Universidad de Sta. Isabel COLLEGE OF HEALTH EDUCATION

Bachelor of Science in NursingAcademic Year 2012-2013

CASE PRESENTATION

Chronic Obstructive Pulmonary Disease (COPD)

 

Prepared by: CLIMACO,Karen

ELOPRE, Ma. Rogine C.ESPEDIDO, Janine F.

FAJARDO, Cristina Joy K.FAVORITO, Carl Earvin L.

FELIPE, Eloisa Julia B.

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease

(COPD)

Objectives:•To be able to know what causes the disease.•To identify preventive measures against the disease.•To be able to know the nursing interventions and medical managements/treatments for the disease.•To identify what the disease is and how it exist in a person.

INTRODUCTIONChronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible, also known as chronic obstructive lung disease (COLD), chronic obstructive airway disease (COAD), chronic airflow limitation (CAL) and chronic obstructive respiratory disease (CORD), it is the occurrence of chronic bronchitis or emphysema, a pair of commonly co-existing diseases of the lungs in which the airways narrow over time. This limits airflow to and from the lungs, causing shortness of breath (dyspnea).

Chronic obstructive pulmonary disease (COPD) ranks among the leading causes of adult morbidity and mortality worldwide, especially among smokers. An estimated 16 million Americans have the disorder.According to World Health Organization COPD as a single cause of death shares 4th and 5th places with HIV/AIDS (after coronary heart disease, cerebrovascular disease and acute respiratory infection). In 1990, a study by the World Bank and WHO ranked COPD 12th as a burden of disease; by 2020, it is estimated that COPD will be ranked 5th. According to the WHO, passive smoking carries serious risks, especially for children and those chronically exposed. The WHO estimates that passive smoking is associated with a 10 to 43 percent increase in risk of COPD in adults.

INCIDENCE

Based on the 2004 Global Burden of Diseases, COPD is among the leading causes of death worldwide, along with lower respiratory tract infections, tuberculosis and lung cancer. Due to tobacco use and population ageing, the burden of chronic respiratory diseases such as COPD, lung cancer and asthma are also likely to worsen. In 2004, WHO estimated that there are 64 million people with COPD, and in 2005, more than 3 million people died of the disease. Almost 90% of deaths due to COPD occur in low and middle income countries. WHO also predicted that by 2030, COPD will become the third leading cause of death worldwide.

INCIDENCE

In the Philippines, the Department of Health (DOH)considers COPD as one of the country's major health problems. It is seventh among the top ten causes of mortality in the country. Although, there is no large scale study to determine the prevalence of COPD in the Philippines, estimates have been based primarily on morality statistics. However, proceedings of the Asia-Pacific regional workshop in 2000 cited that there is 6.3% prevalence of COPD in the country. In 1997, on a spirometry based study in a rural community, it found out that 3.7% of its population has irreversible airway obstruction. 

INCIDENCE

What is COPD?

• COPD, or chronic obstructive pulmonary disorder, is a lung disease that makes it hard to breathe. The first symptoms can be so mild that people mistakenly chalk them up to "getting old." People with COPD may develop chronic bronchitis, emphysema, or both. COPD tends to get worse over time, but catching it early, along with good care, can help many people stay active and may slow the disease.

Symptoms of COPD ;Inside the lungs, COPD can clog the airways

and damage the tiny, balloon-like sacs (alveoli) that absorb oxygen. These changes can cause the following symptoms:

Shortness of breath in everyday activities Wheezing Chest tightness Constant coughing Producing a lot of mucus (sputum) Feeling tired Frequent colds or flu

Advanced Symptoms of COPD;

Severe COPD can make it difficult to walk, cook, clean house, or even bathe. Coughing up excess mucus and feeling short of breath may worsen. Advanced illness can also cause: Swollen legs or feet from fluid buildup Weight loss Less muscle strength and endurance A headache in the morning Blue or grey lips or fingernails (due to low oxygen levels)

COPD: Chronic Bronchitis

This condition is the main problem for some people with COPD. Its calling card is a nagging cough with plenty of mucus (phlegm). Inside the lungs, the small airways have swollen walls, constant oozing of mucus, and scarring. Trapped mucus can block airflow and become a breeding ground for germs. A "smoker's cough" is typically a sign of chronic bronchitis. The cough is often worse in the morning and in damp, cold weather.

Signs & Symptoms of Chronic Bronchitis:

Long-Term Cough Increased Mucus Production Shortness of Breath Frequent Respiratory Infections Wheezing Swelling and Weight Gain

COPD: Emphysema

Emphysema damages the tiny air sacs in the lungs, which inflate when we take in a breath and move oxygen into the blood. They also push out carbon dioxide, a waste gas, when we breathe out. When you have emphysema, these delicate air sacs can't expand and contract properly. In time, the damage destroys the air sacs, leaving large holes in the lungs, which trap stale air. People with emphysema can have great trouble exhaling.

Presentation TitleSymptoms of Emphysema

Shortness of Breath Rapid Breathing Chronic Cough (With or Without Sputum) Wheezing Reduced Exercise Tolerance Loss of Appetite Leading to Weight Loss Barrel Chest

Diagnosis: Spirometry Breath

Test

Spirometry is the main test for COPD. It measures how much air you can move in and out of your lungs, and how quickly you do it. You take a deep breath and blow as hard as you can into a tube. You might repeat the test after

inhaling a puff of a bronchodilator medicine, which opens your airways. Spirometry can find problems even before you have symptoms of COPD. It also helps determine the stage

of COPD.

PATIENT PROFILE

Name: Mr. A Age: 59 years oldGender: MaleOccupation: Construction worker and PainterReligion: Roman CatholicCitizenship: FilipinoAttending Physicians: Dr. Dee, Dr.

Divinagracia, Dr. De LeonCC: Difficulty of Breathing, easy fatigability

upon exertionDx: Chronic Bronchitis 

PERSONAL BACKGROUND:

Mr. A is a 59 years old construction worker/ painter and currently living with his three children and wife who is a vendor. He was a construction worker for almost 20 years. Mr. A admits to be a smoker since he was 18 years old, during his early 20’s, he consumed ten sticks of cigarette per day and drinks alcoholic beverages occasionally with his friends. According to him, they have a history of lung cancer because his father was diagnosed with this kind of disease.

Medical History: Prior to admission the client had experienced productive cough for 8 days, accompanied by easy fatigability. He has poor appetite and constantly feels exhausted. To manage the symptoms, her daughter brought him mucolytic for his cough, but the condition get worse for several days due to DOB, her daughter decided to admit him to the hospital. Upon admission, he was hooked to O2 inhalation 2-3 LPM via nasal cannula and inserted with dextrose aseptically at left cephalic vein. His attending physician ordered some lab exam such as CBC and ABG. After undergoing a thorough examination, he was diagnosed to have a chronic obstructive pulmonary disease.  

CLIENTS PRESENT STATUS:Presently the client is stable, but still hooked to O2 inhalation, and currently manage with antibiotics agents, bronchodilators and mucolytic agents.

PHYSICAL EXAM:• General Appearance:

obviously underweight with very reduced muscle mass & strength, using accessory muscles of respiration when breathing

• Vital signs: T= 37.7 P=92bpm R= 26cpm BP= 130/80

• Heart: regular rate and rhythm, with slightly enlargement noted.

• Extremities: slightly cyanotic but no clubbing noted

• Neurologic: Coherent and oriented• Skin: Warm and dry, 2-3 second

capillary refill of finger nail beds• Chest/ Lungs: decreased breath

sounds, prolonged expiration w/ wheezing and rhonchi using accessory muscle @ rest, with productive cough( clear & thick mucus).

Gordon’s Functional Health Pattern

Health Perception – Health Management

Mr. A’s daughter brought him mucolytics for his cough but the condition get worse for several days due to difficulty of breathing, her daughter decided to bring him to the hospital.

Nutritional-MetabolicHe eats three times a day almost consist of vegetables, rice. He seldom eats meat and fruits. Sometimes she eats a very small amount of foods if his appetite is low.

Elimination He eliminates every other day and he urinates 4-5 times a day with a little amount, it depends to the amount of water he takes.

 

Activity-Exercise Before he has no time for

exercise because of his work, he said that “dikit lang na lakaw lakaw ang exercise ko.” Now, he cannot exercise because of easy fatigability and difficulty of breathing.

Role-Relationship He has a strong relationship with his wife and children. He tries to be strong to make himself feel better and his family not to worry about him.

Sleep- Rest Pattern

He sleeps less than 6 hours per day because of his cough and DOB.

Coping-Stress ToleranceMr. A would just have a rest (sleep) every time he is on stress. Watching TV is also a form of relaxing for him.

Value-Belief Mr. A is a roman catholic. He always prays to God for her good health and long life, but he seldom goes to church every Sunday.

Anatomy & Physiology of the

Respiratory System

Anatomy & Physiology of the

Respiratory System

Function of the Respiratory Function of the Respiratory SystemSystem Oversees gas exchanges (oxygen and

carbon dioxide) between the blood and external environment

Exchange of gasses takes place within the lungs in the alveoli(only site of gas exchange, other structures passageways

Passageways to the lungs purify, warm, and humidify the incoming air

Shares responsibility with cardiovascular system

Nose

Pharynx

Larynx

Trachea

Bronchi

Lungs – alveoli

Organs of the Respiratory Organs of the Respiratory systemsystem

Upper Respiratory TractUpper Respiratory Tract

NOSE The nose function primarily as the organ of smell and as a passage through which are travels on its way in and out of e lungs.The upper part of the nose is supported by bone and the lower part is supported by cartilage.The external opening of the nose are the nostril or nares.

PARANASAL SINUSES

It include the frontal sinuses, located in the lower forehead between and above the eyes; the ethmoidal group of sinuses, both anterior and posterior, extended along the roof of the nostrils; the sphenoidal sinuses, opening at the rear; and the maxillary sinuses are located on either side of the nose. The same type of ciliated epithelium that lines the nasal passages also lines these paranasal sinuses.

TURBINATE BONES (CONCHAE)

• (The name is suggested by their shell-like appearance ) are adapted by shape and position to increase the mucous membrane surface of the nasal passages and to slightly obstruct the current of air flowing through them.

• The sense organ of smell is located in the olfactory membrane, which covers the roof of the nose and the superior turbinate bone.

The pharynx or throat, is limited below by the larynx and the upper portion of the esophagus .Its upper extension is the nasopharynx, into which open the posterior nostril ad the auditory (euthachian)tube from the middle ears.

PHARYNX

Larynx(voice box)

• Is a cartilaginous epithelium-lined structure that is the transition between the upper airway and the lower airway.

• The major function of the larynx is to permit vocalization

• It also protect the lower airway from foreign substances and facilitates coughing.

• Routes air and food into proper channels

• Plays a role in speech

Structures of the LarynxStructures of the Larynx• Epiglottis- a valve flat of cartilage that covers

the opening to the larynx during swallowing • Glottis- the opening between the vocal cord

and the larynx• Thyroid cartilage- part of it forms the

“adam’s apple,” the largest cartilage in the trachea

• Arytenoids cartilages- use in vocal cord movement with the thyroid cartilage

• Vocal cords- ligaments controlled by muscular movement that produce vocal sounds; they are mounted in the lumen of the larynx

Trachea (Windpipe)• Connects larynx with bronchi• Lined with ciliated mucosa

– Beat continuously in the opposite direction of incoming air

– Expel mucus loaded with dust and other debris away from lungs

• Walls are reinforced with C-shaped hyaline cartilage

Primary BronchiPrimary Bronchi Formed by division of the

trachea

Enters the lung at the hilus (medial depression)

Right bronchus is wider, shorter, and straighter than left

Bronchi subdivide into smaller and smaller branches

LUNGSLUNGS

Coverings of the LungsCoverings of the Lungs Pulmonary (visceral) pleura covers the lung surface

Parietal pleura lines the walls of the thoracic cavity

Pleural fluid fills the area between layers of pleura to allow gliding

• Each lung is divided into lobes. The right lung, which has three lobes, is slightly larger than the left, which has two. The lungs are housed in the chest cavity, or thoracic cavity, and covered by a protective membrane called the pleura. The diaphragm, the primary muscle involved in respiration, separates the lungs from the abdominal cavity.

•The pulmonary arteries carry de-oxygenated blood from the right ventricle of the heart to the lungs. The pulmonary veins, on the other hand, carry oxygenated blood from the lungs to the heart, so it can be pumped to the rest of the body.

• From the outside, lungs are pink and a bit soggy, like a sponge. At the bottom of the trachea or windpipe, there are two large tubes. These tubes are called the main stem bronchi, and one heads left into the left lung, while the other heads right into the right lung.

• Each main stem bronchus — then branches off into tubes that get smaller. The tiniest tubes are called bronchioles and there are about 30,000 of them in each lung.

At the end of each bronchiole is a special area that leads into clumps of tiny air sacs called alveoli. There are about 600 million alveoli in the lungs. Each alveolus— has a mesh-like covering of very small blood vessels called capillaries. These capillaries are so tiny that the cells in the blood need to line up single file just to pass through them.

BRONCHIOLESBRONCHIOLES

Figure 13.5a

Smallest branches of the bronchi

BRONCHIOLESBRONCHIOLES

Figure 13.5a

All but the smallest branches have reinforcing cartilage

BRONCHIOLESBRONCHIOLES

Terminal bronchioles end in alveoli

Figure 13.5a

Mechanics of Breathing• To take a breath in, the external

intercostal muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax.

• The lungs are held to the thoracic wall by the pleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways.

Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax).

PHYSIOLOGY OF GAS EXCHANGE

Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveoli in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over.

• Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients.

• CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.

Control of Respiratory System

• Respiratory control centers – found in the pons and the medulla oblongata

• Control breathing • Adjusts the rate and

depth of breathing according to oxygen and carbon dioxide levels

• Afferent connections to the brainstem

• Hypothalamus and limbic system send signals to respiratory control centers

Chronic Obstructive Pulmonary Disease (COPD)

LABORATORY RESULTS

Test Result Interpretation

Normal Value

Implication

WBC 15 High 4.3-10 An elevated WBC count (leukocytosis) commonly signals infection.

Hemoglobin

11.5 Low 12-16 g/dl A low Hgb. count is a below-average concentration of oxygen carrying Hgb. proteins in the blood. This is supported by dyspnea experiencing by the patient.

Hematocrit 34 Low 37-47% Decrease hct. Suggests fluid overload and increase plasma volume. Both decrease in hgb. And hct. Indicates anemia.

Lymphocytes

10 Low 25-40% Decrease lymphocyte indicates severe debilitating illness like heart failure and renal failure.

HEMATOLOGY REPORT

Test Result

Interpretation

Normal Value

Implication

Albumin 3.2 Low 3.5-5.0 g/dl

Low albumin levels indicates  inflammation, shock, and malnutrition. It may be seen with conditions in which the body does not properly absorb and digest protein.

Total protein

5.8 Low 6.0-8.0 g/dl

Low total protein commonly indicates liver disease, malabsorption and malnutrition.

BUN 9 High 8.26 mg/dl High BUN levels occur in reduce renal blood flow (from dehydration).

ABG REPORT

Test Result Interpretation

Normal Value

Implication

PCO2 50.9 High 35-45 mmHg

If the PCO2 is elevated, it indicates pulmonary edema; there is an extra layer of fluid in the alveoli that interferes with the lungs' ability to get rid of CO2. This leads to a rise in pCO2.

P02 76.8 Low >80 mmHg Low PO2 level indicates an interference with ventilation process. Decreased oxygen levels in the inhaled air & Heart decompensation.

C02 Content

31 High 25-30 mmol/L

Elevated C02 level indicates impaired renal function and unusual losses (diarrhea) which are seen in severe vomiting and in COPD patients.

CHEST X-RAY :

Chest X-ray shows softening of the diaphragm, slight cardiac enlargement, prominent vascular and bronchial markings, and patchy infiltrates.

MEDICATIONS

MEDICATION

CLASSIFICATION

INDICATION ACTION

Combivent/ Asmavent

Bronchodilators

Bronchodilators are often used to treat conditions that cause airways to narrow or become inflamed, such as:breathlessnessasthma bronchiectasis – a lung condition where the airways are abnormally widenedchronic obstructive pulmonary disease (COPD)– permanent lung damage usually caused by smoking

 Medicines that relax (dilate) the airways of the lungs (bronchial tubes). This makes it easier for a person to breathe in more air.

Hydrocortisone

Corticosteroids Corticosteroids may be used to treat chronic obstructive pulmonary disease (COPD) when symptoms rapidly get worse (COPD exacerbation), especially when there is increased mucus production.

Corticosteroids decrease inflammation in the airways (reducing swelling and mucusproduction), making breathing easier.

MEDICATION CLASSIFICATION

INDICATION ACTION

Cefuroxime Antibiotic Treatment of infections of lower respiratory tract, urinary tract, skin and skin structures, bone and joint; preoperative prophylaxis; treatment of septicemia, gonorrhea, and meningitis caused by susceptible strains of specific microorganisms.

Inhibits mucopeptide synthesis in bacterial cell wall.

Fluimucil Mucolytic Treatment of respiratory affections characterized by thick and viscoushypersecretions: acute bronchitis, chronic bronchitis and its exacerbations; pulmonaryemphysema, mucoviscidosis and bronchiectasis.

Exerts mucolytic action through its free sulfhydryl group which opensup the disulfide bonds in the mucoproteins thus lowering mucous viscosity. The exactmechanism of action in acetaminophen toxicity is unknown. It is thought to act by providingsubstrate for conjugation with the toxic metabolite.

Paracetamol Antipyretic pain reliever and a fever reducer. The exact mechanism of action of is not known.

DISCHARGE PLAN

MEDICINES 

The patient was prescribed to take:  Combivent/ Asmavent neb TID - management of asthma.  Hydrocortisone q 6 hr. -   Cefuroxime 750 mg - is an antibiotic. It is used to treat

certain bacterial infection  Fluimucil 200mg- Acute & chronic resp tract infections w/

abundant mucus secretions due to acute bronchitis

Paracetamol 500mg- nd for symptomatic relief of fever and pain, Upper respiratory tract infections

EXERCISE Aerobic exercise is very beneficial for COPD. This type of

exercise, which uses large muscle groups, strengthens the lungs and heart. It also helps the body to use oxygen better and lowers your heart rate. It will improve breathing, because the heart won't have to work as hard during exercise,

Practice a coughing exercise to help keep your lungs clear. Start by sitting in a chair. Relax. Lean your head forward slightly. Both feet should be placed firmly on the floor. Breathe in deeply and slowly. Hold your breath for three seconds, if possible. Open your mouth a little and cough twice. Take a breath, then repeat the exercise two to four times.

A pursed lip breathing exercise can help release air trapped in your lungs. It also helps to eliminate shortness of breath and improves ventilation. 

TREATMENT• Nicotine Replacement Therapy - Including gum,

inhalers, tablets, patches and nasal spray. These aids help reduce cravings, making it easier to quit.

• Aerosol therapy is the process of dispensing particles of medication in a fine spray or mist by way of a nebulizer. The medications frequently used during this process are bronchodilators. Nebulizer aerosols work by relieving spasms in the lungs, decreasing swelling, and making your secretions easier to cough up.

• Oxygen therapy not only increases survival rates in patients with COPD, but it may help alleviate symptoms and improve your quality of life. Remember, oxygen is a drug and must be prescribed by a physician

HEALTH TEACHING Teach the patient and his family how to recognize

early signs of infection; warn the patient to avoid contact with people with respiratory infections. Encourage good oral hygiene to help prevent infection.

Help the patient and his family adjust their lifestyles to accommodate the limitations imposed by this debilitating chronic disease. Instruct the patient to allow for daily rest periods and to exercise daily as directed.

Teach good habits of well-balanced, nutritious intake. Encourage high-protein diet with adequate mineral,

vitamin, and fluid intake. Advise against excessive hot or cold fluids and foods,

which may provoke an irritating cough.

Advise to avoid hard-to-chew foods (causes tiring) and gas-forming foods, which cause distention and restrict diaphragmatic movement.

Advise patient to stop smoking and avoid exposure to second-hand smoke.

 Advise patient to avoid sweeping, dusting, and exposure to paint, aerosols, bleaches,ammonia, and other respiratory irritants.

 Advise patient to keep entire house well-ventilated. Warn patient to stay out of extremely hot/cold weather to avoid

bronchospasm and dyspnea Breathing exercises to strengthen and coordinate muscles of

breathing to lessen work of breathing and help lung empty more completely.

If the patient use oxygen therapy at home, teach him how to use the equipment correctly.

OPD

Follow up your doctor for further

advises and if any unusual symptoms

arise.

Follow the treatment regimen

DIET Warn against potassium depletion. Patients with

COPD tend to have low potassium levels; also, patient may be taking diuretics; Watch for weakness, numbness, tingling of fingers, leg cramps, Encourage foods high in potassium include bananas, dried fruits, dates, figs, orange juice, grape juice, milk, peaches, potatoes, tomatoes.

Advise patient on restricting sodium as directed. Limit carbohydrates if CO2 is retained by

patient, because they increase CO2

SPIRITUAL

You may also find yourself facing some tough questions, suchas how long you have to live and what you will do if you no longer can take care of yourself.Share your fears and feelings with your family, friends and doctor. And always have a strong faith in God.

THANKYOU FOR LISTENING!