Chronic Obstructive Pulmonary Disease PDF

MEDICAL SURGICAL | 1ST | 2024-2025  PINK PUFFER-is a thin, cathetic person with marked shortness of breath. The 1 CHAPTER 1...

MEDICAL SURGICAL | 1ST | 2024-2025  PINK PUFFER-is a thin, cathetic person with marked shortness of breath. The 1 CHAPTER 1 blood remains well oxygenated because both ventilation and perfusion are reduced  Loss of elastin fibers reduces structural CHRONIC OBSTRUCTIVE PULMONARY support for alveoli and small airways, DISEASE which makes then prone to collapse on expiration, leading to air trapping.  is a condition of chronic dyspnea with  Pursed lip breathing allows expiratory airflow limitation that does maintenance of positive end expiratory not significantly fluctuate. procedure (PEEP) which keeps the  It has been defined as a preventable and airway open. The decreased lung treatable disease with some compliance leads to increased work of significantly extrapulmonary effects breathing and dyspnea. that may significantly contribute to the  There is abnormal distention of severity in individual patients. (The airspaces beyond the bronchioles and Global Initiative for Chronic Obstructive destruction of the walls of the alveoli. Pulmonary Disease) There is impaired carbon dioxide and oxygen exchange due to the destruction CLASSIFICATION of the walls of the overdistended alveoli  Chronic Bronchitis  They can be Panlobular- there is  Emphysema destruction of the respiratory NOTES : bronchioles, alveolar duct and the These two classifications of COPD can alveolus be confusing because there are  Centrilobular-changes occur in the patients who have overlapping signs secondary lobules and symptoms CHRONIC BRONCHITIS  is a disease of the airways that is characterised by cough and sputum production for at least 3 months each of 2 consecutive years.  BLUE BLOATERS-large edematous, cyanotic and with minimal dyspnea.  Airway obstruction leads to hypoxia, subsequently causing vasoconstriction (pulmonary hypertension) further causing reduced circulatory blood PATHOPHYSIOLOGY volume and right sided heart failure which can lead to cor pulmonale. This  In COPD, the airflow is both leads to hypoxemia and polycythemia progressive and associated with an causing cyanosis. abnormal inflammatory response of the  A wide range of viral, bacterial and lungs to noxious gases or particles. mycoplasmal infections can produce acute episodes of bronchitis WHAT HAPPENS: EMPHYSEMA 1 MEDICAL SURGICAL | 1ST | 2024-2025  An inflammatory response happens Two major life threatening complications throughout the proximal and peripheral  Respiratory failure airways, lung parenchyma and  Respiratory insufficiency pulmonary blood vessels  Due to this chronic inflammation, changes and narrowing occurs in the ASSESSMENT AND DIAGNOSTIC FINDINGS airways  There is an increase in the number of Carefully assess the history and findings goblet cells and enlarged submucosal 1. Health history glands causing the increased secretions 2. Pulmonary function studies of mucus o Spirometry  Causes scar formation in the long term o ABG and narrowing of the airways. o Chest x-ray  Wall destruction leads to loss of alveolar o CT scan attachments and decrease in elastic o Bronchogram recoil o Lung scan  This chronic inflammatory process o CBC affects the pulmonary vessels and o Blood chemistry subsequent thickening of the vessel o Sputum cultures lining and hypertrophy of smooth o Cytology exams muscle. o ECGs o Stress test EPIDIMELOGY MEDICAL MANAGEMENT  In the United States it's the FOURTH leading mortality cause I. Bronchodilators  More death in WOMEN II. Corticosteroids III. Others CLINICAL MANIFESTATION  Alpha 1-antitrypsin augmentation therapy The natural history of COPD is variable but is a  Antibiotics generally progressive disease  Mucolytics 1.. Chronic cough  Antitussive 2. Sputum production  Vasodilators 3. Dyspnea on exertion  narcotics 4. Dyspnea at rest 5. Weight loss MANAGEMENT EXCARBATIONS 6. Barrel chest  Bronchodilators PREVENTION  Hospitalisation  Oxygen therapy 1. STOP SMOKING- this is the single most  Antibiotics cost effective intervention SURGERY 2. As nurses we can help promote the stoppage of smoking by explaining the  Bullectomy risks of smoking personally to the  Lung volume reduction surgery patient  Lung transplantation COMPLICATION 2 MEDICAL SURGICAL | 1ST | 2024-2025 Nursing Diagnosis: (depends on the assessment  Monitor cognitive changes data gathered)  Monitor pulse oximetry changes  Prevent infection  Impaired gas exchange due to chronic inhalation of toxins EVALUATION  Ineffective airway clearance related to bronchoconstriction, increased mucus  Identifies the hazards of smoking production, ineffective cough and other  Identifies resources for stopping complications smoking  Ineffective breathing patterns related to  Minimizes or eliminates exposure shortness of breath, mucus,  Verbalizes the needs for fluids bronchoconstriction, and airway  Is free of infection irritants  Practices breathing exercises  Self care deficit related to fatigue  Performs activities with less shortness  Activity intolerance related to of breath hypoxemia and ineffective breathing DISCHARGE AND HOME CARE patterns  Setting goals NURSING MANAGEMENT  Temperature control  Activity moderation  Planning and Goals  Breathing retraining  Improvement in gas exchange  Achievement in airway clearance  Improvement in breathing pattern ACUTE RESPIRATORY DISTRESS  Independence in self care activities SYNDROME  Improvement in activity intolerance  Ventilation/oxygenation adequate to  Is a life threatening lung condition meet self care needs where there is a failure in breathing that  Nutritional intake meeting caloric needs can occur in the very ill or severely  Infection treated/prevented injured people.  Disease process/prognosis and  This is not a specific disease therapeutic regimen understood  It starts with the swelling of tissue in the  Plan in place to meet needs after lungs and build up of fluids in the tiny air discharge sacs that transfer oxygen to the bloodstream subsequently leading to Nursing Priorities low blood oxygen levels.  This is similar to the infant respiratory  Airway patency distress syndrome. Though they differ in  Measures to facilitate gas exchange the causes and the treatment. ARDS can  Enhance nutritional intake occur in anyone over the age of one  Prevent complications, slow Causes: progression  Provide information about disease  DIRECT INJURY TO THE LUNGS process/prognosis and treatment o Chest trauma (heavy blow) regimen o Breathing vomit o Breathing smoke, chemicals or Nursing interventions saltwater o Burns  Manage and monitor potential  INDIRECT INJURY TO THE LUNGS complications o Severe infection 3 MEDICAL SURGICAL | 1ST | 2024-2025 o Massive blood transfusion  Disease process/prognosis and o Pneumonia therapeutic regimen understood o Severe inflammation of the  Plan in place to meet needs after pancreas (pancreatitis) discharge o Alcohol or drug overdose o Lung and bone transplantation Nursing Priorities  Airway patency SYMPTOMS  Measures to facilitate gas exchange  Enhance nutritional intake  Shortness of breath  Prevent complications, slow  Fast, labored breathing progression  Bluish skin or fingernails  Provide information about disease  Rapid pulse process/prognosis and treatment regimen PATHOPHYSIOLOGY Nursing interventions  When lung tissues are injured, the alveoli  Provide supportive care 5 Ps of the ARDS Therapy becomes  Manage the underlying conditions  Perfusion permeable to  Administer medications as prescribed  Positioning lung proteins  Adores the cause of sepsis  Protective lung  Entry of  Prevent complications associated with ventilation more mechanical ventilation and ICU stay  Protocol weaning proteins,  Provide Oxygenation  Preventing debris and complications fluids into the lungs  Inflammation breaks down surfactant making the lungs less compliant THREE STAGE: 1. Exudative 2. Proliferative 3. Fibrotic Initially mild symptoms like dyspnea, cough, tachypnea and restlessness are observed, but as the  Administer oxygen as ordered syndrome progresses the symptoms worsen as  Consider mechanical ventilation  and Goals  Consider tracheostomy  Improvement in gas exchange  Turn the patient to PRONE POSITION  Achievement in airway clearance  Administer fluids with caution  Improvement in breathing pattern  Administer nutritional support  Independence in self care activities  Promote bed rest  Improvement in activity intolerance  Minimise sedation  Ventilation/oxygenation adequate to  Refer for rehab meet self care needs  Nutritional intake meeting caloric needs NURSING CARE PLANS  Infection treated/prevented Impaired gas exchange 4 MEDICAL SURGICAL | 1ST | 2024-2025 Related to:  Restlessness o Damage to the alveolar capillary  Respiratory muscle fatigue membrane o Change in lung compliance Risk for infection o Imbalance in ventilation perfusion Related to: Ineffective breathing pattern  Sepsis  Invasive lines As evidenced by:  Surgical incisions  Abnormal arterial pH  Wounds  Cyanosis  Stress  Altered respiratory depth and rhythm  Prolonged hospital stay  Hypoxemia  Prolonged immobility  Hypoxia  Nasal flaring PULMONARY EMBOLISM  Altered mental status  Refers to the obstruction of the Ineffective airway clearance pulmonary artery or one dits branches by a thrombus (or thrombi) that Related to: originates somewhere in the venous  Excessive mucUS system or in the right side of the heart  Retained secretions  The cause is usually a blood clot in the  Airway spasm leg called a deep vein thrombosis that  Inflammatory process breaks, loose and travels through the  Lung injury bloodstream to the lungs.  Decreased surfactant  It can damage part of the lungs due to restricted blood flow, decrease oxygen As evidenced by: levels in the blood, and affect other  Adventitious breath sounds organs as well. Large or multiple blood  Altered respiratory rate and rhythm clots can be fatal.  Tachypnea  The blockage can be life-threatening.  Tachycardia  Cyanosis  Excessive sputum CLASSIFICATION  Nasal flaring  Shortness of breath Most commonly, pulmonary embolism is due to a blood clot or thrombus, but there are other types of Ineffective Breathing Pattern emboli: fat, air, amniotic fluid, and septic.  Fat emboli. Fat emboli are cholesterol or Related to: fatty substances that may clog the  Alveolar impairment arteries when fatty foods are consumed  Poor lung expansion more.  Reduced surfactant  Air emboli. Air emboli usually come from  Lung fibrosis intravenous devices.  Fluid in the lungs  Amniotic fluid emboli. Amniotic fluid emboli are caused by amniotic fluid that As evidenced by: has leaked towards the arteries.  Tachypnea  Septic emboli. Septic emboli originate  Dyspnea from a bacterial invasion of the  Accessory muscle use thrombus.  Anxiety 5 MEDICAL SURGICAL | 1ST | 2024-2025  Post operative risk can be reduced by early ambulation or use of TEDS CAUSES (thromboemobolic) stockings  Other types include fat emboli from the  Blood clots can form for a variety of bone marrow resulting from fracture of a reasons. Pulmonary embolisms are large bone, vegetations resulting from most often caused by deep vein endocarditis in the right side of the thrombosis, a condition in which blood heart, amniotic fluid emboli from clots form in veins deep in the body. The placental tears occuring during labor blood clots that most often cause and delivery, tumor cell emboli that pulmonary embolisms begin in the legs break away from amalignant mass, or or pelvis. air embolus injected into a vein Blood clots in the deep veins of the body can have several different causes,including: PATHOPHYSIOLOGY  Injury or damage: Injuries like bone fractures or muscle tears can cause  The effects of pulmonary embolus damage to blood vessels, leading to depend somewhat on the material but dots. largely on the size and therefore on the location of the obstruction.  Inactivity: During long periods of  Because lung tissue is supplied with inactivity, gravity causes blood to oxygen and nutrients by the bronchial stagnate in the lowest areas of circulation, infarction does not follow obstruction of the pulmonary circulation unless the general your body, which may lead to a blood circulation is compromised or there is clot. This could occur if you're sitting for prior lung disease. a lengthy trip or if you're lying in bed  Infarction usually involves a segment of recovering from an illness. the lung and the pleural membrane in the area.  Medical conditions: Some health  Large emboli (usually those involving conditions cause blood to clot too easily, than more 60% of the long tissue) tht which can lead to pulmonary embolism. the cardiovascular system, asing right- Treatments for medical conditions, such sided heart failure and decreased cardiac as surgery or chemotherapy for cancer, output (shock). can also cause blood clots.  Sudden death often results in these cases, which involve greatly increased resistance in the pulmonary arteries RISK FACTORS because of the embolus plus refiex vasoconstriction due to released  Includes immobility, trauma to the legs, chemical mediators such as serotonin childbirth, congestive heart failure, and histamine. This resistance to the dehydration, increased coagulability of output from the right ventricle causes the blood, and cancer acute cor pulmonale  Thrombi tend to break off with sudden muscle action or massage, trauma, or A series of happenings occur inside a patient's body changes in the blood flow when he or she has an emboli.  Obstruction. When a thrombus completely or partially obstructs the 6 MEDICAL SURGICAL | 1ST | 2024-2025 pulmonary artery or its branches, the  ECG - usually shows sinus tachycardia, alveolar dead space is increased. PR-interval depression, and nonspecific  Impairment. The area receives little to no T-wave changes. blood flow and gas exchange is  ABG analysis - ABG analysis may show impaired. hypoxemia and hypocapnia; however,  Constriction, Various substances are ABG measurements may be normal even released from the clot and surrounding in the presence of PE. area that cause constriction of the blood  Pulmonary angiography - allows for vessels and results in pulmonary direct visualization under fluoroscopy of resistance. the arterial obstruction and accurate  Consequences. Increased pulmonary assessment of the perfusion deficit. vascular resistance due to regional  duplex venous ultrasound - This test vasoconstriction leading to increase in uses radio waves to visualize the flow of pulmonary arterial pressure and blood and to check for blood clots in your increased right ventricle workload are legs. the consequences that follow.  Venography - This is a specialized X-  Failure. When the workload of the right ray of the veins of your legs. ventricle exceeds the limit, failure may  D-dimer test - A type of blood test that occur. is used to help rule out the presence of an SYMPTOMS inappropriate blood clot.  V/Q scan (ventilation/perfusion lung  Small emboli-a transient chest pain, scan) - evaluates the different regions of cough, or dyspnea may occur. Often the lung and allows comparisons of the unnoticed but can be significant percentage of ventilation and perfusion because it may be a warning of more in each area. emboli developing  Larger emboli-chest pain that increases with coughing or deep MEDICAL MANAGEMENT breathing, tachypnea, and dyspnea  Because PE is often a medical develop suddenly. Later, hemoptysis emergency, emergency management is and fever are present. of primary concern.  Hypoxia stimulates a sympathetic  Anticoagulation therapy. Heparin, and response, with anxiety and warfarin sodium has been traditionally restlessness, pallor and tachycardia been the primary method for managing  Massive emboli-cause severe acute DVT and PE. crushing chest pain, low blood pressure,  Thrombolytic therapy. Urokinase, rapid weak pulse, and loss of streptokinase, alteplase are used in consciousness. treating PE, particularly in patients who  Fat emboli-development of acute are severely compromised. respiratory distress, a petechial rash on the trunk, and neurologic signs such as PATHOPHYSIOLOGY confusion and disorientation  When lung tissues are injured, the alveoli becomes permeable to lung proteins DIAGNOSTIC TEST  Entry of more proteins, debris and  Chest X-ray - usually normal but may fluids into the lungs show infiltrates, atelectasis, elevation of  Inflammation breaks down surfactant the diaphragm on the affected side, or a making the lungs less compliant pleural effusion. 7 MEDICAL SURGICAL | 1ST | 2024-2025 SURGICAL MANAGEMENT Discharge and Home Care Guidelines  Prevent recurrence. The nurse should Removal of the emboli may sometimes need instruct the patient about preventing surgical management. recurrence and reporting signs and  Surgical embolectomy. This is the symptoms. removal of the actual clot and must be performed by a cardiovascular surgical  Adherence. The nurse should monitor team with the patient on the patient's adherence to the cardiopulmonary bypass. prescribed management plan and  Transvenous catheter embolectomy. This enforces previous instructions. is a technique in which a vacuum- cupped catheter is introduced  Residual effects. The nurse should also transvenously into the affected monitor for residual effects of the PE pulmonary artery. and recovery.  Interrupting the vena cava. This approach prevents dislodged thrombi from being  Follow-up checkups. Remind the swept into the lungs while allowing patient about keeping up with follow-up adequate blood flow. appointments for coagulation tests and appointments with the primary care NURSING MANAGEMENT provider.  Prevent venous stasis. Encourage ambulation and active and passive leg exercises to prevent venous stasis.  Manage pain. Turn patient frequently and reposition to improve ventilation- perfusion ratio.  Manage oxygen therapy. Assess for signs of hypoxemia and monitor the pulse oximetry values.  Relieve anxiety. Encourage the patient to talk about any fears or concerns related to this frightening episode.  Monitor thrombolytic therapy. Monitoring thrombolytic and anticoagulant therapy through INR or PTT.  INR (International Normalized Ratio) and PTT (partial thromboplastin time) are used to monitor effectiveness of the anticoagulant warfarin.  Normal range of INR is 1 to 2, while for PTT is 30 to 45 seconds.  Extended PTT times can be a result of anticoagulation therapy, liver problems, lupus, and other diseases that result in poor clotting. 8