NURS 308 - Chronic Obstructive Pulmonary Disease

apprehension (anxiety)

restlessness

irritability

confusion

lethargy

combativeness

coma

neurological manifestations of hypoxemia:

tachypnea

dyspnea

use of accessory muscles

retractions

pauses for breaths between words or sentences

* tachypnea because the lungs are trying to compensate for lack of oxygen

respiratory manifestations of hypoxemia:

tachycardia

blood pressure abnormalities

dysrhythmias

cyanosis

cool, clammy skin

* tachycardia because the heart is trying to compensate for lack of oxygen by beating faster to increase cardiac output and get more oxygen out to the body

cardiovascular manifestations of hypoxemia:

- chest wall muscles stiffen

- decreased alveolar elasticity *holds on to old, stale air

- decreased respiratory muscle strength

- decreased immune function

- decreased ciliary function *increases risk for infection

- decreased cough force *inability to clear lungs of secretions

- decreased response to hypoxia

- decreased response to hypercapnia

* no symptoms of hypoxia, so we are unaware. no symptoms of hypercapnia, so they won’t speed up their breathing, and respiratory acidosis may result

gerontologic considerations of respiratory function:

COPD

chronic, progressive lung disease (worsens over time)

no smoking

the number one way to prevent COPD

COPD

persistent airflow limitation that is usually progressive, and is associated with an enhanced chronic inflammatory response in airways and the lung to noxious particles or gasses

chronic bronchitis

* most people with COPD have a combination of both airflow limitation due to chronic inflammation (chronic bronchitis) and destruction of alveoli which impairs gas exchange (emphysema)

chronic cough and sputum production with airflow limitation

emphysema

* most people with COPD have a combination of both airflow limitation due to chronic inflammation (chronic bronchitis) and destruction of alveoli which impairs gas exchange (emphysema)

destruction of the alveoli, impaired gas exchange

- cigarette smoking *major risk factor

- occupational chemicals and dust

- air pollution

- recurrent respiratory infections, especially in childhood *scars the lungs and alveoli

- genetics *AAT deficiency

- aging

- asthma

- gender *men more likely

risks of COPD:

- chronic cough and sputum production *productive cough

- progressive dyspnea, air hunger

- expiratory wheeze

- fatigue

- unexplained weight loss and anorexia, thin in appearance

- barrel chest *1:1 AP:lat

- tripod positioning, orthopnea

- pursed-lip breathing

- use of accessory muscles

- prolonged expiratory time

- edema in ankles **right HF

- digital clubbing *chronic hypoxia

- hypoxemia

- O2 sat < 88%

- hypercapnia

- polycythemia *compensatory elevation of RBCs - body produced excess hemoglobin in an attempt to hold on to more oxygen and provide more oxygen to the tissues

- bluish-red discoloration of the skin *cyanosis + polycythemia

clinical manifestations of COPD:

cor pulmonale

acute exacerbations

acute respiratory failure

complications of COPD:

cor pulmonale

caused primarily by constriction of pulmonary vessels due to alveolar hypoxia - leads to high pressures in the lungs, which leads to high pressures on the right side of the heart, leading to right sided heart failure

acute exacerbations

the number one complication of COPD

acute respiratory failure

* most commonly precipitated by discontinuing medications, exacerbations, or waiting too long to contact the healthcare provider

most life-threatening complication of COPD

- higher incidence of exacerbation and hospitalizations

- gradual loss of lung’s elastic recoil in the alveoli

- changes in lung structure *lungs get smaller and rounded

- decreased number of functional alveoli *similar to emphysema

- comorbidities are common and increase the risk (cardiovascular disease, infections, osteoporosis, psychological changes, problems with cognition, lung cancer)

- weakness

- impaired quality of life

gerontologic considerations of COPD:

post-bronchodilator spirometry

* measures forced expiratory volume and end tidal volume

the gold standard diagnostic test of COPD that confirms a suspected COPD diagnosis

forced expiratory volume

measures how much air the patient can expel in one second

end tidal volume

measures how much air the patient was able to expel from their lungs completely

a flattening of the diaphragm and hyperinflation of the lungs

* not a definitive diagnostic

a CXR in a patient with COPD generally shows:

AAT deficiency (α1 antitrypsin)

*genetic disorder

diagnostic test that may be completed if a patient has no risk factors of COPD, but symptoms of COPD

short-acting beta agonists (SABA) *rescue

* SABA drugs dilates the bronchial tree, allows increased oxygenation, relieves symptoms, and prevents respiratory failure

medication for COPD indicated when the patient is having symptoms: increased cough, increased sputum production, SOB, hypoxia

long-acting beta agonists (LABA) *control

* LABA drugs should be taken every day, even if no symptoms are present (prevents exacerbation and symptoms)

medication for COPD that maintains the dilation of the bronchial tree and optimizes respiratory function

inhaled corticosteroids

* should be taken every day, even if no symptoms are present

medication for COPD indicated for chronic inflammation

> 90%

* for patients with advanced COPD (gold 3, gold 4) it may not be possible to get their O2 sat to 93% or above

* patients with early COPD and not on oxygen therapy (gold 1, gold 2) should maintain an O2 sat in the normal range (above 93%)

the goal for a patient with COPD on chronic oxygen therapy is an O2 sat of _____ during rest, sleep, and exertion

COPD patients become tolerant of high CO2, so their drive to breathe becomes hypoxia. elevated PO2 with oxygen therapy can diminish their drive to breathe

also are at risk for O2 toxicity because of air trapping *O2 toxicity can cause scarring in the lungs, cerebral edema, problems with the eyes, etc.

why should you administer oxygen with caution for a patient with COPD?

increases pressure in the alveoli, allowing for better gas exchange

how does pursed-lip breathing help a patient with COPD?

- effective huff coughing *helps to mobilize secretions

- chest physiotherapy *helps to break up secretions

- postural drainage

- airway clearance devices *positive expiratory pressure, increases expiratory force

airway clearance techniques (ACTs):

increased inflammatory mediators

increased metabolic rate

lack of appetite

weight loss *predictor of poor prognosis

malnutrition in COPD is caused by:

high protein

moderate carbohydrates

moderate to high fat

5-6 small meals daily

supplements for additional protein and calories

** avoid foods that require a great deal of chewing. complete exercises and treatments 1 hour before and after eating so that the body can use the energy and metabolism to digest their meals. avoid gas forming foods

a balanced diet for a patient with COPD should include:

gas in the GI tract further limits the space in the thoracic cavity, increasing SOB

why should you avoid gas-forming foods for a patient for COPD?

- rest at least 30 minutes before eating

- avoid exercise for 1 hour before and after eating

- use a bronchodilator

- supplemental O2 therapy may be helpful *may have to complete intermittently throughout the meal because O2 alters their taste

- high-calorie, high-protein diet is recommended

- eat 5-6 small meals to avoid bloating and early satiety

what can you do to decrease dyspnea and conserve energy demands for a patient with COPD?

lung volume reduction surgery (LVRS)

surgery indicated for patients with a significant barrel chest - the most diseased portion of the lung is removed so the remaining portion can work better (reduces the nonfunctional lung volume, keeping the functional lungs intact)

bronchoscopic LVRS

surgery indicated for patients with COPD - similar to LVRS, one-way valves are implanted so that air goes out and can't get back in

bullectomy

surgery indicated for patients with COPD - bullae (large sacks that form when the alveoli are destroyed) are removed surgically; removes non functioning alveoli so that more air can go into the functioning alveoli, improving gas exchange

arrhythmias

hypoxia can affect the heart muscle as well, leading to ______

weight loss

muscle atrophy

*something that hospice looks at to determine eligibility

prognostic factors of COPD, indicating that the condition is worsening

relief of symptoms

the number one nursing goal for a patient with COPD

- monitor respiratory function (vital signs, O2 sat, lung sounds, respiratory effort, manifestations of hypoxia)

- daily weights, I&O *risk for right sided HF

- administer O2 as prescribed and as indicated *when the limit of the titration order is reached, call the provider

- encourage use of incentive spirometry *helps to expand the alveoli and loosen secretions to be coughed up

- position to optimize respiratory function (high fowler’s or tripod position)

- give IV fluids and encourage oral fluids *maintaining hydration thins the respiratory secretions so they can be loosened and coughed up

- promote rest periods and limit visitors as needed

- ensure adequate nutrition with small frequent meals and supplements

nursing management of an acute COPD exacerbation: