Resource Unit On The Care Of The Client With Chronic Obstructive Pulmonary Disease

Submitted to:

Asst. Prof. Marnesa P. Campoy

Submitted by:

Tingas, Czarina Torres, Diana Jane

Placement: Level IV- 2nd Semester , S.Y. 2013-2014 Rotation: Medicine Rotation, Silliman Medical Center (SMC) Time Allotment: 60mins General Objective: At the end of the ward class report, the learners will gain knowledge about COPD and that they will enhance their ability to perform care of patients having this condition, and manifest desirable outcome of care on the management of COPD clients.

SPECIFIC OBJECTIVES Given the resources and the use of the conceptual approach the learners shall grasp the concept of the care of the client with Chronic Obstructive Pulmonary Disease by: I. Prayer

CONTENT

T/A

T-L ACTIVITIES

RESOURCES

EVALUATION

1 min 2 mins Lectutre discussion with powerpoint presentatio n and visual aids
Marieb, E. (2006). Essentials of human anatomy and physiology. 8th edition. Singapore: Pearson education, Inc.

II. Introduction 1. Discuss briefly the structures and functions of the III. Anatomy and physiology of the Respiratory respiratory system System
Anatomy: Locate selected parts of the respiratory system. Epiglottis Glottis bronchus bronchiole alveolus diaphragm

5 mins

Comprehensive discussion of the anatomy and physiology of the respiratory system and pathophysiology of COPD.

2. Differentiate the 2 types of COPD

IV. Types of COPD A. Emphysema

-an abnormal distention of the air spaces beyond the terminal bronchioles, with destruction of alveoli. -there is an impaired gas oxygen and carbon dioxide exchange results from destruction of the walls of over distended alveoli -it is the end stage of a process that has progressed slowly for many years -As the walls of alveoli are destroyed, the alveolar surface area in direct contact with the pulmonary capillaries continually decreases, causing in the increase the dead space and impaired oxygen diffusion, which leads to hypoxemia. -in the later stages of disease, carbon dioxide elimination is impaired, resulting in increased carbon dioxide tension in arterial blood and causes respiratory acidosis -as the alveolar walls continue to break down, the pulmonary blood flow is increased forcing, forcing the right ventricle to maintain a higher blood pressure in the pulmonary artery. Hyporexemia may further

5 mins

Lectutre discussion with powerpoint presentatio n and visual aids

Smeltzer, S. (2008). Textbook of medicalsurgical nursing. 11th ed. Lipincott Williams and Wilkins.

increase pulmonary artery pressures. -for this reason, right sided heart failure is one of the complications of emphysema.

B. Bronchitis
-presence of cough and sputum production for at least 3 months in each of two consecutive years. -constant irritation of airways (smoke or other environmental pollutants) causes mucus-secreting glands and goblet cells to increase in number. Ciliary function is reduced, and more mucus is produced -bronchial walls becomes thickened, the bronchial lumen narrows and mucus may plug the airway -alveoli adjacent to bronchioles may become damaged and fibrosed, resulting in altered function of the alveolar macrophages. -which then causes patient to be more susceptible to respiratory infection.

3. Describe the pathophysiology of COPD from the onset of injury to the rehabilitation phase

V. Pathophysiology - COPD is characterized by chronic inflammation found in the airways, lung parenchyma (gas-exchanging surfaces of the lung [respiratory bronchioles and alveoli], and pulmonary vasculature).

15mins

Black J. & Hawks, J. (2004). Medicalsurgical nursing. 7th edition. Singapore:

The pathogenesis of COPD is complex and involves many mechanisms. However, the primary process is inflammation.
Risk factors for COPD Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases Passive smoking Occupational exposure Ambient air pollution Genetic abnormalities, including a deficiency of a alpha1-antitrypsin, an enzyme inhibitor that normally counteracts the destruction of lung tissue by certain other enzymes.

Elsevier, Inc.

Lectutre discussion with powerpoint presentatio n and visual aids

4. Identify at least 4 out of 7 clinical manifestations of COPD.. VI. Clinical manifestation - Cough (may be productive or intermittent) - Dyspnea - Activity intolerance - Crackles, wheezes, diminished breath sounds - Barrel chest - Use of accessory muscle - Elevated PaCO2, decreased PaO2

5mins

Lewis, S. et.al (2005). Medical- Surgical Nursing Assessment and Management of Clinical Problems.

5. Give 4 common diagnostic study results and its implications.

VII. Diagnostic findings History taking and Physical Examination

a thorough health history should be obtain for patients with known or potential COPD. -Key factors to assess o o o o o Exposure to risk factors- types, intensity, duration Past medical history Family history of COPD or other chronic disease Pattern of symptom development History of exacerbations or previous hospitalizations for respiratory problems Presence of co-morbidities Appropriateness of current medical treatments Impact of the disease on quality of life Available social and family support for patient Potential for reducing risk factors

5 mins

Correct assessment and identification of diagnosis, pharmacology and collaborative care at 76% level of competency.

o o o o o

Chest X-ray o to determine presence of inflamed bronchioles or presence of mucus. o seldom diagnostic in COPD unless obvious
bollous disease is present.

Pulmonary function tests o are performed to assess lung function and

determine the degree of damage to the lungs. Pulmonary function tests are used for a number of reasons: o Screening for the existence of lung diseases o Determining the patient's condition prior to surgery to assess the risk of respiratory complications after surgery. o Evaluating the ability for a patient to be weaned from a ventilator o Assessing the progression of lung disease and the effectiveness of treatment Types of Pulmonary Testing o o Spirometry is the most common of all pulmonary function test used to evaluate airflow obstruction, which is determined by the ratio of FEV1 to forced vital capacity (FVC). when there is an obstruction on the airway there will be a decrease on FEV1. obstructive lung disease is defined as a FEV1/FVC ratio of less than 70%. Commonly used for knowing the COPD stages Stage 0 (at risk) Characteristics

Huether, S. & McCance, K.(2008). Understanding Pathophysiology. 4th edition. Singapore: Elsevier Inc.

o o o

Normal spirometry Chronic symptom of cough, sputum production I (mild COPD) FEV1/FVC<70% FEV1 80% predicted With orwithout chronic symptoms of cough, sputum production

II (moderate FEV1/FVC<70% COPD) FEV1 50-80% Predicted With withoutchronic symptoms of cough,sputum production III (severe FEV1/FVC<70% COPD) FEV1<30-50% or

predicted With withoutchronic symptoms IV severe) (very FEV1/FVC<70% FEV1<30-50% predicted Chronic respiratory failure

or

Exercise testing-used to measure the performance of your heart and lungs during strenuous exercise - will be asked to run on a treadmill or use an exercise bicycle for a period of time, during which the exercise is made increasingly more strenuous - During this exercise, patients breathing, heart rate and blood oxygen level can be measured to give a picture of your heart and lung function.

Serum 1 - antitrypsin levels

may be performed for patients younger than 45 years old and those with strong family history of COPD.

ABGs - Arterial blood gas (ABG) measurements

provide information on how well your lungs transfer oxygen into your blood and how well they remove carbon dioxide from it. For these measurements, blood needs to be drawn from an artery so that it is high in oxygen. Unfortunately, drawing blood from an artery can be more painful than drawing blood from a vein, so the area is usually numbed before blood sampling.

Smeltzer, S. (2008). Textbook of medicalsurgical nursing. 11th ed. Lipincott Williams and Wilkins.

ECG - An ECG may be normal or show signs indicative of right ventricular failure (e.g., low voltage, right-axis deviation, P pulmonale). - An echocardiogram can be used to evaluate right-sided ventricular and left ventricular function. Sputum specimen for Gram stain and culture - May be obtained if the patient is hospitalized for an acute exacerbation and hasnt responded to empiric therapy with antibiotics.
Black J. & Hawks, J.

6. Name at least 3 common complications. Complications. VIII. Complications A. Cor pulmonale - Is hypertrophy of the right side of the heart, with or without heart failure, resulting from pulmonary hypertension. It is caused by diseases affecting the lungs or pulmonary blood vessels. - Cor pulmonale is a late manifestation of chronic pulmonary heart disease. B. Acute Respiratory Failure - Patients with severe COPD who have exarcerbations are at risk for the development of respiratory failure. C. Exacerbations of COPD - Are signaled by a change in the patients usual dyspnea, cough, and/or sputum that is different from the usual daily patterns. - The primary causes of exarcerbations of COPD are tracheobronchial infection and air pollution. D. Peptic Ulcer and Gastroesophageal Reflux Disease - The incidence of PUD is increased in persons with COPD. The reason for this occurence is partly explained by hypersecretion of gastric acid resulting from increase arterial CO2 and decrease 5 mins

(2004). Medicalsurgical nursing. 7th edition. Singapore: Elsevier, Inc.

Lewis, S. et.al (2005). Medical- Surgical Nursing Assessment and Management of Clinical Problems.

7. Give at least 5 kinds of collaborative care given to patients with COPD.

arterial O2 tension. E. Depression and Anxiety - Patients with COPD experience many losses as the disease progresses over time. - They can feel helpless with low selfesteem and unable to vent their emotions for fear for compromising their breathing. - Anxiety can complicate respiratory compromise and may precipitate dyspnea and hyperventilation. IX. Collaborative Care A. Cessation of Cigarette Smoking - The single most important therapeutic
intervention for patients with COPD.

B. Bronchodilators
Relieve bronchospasm by altering smooth muscle tone and reduce airway obstruction by allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation. They may also be used prophylactically to prevent breathlessness by having the patient use them before participating in or completing an activity, such as eating or walking. These agents can be delivered through a metered-dose inhaler (MDIs) inhaler, breath actuated MDIs, dry powder inhalers, spacers or valved-holding chambers, and nebulizers, or via the oral route or pill of

10 mins

Black J. & Hawks, J. (2004). Medicalsurgical nursing. 7th edition. Singapore:

liquid form.

Elsevier, Inc.

B 2- Adrenergic agonists

Anticholinergic agents C. Corticosteroids

They do not slow the decline in lung function. Their effects are less dramatic than in asthma. A short trial course of oral corticosteroids may be prescribed for patients to determine whether pulmonary function improves and symptoms decrease. Long-term treatment withoral corticosteroids in snot recommended in COPD and can cause steroid myopathy, leading to muscle weakness, decreased ability to function and in advanced disease, respiratory failure.

D. Chest Physiotherapy and Postural Drainage - Is indicated in the patient with excessive bronchial secretions who has difficulty clearing secretions with expectorated sputum production >25 ml/day, evidence or suggestion of retained secretions in the presence of an artificial airway, or lobar atelectasis caused by or suspected of being caused by mucus plugging. - The frequency and choice of postural drainage positions depend on the location of the retained secretions and

patients tolerance to dependent position. - A common order is 2-4 times a day. E. Hydration - Increase in hydration can help in loosening the secretions and ease in expectorating secretions. F. Breathing Exercises The nurse may help patient do inspiratory muscle training and breathing retraining to help Improve patients breathing patterns. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration. In addition, pursed-lip breathing helps to slow expiration, prevents collapse of small airways, and helps the patient to control the rate and depth of respiration. It also promotes relaxation, which enables the patient to gain control of dyspnea and reduce feelings of panic. G. O2 Therapy can be administered as long-term continuous therapy, during exercise, or to prevent acute dyspnea. Supplemental oxygen it effective in prolonging survival

of patients with COPD who have a resting partial arterial pressure of oxygen (PaO2) of less than 60 mmHg at sea level. Longterm oxygen therapy (more than 15 hours per day) has also been shown to improve quality of life, has a mild beneficial effect on pulmonary arterial pressure, and decreases dyspnea (Smeltzer, et al, 2004). H. Nutritional supplement - Eaitng becomes an effort because of dyspnea and O2 desaturation especially in the later stages of COPD. A full stomach presses up on the flattened diaphragm causing increase dyspnea and discomfort. - The patient with COPD should try to keep BMI between 21 and 25 kg/m2. - Being either overweight or underweight can be a problem with COPD. I. Pneumovax Immunization
Chronic obstructive pulmonary disease (COPD) is a disease of the lungs that affects many smokers. Patients with COPD are at higher risk for bacterial infections, including those caused by a kind of bacteria named Streptococcus pneumoniae, also called pneumococcus. Pneumococcus can cause pneumonia, meningitis (an infection of the protective coverings of the brain and spinal cord), infections of the blood, or COPD

exacerbations or flare-ups, a temporary worsening of lung symptoms that may require admission to the hospital and could be life-threatening.

8. Differentiate the three kinds of surgical interventions for COPD at 76% level of mastery.

X. Surgical Intervention A. Lung Volume Reduction Surgery (LVRS) treatment option for patients with endstage COPD (stage IV) with a primary emphysematous component are limited. It involves the removal of a portion of the diseased lung parenchyma. This reduces hyperinflation and allows the functional tissue to expand, resulting in improved elastic recoil of the lung and improved chest wall and diaphragmatic mechanics. This type of surgery does not cure the disease or improve life expectancy, but may decrease dyspnea, improve lung function, and improve the patients overall quality of life (Smeltzer, et al, 2004). B. Bullectomy a surgical option for select patients with bullous emphysema. Bullae are enlarged airspaces that do not contribute to ventilation but occupy space in the thorax; these areas may be surgically excised. Bullectomy may help reduce

dyspnea and improve lung function. It can be performed thorascopically (with a video assisted thorascope) or via a limited thoracotomy incision (Smeltzer, et al, 2004). C. Lung Transplant a viable alternative for definitive surgical treatment of end-stage emphysema. Single lung transplantation may be considered for patients with end-stage emphysema who have an FEV1 less than 25% of the predicted normal and who have complications such as pulmonary hypertension, marked hypoxemia and hypercapnia (Smeltzer, et al, 2004).

Lewis, S. et.al (2005). Medical- Surgical Nursing Assessment and Management of Clinical Problems.

9. Utilize nursing framework for care from acute

setting to rehabilitation XI.Nursing DIagnoses 7 mins Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction, and airway irritants - Goal: Improvement in breathing pattern - Nursing interventions: 1. Teach patient diaphragmatic and pursedlips breathing Rationale: This helps patient prolong expiration time and decreases air trapping. With these techniques, patient will breathe more efficiently and effectively.

Expected outcomes: Practices pursed-lips and diaphragmatic breathing and uses them when short of breathing and uses them when short of breath and with activity. 2. Encourage alternating activity with rest periods. Allow patient to make some decisions (bath, shaving) about care based on tolerance level. Rationale: Pacing activities permit patient to perform activities without excessive distress. Expected outcomes: Shows signs of decreased respiratory effort and paces activities. 3. Encourage the use of an inspiratory muscle trainer if prescribed. Rationale: This strengthens and conditions the respiratory muscles. Expected outcomes: Uses inspiratory muscle trainer as prescribed. Ineffective tissue perfusion renal, cerebral) related to transport of oxygen across and/or capillary membrane Nursing interventions 1. Monitor respiratory status, (cardiac, impaired alveolar

including

rate and pattern of respirations, breath sounds, pulse oximetry, and signs and symptoms of acute respiratory distress. Rationale: Dyspnea is the primary symptom of pulmonary arterial hypertension. Other symptoms include fatigue, angina, near syncope, edema and palpations. Expected outcomes: Normal respiratory rate and pattern for patient 2. Assess for signs and symptoms of right-sided heart failure, including peripheral edema, ascites, distended neck veins, crackles, and heart murmur. Rationale: Right-sided heart failure is common clinical manifestation of pulmonary arterial hypertension due to increased right ventricular workload. Expected outcome: Exhibits no signs and symptoms of right-sided failure. 3. Administer prescribed. oxygen therapy, as

Rationale: Continuous oxygen therapy is a major component of management of pulmonary arterial hypertension by preventing hypoxemia and thereby reducing pulmonary vascular constriction (resistance) secondary hypoxemia. Expected outcomes: Maintains baseline pulse oximetry values and arterial blood gases. Activity intolerance due to fatigue, hypoxemia, and ineffective breathing pattern - Goal: Improving activity intolerance - Nursing interventions 1. Support the patient in establishing a regular regimen of exercise using treadmill and exercise bicycle, walking or other appropriate exercises such as mall walking. a. Assess the patients current level of functioning and develop exercise plan based on baseline functional status b. Suggest consultation with physical therapist or pulmonary rehabilitation program to determine an exercise program specific to the patients capability. Have portable oxygen is

prescribed for exercise. Rationale: Muscles that are deconditioned consume more oxygen and place and additional burden on the lungs. Through regular, graded exercise, these muscle groups become more conditioned, and the patient can do more without getting as short of breath. Graded exercise breaks the cycle of debilitation. Expected outcomes: Performs activities with less shortness of breath Verbalizes need to exercise plan to be carried out at home Walks and gradually increases walking time and distance to improve physical condition Exercise both upper and lower body muscle groups Ineffective therapeutic regimen management related to low salience of the problem Nursing Interventions 1. Teach the patient about disease,

medications, procedures, and how and when to seek help 2. Provide health teachings; use of visual aids that might help the patient

10. Identify nursing responsibilities and patientteachings at home.

XI. XI. Nursing Responsibilities Pain - Provide comfort measures (e.g., touch, repositioning, use of heat or cold packs, nurses presence), quite environment, and calm activities to promote nonpharmacological pain management - Administer analgesics, as indicated, to maximum dosage, as needed to maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal. - Encourage adequate rest periods to prevent fatigue. Monitoring - Auscultation of breath sounds, noting areas of decreased flow of air and / or additional noise. - Assess the frequency, depth of breathing, note the use of accessory muscles, mouth

breathing, inability to speak / talk. - Monitor vital signs Rest and Comfort - Elevate head of bed, help patients to choose a position that is easy to breathe. - Encourage deep breathing or breath lips slowly as needed / individual tolerance. Anxiety - Encourage expression of feelings, anxieties. - Encourage activity to level of symptom tolerance - Enroll patients in pulmonary rehabilitation program where available. Emotional and behavioral reactions - Active-listening to clients concerns and negative verbalizations without comment or judgment - Provide opportunity for client to practice alternative coping strategies, including progressive socialization opportunities.

Ambulatory and home care A. Patient Teaching A major area of teaching involves setting

and accepting is realistic short-term and long-term goals. If the COPD is mild, the objectives of treatment are to increase exercise tolerance and prevent further loss of pulmonary function. If the COPD is severe, these objectives are to preserve current pulmonary function and relieve symptoms as much as possible. The nurse instructs the patients to: Avoid extremes of heat and cold. Rationale: Heat increases the body temperature, thereby raising oxygen requirements, and Cold tends to promote bronchospasm. Avoid air pollutants such as fumes, smoke, and dust, and even talcum, lint and aerosol sprays. Rationale: Initiate bronchospasm. High altitudes aggravate hypoxemia Adopt a lifestyle of moderate activity, ideally in a climate with minimal shifts in temperature and humidity. Avoid emotional disturbances and stressful situations that might trigger a coughing episode.

Smoking cessation. Rationale: The single most important therapeutic intervention for patients with COPD. Physical Exercise Patients with COPD experience progressive activity and exercise intolerance and disability. Education is focused on rehabilitative therapies to promote independence in executing ADLs. This may include: Pacing activities throughout the day Use of walking aids may be recommended to improve the activity levels and ambulation. Physical conditioning techniques include: breathing exercises general exercises intended to conserve energy and increase pulmonary ventilation.

10. Clarify and ask questions related to the topic presented and give appropriate evaluation of the discussion as a whole (good points and points for improvement).

XI. Open Forum

5 mins

Conduct a question and answer in a form of a game.