COPD.pdf

NCM 118 MARY CHILES COLLEGE B.S. NURSING RESPONSE TO ALTERED VENTILATORY FUNCTION...

NCM 118 MARY CHILES COLLEGE B.S. NURSING RESPONSE TO ALTERED VENTILATORY FUNCTION LEVEL IV CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) CHRONIC OBSTRUCTIVE PULMONARY DISEASE EMPHYSEMA (COPD) Damage in the alveolar sacs Used for 2 different chronic lung diseases A disease of the airways characterized by Preventable and treatable destruction of the walls of over distended Slowly progressive respiratory disease of airflow alveoli causing loss of shape, larger and fewer obstruction, which hinders breathing by air sacs instead of many tiny, and reduced limiting airflow into the lungs surface area for gas exchange resulting in It involves the airways, pulmonary decreased air in the lungs parenchyma (any form of lung tissue Progressive to permanent destruction of the bronchioles, bronchi, blood vessels, and alveoli because of irreversible destruction of alveoli) or both elastin It is the leading cause of morbidity and Both types of emphysema may occur in the mortality in the United States same client 5th leading cause of death 2 TYPES OF EMPHYSEMA In case of COPD, it causes the volume of air 1. PANLOBULAR (PANACINAR) TYPE – there is a that is inhaled and exhaled to be reduced destruction of the respiratory bronchiole, Causes: alveolar duct, and alveoli; all air spaces within ○ Clogging of air passages due to mucus the lobule are essentially enlarged, but there is ○ Inflammation or thickening of the walls of little inflammatory disease; the client typically air passages has a hyperinflated (hyperexpanded) chest ○ Damaged alveolar walls (barrel chest on physical examination), ○ Alveoli and air passages losing their marked dyspnea on exertion, and weight loss; stretching ability the client becomes increasingly short of 2 TYPES OF COPD breath, chest becomes rigid, and ribs are fixed 1. Emphysema at their joints 2. Chronic bronchitis 2. CENTRILOBULAR (CENTROACINAR) FORM – pathologic changes takes place mainly in the center of the secondary lobule, preserving the peripheral portions of the acinus; frequently, there is a derangement of ventilation, such as perfusion ratios, producing chronic hypoxemia, hypercapnia (increased CO2 in the arterial blood), polycythemia, and episodes of right-sided heart failure; this leads to central cyanosis, peripheral edema, and respiratory failure; the client may receive diuretic therapy for edema CHRONIC BRONCHITIS A disease of the airways in which the lining of the air passages are clogged with mucus due to inflammation, irritation, and swelling It is also common for a person to have both of the diseases  TYPICAL PROGRESSION OF COPD No symptoms occur for the 1st 10 years after beginning smoking After 10 years, chronic cough with clear sputum develops At about 40-50 y/o, dyspnea begins At about 50 y/o, increased susceptibility to colds with longer recovery time needed CLINICAL MANIFESTATIONS COMMON SIGNS AND SYMPTOMS Persistent cough for 3 or more months accompanied by sputum production for at least a combined total of 3 months in each of 2 consecutive years; worsening during early morning Dyspnea (SOB) especially with physically demanding activities Frequent respiratory infections like cold and pneumonia Tightness of chest Wheezing Fatigue RISK FACTORS Exposure to tobacco smoke accounts for an ADVANCED COPD SYMPTOMS estimated 80-90% of COPD cases; the most Difficulty with catching up breathing and important and common risk factor talking Passive smoking (2nd hand smoke) Fever and headache due to high CO2 level in Increased age the blood Occupational exposure (dust or chemicals) Cyanosis (lips and fingernails) due to low levels and ambient air pollution (indoor or outdoor of O2 in the blood pollutants) that causes irritation of the air Barrel chest like appearance passages and lungs; less common Swollen feet and ankles Genetic abnormalities known as Alpha 1- Lack of mental alertness Antitrypsin Deficiency-AAT, an enzyme Clubbing of fingers and toes inhibitor that normally counteracts the EMPHYSEMA (PINK PUFFERS) destruction of lung tissue by certain other Increased CO2 retention (pink) enzymes; rare No cyanosis SMOKING Pursed lip breathing Depresses the activity of scavenger cells and Increased mucus affects the respiratory tract’s ciliary cleansing Barrel chest mechanism, which keeps breathing passages SOB free of inhaled irritants, bacteria, and other Dyspnea on exertion and progressive disability foreign matter Easily fatigued The alveoli greatly distend, which diminishes Wheezing lung capacity Speak in short sentence In addition, CO (byproduct of smoking) Thin in appearance combines with hemoglobin to form Increased CO2 in the blood by ABG carboxyhemoglobin General clinical manifestations appear later in Hemoglobin that is bound by the disease process carboxyhemoglobin cannot carry O2 efficiently  CHRONIC BRONCHITIS (BLUE BLOATER) Bronchodilator reversibility testing may be Decreased oxygenation produces cyanotic performed to rule out the diagnosis of asthma (bluish) appearance Arterial blood gas measurements may also be Recurrent chronic cough and sputum obtained to assess baseline oxygenation and production lasting for 3 months of the year for gas exchange 2 consecutive years Severity of respiratory failure depend on Common symptom are wheezing or dyspnea client’s baseline pulmonary function, pulse Increased RR oximetry, and ABG values Exertional dyspnea COMPLICATIONS Use of accessory muscles to breathe Respiratory insufficiency and failure are major Cor pulmonale (abnormal rhythms, RV life-threatening complications of COPD enlarges and thickens) Other complications include: Dependent edema with right-sided heart ○ Pneumonia failure later in the disease ○ Atelectasis SYMPTOMS OF COPD ○ Pneumothorax Early morning cough with the production of ○ Cor pulmonale clear sputum (earliest presenting symptom) MEDICAL MANAGEMENT Sputum turn to yellow or green (older person develop respiratory infection) RISK REDUCTION Increased mucus secretion and its viscosity Smoking cessation is the single most effective Period of wheezing occur (narrowing of the intervention to prevent COPD or slow its airway) during or after colds progression SOB on exertion Nurses play a key role in promoting smoking Severe episodes of dyspnea cessation and educating clients about ways Recurring infection of the lower lungs to do so Dyspnea from air hunger (most common Clients diagnosed with COPD who continue to reason for emergency) smoke must be encouraged and assisted to quit DYSPNEA SEVERITY GRADE I – dyspnea only in heavy exertion PHARMACOLOGIC THERAPY GRADE II – dyspnea only on moderate exertion BRONCHODILATORS GRADE III – dyspnea on mild or minimal exertion Relieve bronchospasm and reduce airway GRADE IV – dyspnea at rest obstruction by allowing increased O2 distribution throughout the lungs and AS COPD PROGRESSES improving alveolar ventilation Mouth breathing, puffing Route: Use of accessory muscles of breathing ○ Metered-dose inhaler Inability to finish sentence without catching ○ Nebulization one’s breath ○ Oral route in pill or liquid form Sleep in a semi sitting position (unable to Often administered regularly throughout the breathe on lie flat) day as well as on an as-needed basis Diagnosis confirmation They may also be used prophylactically to ASSESSMENT AND DIAGNOSTIC FINDINGS prevent breathlessness by having the client Obtain a thorough health history for a client use them before an activity, such as eating or with known or potential COPD walking Pulmonary function studies are used to help Several classes of bronchodilators are used confirm the diagnosis of COPD, to determine ○ Beta-adrenergic agonists disease severity, to follow disease progression ○ Anticholinergic agents Spirometry is used to evaluate airflow ○ Methylxanthines obstruction, which is determined by the ratio CORTICOSTEROIDS of FEV1 (volume of air that the client can Inhaled and systemic corticosteroids (oral or forcibly exhale in 1 second) to forced vital intravenous) more frequently in asthma capacity  Do not slow the decline in lung function Clients who are hypoxemic while awake are These medications may improve symptoms likely to be so during sleep, therefore, night only time O2 therapy is recommended Prescription for O2 therapy is for continuous OTHER MEDICATIONS 24-hour use Every year influenza vaccine Intermittent O2 therapy is indicated for those Pneumococcal vaccine every 5-7 years as who desaturate only during exercise or sleep preventive measures In most healthy adults, pneumococcal NURSING ALERT: Because hypoxemia stimulates vaccine persist for 5 or more years respiration in the client with severe COPD, Other pharmacologic: increasing the O2 flow to a high rate may greatly ○ Alpha 1 antitrypsin augmentation therapy raise the client’s blood O2 level. At the same time, ○ Antibiotic agents this will suppress the respiratory drive, causing ○ Mucolytic agents increased retention of CO2 and CO2 narcosis. ○ Antitussive agents The nurse should closely monitor the client’s respiratory response to O2 administration via MANAGEMENT OF EXACERBATION physical assessment, pulse oximetry, and ABG Primary causes: ○ Tracheobronchial infection SURGICAL MANAGEMENT ○ Air pollution Bullectomy Secondary causes: Lung volume reduction surgery ○ Pneumonia Lung transplantation ○ Pulmonary embolism NURSING MANAGEMENT ○ Pneumothorax ○ Rib fractures CLIENT EDUCATION ○ Chest trauma Broad variety of topics, such as anatomy and ○ Inappropriate use of sedative, opioid, or physiology of the lung as well as beta-blocking agents pathophysiology and changes with COPD ○ Right- or left-sided heart failure Medications and home O2 therapy ○ Secondary polycythemia Respiratory therapy treatments and symptom Symptoms: alleviation ○ Increased dyspnea Smoking cessation, sexuality and COPD, and ○ Increased sputum and purulence coping with chronic disease ○ Respiratory failure Communication with the healthcare team ○ Changes in mental status and planning for the future, such as advance ○ Worsening blood gas abnormalities directives, living wills, and informed decision Indications for hospitalization: making about healthcare alternatives ○ Severe dyspnea that does not respond BREATHING EXERCISES adequately to initial therapy Pursed lip breathing helps to slow expiration, ○ Confusion or lethargy prevents collapse of small airways, and helps ○ Respiratory muscle fatigue the client to control the rate and depth of ○ Paradoxical chest wall movement respiration ○ Peripheral edema It also promotes relaxation, enabling the client ○ Worsening or new onset of central to gain control of dyspnea and reduce cyanosis feelings of panic ○ Persistent or worsening hypoxemia INSPIRATORY MUSCLE TRAINING OXYGEN THERAPY Once the client masters diaphragmatic Can be administered as long-term continuous breathing, a program of inspiratory muscle therapy during exercise or to prevent acute training may be prescribed to help strengthen dyspnea the muscles used in breathing Long-term O2 therapy has been shown to Requires that the client breathe against improve the client’s quality of life and survival resistance for 10-15 minutes every day  ACTIVITY PACING COPING MEASURES Limitations by planning self-care activities and Factor that interferes with normal breathing determining the best time for bathing, quite naturally induces anxiety, depression, dressing, and daily activities and changes in behavior Many clients find the slightest exertion SELF-CARE ACTIVITIES exhausting As breathing pattern improve, the client is Constant SOB and fatigue may make the encouraged to assume increasing client irritable and apprehensive to the point participation in self-care activities of panic The client is taught to coordinate Restricted activity and reversal of family roles diaphragmatic breathing with activities setting due to loss of employment may cause PHYSICAL CONDITIONING frustration of having to work to breathe Breathing exercises and general exercises The realization that the disease is prolonged intended to conserve energy and increase and unrelenting may cause the client to react pulmonary ventilation with anger, depression, and demanding There is a close relationship between physical behavior fitness and respiratory fitness Sexual function may be compromised, which Graded exercises and physical conditioning also diminishes self-esteem programs using treadmills, stationary bicycles, In addition, the nurse needs to provide and measured level walks education and support to the spouse/significant other and family because NUTRITIONAL THERAPY the caregiver role in end-stage COPD can be Counseling are important aspects in the difficult rehabilitation process for the client with COPD A thorough assessment of caloric needs and counseling about meal planning and supplementation are part of the rehabilitation process