smoking
• Clinically significant airway obstruction
develops in 15% of smokers.
• 80% to 90% of COPD deaths are related to
tobacco smoking.
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COPD
Cigarette Smoking
• Effects of nicotine
– Stimulates sympathetic nervous system
• Increases HR
• Causes peripheral vasoconstriction
• Increases BP and cardiac workload
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COPD
Cigarette Smoking
• Effects of nicotine
– ↓ Amount of functional hemoglobin
– ↑ Platelet aggregation
– Compounds problems in CAD
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COPD
Cigarette Smoking
• Effects on respiratory tract
– Increased production of mucus
– Hyperplasia of mucous glands
– Lost or decreased ciliary activity
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COPD
Cigarette Smoking
• Carbon monoxide
– ↓ O2 carrying capacity
• ↑ Heart rate
• Impaired psychomotor performance and judgment
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COPD
Cigarette Smoking
• Passive smoking (second-hand smoke)
– ↓ Pulmonary function
– ↑ Risk of lung cancer
– ↑ Respiratory symptoms
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COPD
Occupational & Environmental
• COPD can develop with intense or prolonged
exposure to
– Dusts, vapors, irritants, or fumes
– High levels of air pollution
– Fumes from indoor heating or cooking with fossil
fuels
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COPD
Infection
• Recurring infections impair normal defense
mechanisms.
• Risk factor for COPD
• Intensify pathologic destruction of lung tissue
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COPD
Aging
• Some degree of emphysema is common
because of physiologic changes of aging lung
tissue.
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Question
• The nurse is assessing the client with COPD.
Which health promotion information is most
important for the nurse to obtain?
– A.
– B.
– C.
– D.
Risk factors for complications.
Ability to administer inhaled medication.
Willingness to modify lifestyle.
Number of years the client has smoked.
COPD
Pathophysiology
• Defining features
– Irreversible airflow limitations during forced
exhalation due to loss of elastic recoil
– Airflow obstruction due to mucous
hypersecretion, mucosal edema, and
bronchospasm
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COPD
Pathophysiology
• Primary process is inflammation.
– Inhalation of noxious particles
– Mediators released cause damage to lung tissue.
– Airways inflamed
– Parenchyma destroyed
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COPD
Pathophysiology
Fig. 29-9. Pathophysiology of COPD.
Fig. 29-7
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COPD
Pathophysiology
• Supporting structures of lungs are destroyed.
– Air goes in easily, but remains in the lungs.
– Bronchioles tend to collapse.
– Causes barrel-chest look
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COPD
Pathophysiology
• Pulmonary vascular changes
– Blood vessels thicken.
– Surface area for diffusion of O2 decreases.
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COPD
Pathophysiology
• Common characteristics
– Mucous hypersecretion
– Dysfunction of cilia
– Hyperinflation of lungs
– Gas exchange abnormalities
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Pulmonary Blebs and Bullae
Fig. 29-10. Pulmonary blebs and bullae.
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COPD
Pathophysiology
• Commonly, emphysema and chronic
bronchitis coexist.
• Distinguishing symptoms can be difficult with
co-morbidities.
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COPD
Clinical Manifestations
• Develops slowly
• Diagnosis is considered with
– Cough
– Sputum production
– Dyspnea
– Exposure to risk factors
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COPD
Clinical Manifestations
• Dyspnea usually prompts medical attention.
– Occurs with exertion in early stages
– Present at rest with advanced disease
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COPD
Clinical Manifestations
• Causes chest breathing
– Use of accessory and intercostal muscles
– Inefficient
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COPD
Clinical Manifestations
• Characteristically underweight with adequate
caloric intake
• Chronic fatigue
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COPD
Clinical Manifestations
• Physical examination findings
– Prolonged expiratory phase
– Wheezes
– Decreased breath sounds
– ↑ Anterior-posterior diameter
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COPD
Clinical Manifestations
• Bluish-red color of skin
– Polycythemia and cyanosis
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Question
• Which clinical manifestation should the nurse
expect to assess in the client recently
diagnosed with COPD?
– A.
– B.
– C.
– D.
Clubbing of the client’s fingers.
Infrequent respiratory infections.
Chronic sputum production
Nonproductive hacking cough.
COPD
Classification
• Classified as
– Mild
– Moderate
– Severe
– Very severe
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COPD
Complications
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Cor pulmonale
Exacerbations of COPD
Acute respiratory failure
Peptic ulcer disease
Depression/anxiety
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COPD
Cor Pulmonale
• Hypertrophy of right side of heart
– Result of pulmonary hypertension
– Late manifestation of chronic pulmonary heart
disease
– Eventually causes right-sided heart failure
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Pathophysiology of Cor Pulmonale
Fig. 29-12. Mechanisms involved in the pathophysiology of cor pulmonale secondary to chronic obstructive
pulmonary disease.
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COPD
Cor Pulmonale
• Dyspnea
• Distended neck veins
• Hepatomegaly with upper quadrant
tenderness
• Peripheral edema
• Weight gain
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COPD
Exacerbations
• Signaled by change in usual
– Dyspnea
– Cough
– Sputum
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COPD
Exacerbations
• Associated with poorer outcomes
• Primary causes
– Infection
– Air pollution
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COPD
Acute Respiratory Failure
• Caused by
– Exacerbations
– Cor pulmonale
– Discontinuing bronchodilator or corticosteroid
medication
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COPD
Acute Respiratory Failure
• Caused by
– Overuse of sedatives, benzodiazepines, and
opioids
– Surgery or severe, painful illness involving chest or
abdomen
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COPD
Depression/Anxiety
• Approximately 50% of COPD patients
experience depression.
• If patient become anxious because of
dyspnea, teach pursed lip breathing.
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COPD
Diagnostic Studies
• Diagnosis confirmed by pulmonary function
tests
– Chest x-rays, spirometry, history, and physical
examination are also important in the diagnostic
workup.
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COPD
Diagnostic Studies
• Spirometry typical findings
– Reduced FEV/FVC ratio
– Increased residual volume
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COPD
Diagnostic Studies
• ABG typical findings
– Low PaO2
– ↑ PaCO2
– ↓ pH
– ↑ Bicarbonate level found in late stages of COPD
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COPD
Diagnostic Studies
• 6-Minute walk test to determine O2
desaturation in the blood with exercise
• ECG can show signs of right ventricular failure.
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COPD
Collaborative Care
• Primary goals of care
– Prevent progression.
– Relieve symptoms.
– Prevent/treat complications.
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COPD
Collaborative Care
• Primary goals of care
– Promote patient participation.
– Prevent/treat exacerbations.
– Improve quality of life and reduce mortality risk.
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COPD
Collaborative Care
• Irritants should be evaluated and avoided.
• Exacerbations treated promptly
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COPD
Collaborative Care
• Smoking cessation
– Most effective intervention
– Accelerated decline in pulmonary function slows
and usually improves.
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COPD
Collaborative Care
• Drug therapy
– Bronchodilators
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•
•
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Relax smooth muscle in the airway
Improve ventilation of the lungs
↓ Dyspnea and ↑ FEV1
Inhaled route is preferred.
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COPD
Collaborative Care
• Drug therapy
– Commonly used bronchodilators
• β2-Adrenergic agonists
• Anticholinergics
• Methylxanthines
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COPD
Collaborative Care
• Drug therapy
– Long-acting anticholinergic
 Tiotropium (Spiriva)
– Inhaled corticosteroid therapy
• Used for moderate to severe cases
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COPD
Collaborative Care
• O2 therapy is used to
– Reduce work of breathing
– Maintain PaO2
– Reduce workload on the heart
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COPD
Collaborative Care
• Long-term O2 therapy improves
– Survival
– Exercise capacity
– Cognitive performance
– Sleep in hypoxemic patients
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COPD
Collaborative Care
• O2 delivery systems are high or low flow.
– Low flow is most common.
– Low flow is mixed with room air, and delivery is
less precise than high flow.
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COPD
Collaborative Care
• Humidification
– Used because O2 has a drying effect on the
mucosa
– Supplied by nebulizers, vapotherm, and bubblethrough humidifiers
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COPD
Collaborative Care
• Complications of oxygen therapy
– Combustion
– CO2 narcosis
– O2 toxicity
– Absorption atelectasis
– Infection
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COPD
Collaborative Care
• Chronic O2 therapy at home improves
– Prognosis
– Mental acuity
– Exercise intolerance
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COPD
Collaborative Care
• Chronic O2 therapy at home reduces
– Hematocrit
– Pulmonary hypertension
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COPD
Collaborative Care
• Chronic O2 therapy at home
– Periodic reevaluations are necessary to determine
duration of use.
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COPD
Collaborative Care
• Surgical therapy
– Lung volume reduction surgery
• Remove diseased lung to enhance performance of
remaining tissue
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COPD
Collaborative Care
• Surgical therapy
– Bullectomy
• Used for emphysema
• Large bullae are resected to improve lung function.
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COPD
Collaborative Care
• Surgical therapy
– Lung transplantation
• Single lung—Most common because of donor
shortages
• Prolongs life
• Improves functional capacity
• Enhances quality of life
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COPD
Collaborative Care
• Respiratory and physical therapy
– Breathing retraining
– Effective coughing
– Chest physiotherapy
• Percussion
• Vibration
• Postural drainage
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COPD
Collaborative Care
• Respiratory and physical therapy
– Airway clearance devices
– High-frequency chest wall oscillation
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COPD
Collaborative Care
• Breathing retraining
– Decreases dyspnea, improves oxygenation, and
slows respiratory rate
• Pursed lip breathing
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COPD
Collaborative Care
• Pursed lip breathing
– Prolongs exhalation and prevents bronchiolar
collapse and air trapping
150
COPD
Collaborative Care
• Effective coughing
– Main goals
• Conserve energy.
• Reduce fatigue.
• Facilitate removal of secretions.
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COPD
Collaborative Care
• Chest physiotherapy indicated for
– Excessive, difficult-to-clear bronchial secretions
– Retained secretions in artificial airway
– Lobular atelectasis from mucous plug
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COPD
Collaborative Care
• Postural drainage
– Gravity assists in bronchial drainage.
– Techniques are individualized according to
patient’s pulmonary condition and response to
initial treatment.
– Commonly ordered 2 to 4 times per day
153
COPD
Collaborative Care
• Percussion
– Hands in a cuplike position to create an air pocket
– Air-cushion impact facilitates movement of thick
mucus.
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Cupped-Hand Position
Fig. 29-15. Cupped-hand position for percussion. The hand should be cupped as though scooping up water.
Fig. 29-16
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COPD
Collaborative Care
• No percussion over
– Kidneys
– Sternum
– Spinal cord
– Bony prominences
– Tender or painful area
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COPD
Collaborative Care
• Vibration
– Facilitates movement of secretions to larger
airways
– Mild vibration tolerated better than percussion
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COPD
Collaborative Care
• Flutter mucus clearance device
– Produces vibration in lungs to loosen mucus for
expectoration
– Hand-held device
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COPD
Collaborative Care
• High-frequency chest wall oscillation
– Inflatable vest that vibrates the chest
– Works on all lobes
– More effective than CPT
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COPD
Collaborative Care
• Acapella
– Vibrates lungs to shake free mucous plugs
– Improves clearance of secretions
– Faster and more tolerable than CPT
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Acapella
Fig. 29-17. Acapella.
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COPD
Collaborative Care
• Nutritional therapy
– Weight loss and malnutrition are common.
• Pressure on diaphragm from a full stomach causes
dyspnea.
• Difficulty breathing while eating leads to inadequate
consumption.
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COPD
Collaborative Care
• Nutritional therapy
– To decrease dyspnea and conserve energy
• Rest at least 30 minutes before eating.
• Use bronchodilator.
• Prepare foods in advance.
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COPD
Collaborative Care
• Nutritional therapy
– Eat five to six small meals to avoid bloating and
early satiety.
– Cold foods may cause less fullness than hot foods.
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COPD
Collaborative Care
• Nutritional therapy
– Avoid
• Foods that require a great deal of chewing
• Exercises and treatments 1 hour before and after eating
• Gas-forming foods
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COPD
Collaborative Care
• Nutritional therapy
– High-calorie, high-protein diet is recommended.
– Fluids (intake of 3 L/day) should be taken between
meals.
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Nursing Management
Nursing Assessment
• Obtain complete health history and conduct a
complete physical assessment.
– See Table 29-24 in textbook for COPD-specific
information.
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Nursing Management
Nursing Diagnoses
• Ineffective airway clearance
• Impaired gas exchange
• Imbalanced nutrition: Less than body
requirements
• Risk for infection
• Insomnia
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Question
• Which outcome is appropriate for the client
problem “ineffective gas exchange” for the client
recently diagnosed with COPD?
– A. The client demonstrates the correct way to pursedlip breathe.
– B. The client lists three (3) signs/symptoms to report
to the HCP.
– C. The client will drink at least 2,500 mL of water
daily.
– D. The client will be able to ambulate 100 feet with
dyspnea.
Nursing Management
Planning
• Goals
– Prevention of disease progression
– Ability to perform ADLs
– Relief from symptoms
– No complications related to COPD
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Nursing Management
Planning
• Goals
– Knowledge and ability to implement long-term
regimen
– Overall improved quality of life
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Nursing Management
Nursing Implementation
• Health promotion
– Abstain from or stop smoking.
– Avoid or control exposure to occupational and
environmental pollutants and irritants.
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Nursing Management
Nursing Implementation
• Health promotion
– Early detection of small-airway disease
– Early diagnosis and treatment of respiratory tract
infection
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Nursing Management
Nursing Implementation
• Health promotion
– Awareness of family history of COPD and AAT
deficiency
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Nursing Management
Nursing Implementation
• Acute intervention
– Required for pneumonia, cor pulmonale, or acute
respiratory failure
– Degree and severity of underlying respiratory
problem should be assessed.
175
Nursing Management
Nursing Implementation
• Ambulatory and home care
– Most important aspect is teaching.
•
•
•
•
•
Pulmonary rehabilitation
Activity considerations
Sexual activity
Sleep
Psychosocial considerations
176
Nursing Management
Nursing Implementation
• Pulmonary rehabilitation
– Increase exercise performance.
– Reduce dyspnea.
– Improve quality of life.
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Nursing Management
Nursing Implementation
• Activity considerations
– Exercise training leads to energy conservation.
• In upper extremities, it may improve muscle function
and reduce dyspnea.
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Nursing Management
Nursing Implementation
• Activity considerations
– Modify ADLs to conserve energy.
– Walk 15 to 20 minutes a day at least
3 times a week with gradual increases.
• Adequate rest should be allowed.
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Nursing Management
Nursing Implementation
• Activity considerations
– Exercise-induced dyspnea should return to
baseline within 5 minutes after exercise.
180
Nursing Management
Nursing Implementation
• Sexual activity
– Plan when breathing is best.
– Use slow, pursed lip breathing.
– Refrain after strenuous activity.
– Do not assume dominant position or prolong
foreplay.
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Nursing Management
Nursing Implementation
• Sleep
– Can be difficult because of medications, postnasal
drip, or coughing
• Nasal saline sprays, decongestants, or nasal steroid
inhalers can help.
182
Nursing Management
Nursing Implementation
• Psychosocial considerations
– Healthy coping is difficult.
– May feel guilt, depression, anxiety, social isolation,
denial, and dependence
183
Nursing Management
Evaluation
• Expected outcomes
– Normal breath sounds
– Effective coughing
– Return of PaO2 to normal range for patient
– Improved mental status
184
Nursing Management
Evaluation
• Expected outcomes
– Maintenance of normal body weight
– Normal serum protein levels
– Feeling of being rested
– Improvement in sleep pattern
185
Nursing Management
Evaluation
• Expected outcomes
– Awareness of need to seek medical attention
– Behaviors minimizing risk of infection
– No infection
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Question
When reviewing the arterial blood gases of a patient with COPD,
the nurse identifies late stage COPD with which of the following
results?
1. pH 7.26, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3
30 mEq/L
2. pH 7.30, PaCO2 45 mm Hg, PaO2 55 mm Hg, HCO3
18 mEq/L
3. pH 7.40, PaCO2 40 mm Hg, PaO2 70 mm Hg, HCO3
25 mEq/L
4. pH 7.52, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3
35 mEq/L
-
-
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Case Study
• 77-Year-old man presents to the hospital
complaining of shortness of breath, morning
cough, and swelling in his lower extremities.
• He has difficulty breathing when he walks.
188
Case Study
• States sleeping in a recliner to make it easier
to breathe
• Feels his shoes are tight at the end of the day
189
Case Study
• Has smoked one pack of cigarettes a day for
the past 30 years
• His breathing is labored.
• Breath sounds faint with prolonged expiration
190
Case Study
• His arterial blood gases show ↓ PaO2 and ↑
PaCO2.
• Chest x-rays show hyperinflation of the lungs.
• 2+ peripheral edema bilateral lower
extremities
191
Discussion Questions
1. He is diagnosed with COPD. What is the basis
for this diagnosis?
2. Why does he have swelling of his feet and
ankles?
192
Discussion Questions
3.
What important teaching measures should
you incorporate into his plan of care?
193