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Focus on Chronic Obstructive Pulmonary Disease (COPD). COPD Description. Airflow limitation not fully reversible Generally progressive Abnormal inflammatory response of lungs to noxious particles or gases. COPD Description. Includes Chronic bronchitis Emphysema. - PowerPoint PPT Presentation
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Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Focus on Chronic Obstructive Pulmonary Disease
(COPD)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
COPD Description
• Airflow limitation not fully reversible• Generally progressive• Abnormal inflammatory response of
lungs to noxious particles or gases
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COPDDescription
• Includes• Chronic bronchitis• Emphysema
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Chronic BronchitisDescription
• Presence of chronic productive cough for 3 or more months in each of 2 successive years • Other causes of chronic cough are
excluded
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EmphysemaDescription
• Abnormal permanent enlargement of the air space distal to the terminal bronchioles• Destruction of bronchioles without
obvious fibrosis
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COPDSignificance
• Fourth leading cause of death in the United States• More than 50% die within 10 years
of diagnosis
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COPDEtiology
• Risk factors• Cigarette smoking• Occupational chemicals and dust• Air pollution
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COPDEtiology
• Risk factors• Infection • Heredity• Aging
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COPDOccupational & Environmental• COPD can develop with intense or
prolonged exposure to• Dusts, vapors, irritants, or fumes• High levels of air pollution• Fumes from indoor heating or cooking
with fossil fuels
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COPDInfection
• Recurring infections impair normal defense mechanisms• Risk factor for COPD• Intensify pathologic destruction of
lung tissue
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COPDHeredity
-Antitrypsin (AAT) deficiency• Genetic risk factor for COPD• Accounts for <1% to 2% of COPD
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COPDAging
• Some degree of emphysema is common due to physiological changes of aging lung tissue
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COPDAging
• Natural changes in the aging lungs• Gradual loss of elastic recoil• Lungs become rounded and smaller• Loss of alveolar supporting structures• Decreased number of functional alveoli
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COPDAging
• Natural changes in the aging lungs• Decreased arterial O2 levels• Thoracic cage changes from
osteoporosis and calcification of costal cartilage
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COPDPathophysiology
• Primary process is inflammation• Inhalation of noxious particles• Mediators released cause damage to
lung tissue• Airways inflamed• Parenchyma destroyed
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EmphysemaPathophysiology
• Two types• Centrilobular• Panlobular
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COPDMorphology
Fig. 29-8
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EmphysemaPathophysiology
• Centrilobular (central part of lobule)• Dilation and destruction of respiratory
bronchioles and pulmonary capillary bed• Prominent in upper lobes
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EmphysemaPathophysiology
• Panlobular (destruction of whole lobule)• Affects respiratory bronchioles,
alveolar ducts, and alveolar sacs• Prominent in lower lobes
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COPDPathophysiology
• Supporting structures of lungs are destroyed• Air goes in easily, but remains in the
lungs• Bronchioles tend to collapse • Causes barrel-chest look
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COPDPathophysiology
• Pulmonary vascular changes • Blood vessels thicken• Surface area for diffusion of O2
decreases
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COPDPathophysiology
• Common characteristics• Mucus hypersecretion• Dysfunction of cilia• Hyperinflation of lungs• Gas exchange abnormalities
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COPDPathophysiology
• Commonly emphysema and chronic bronchitis coexist• Distinguishing symptoms can be
difficult with comorbidities
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COPDClinical Manifestations
• Develops slowly• Diagnosis is considered with• Cough• Sputum production• Dyspnea• Exposure to risk factors
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COPDClinical Manifestations
• Intermittent cough is earliest symptom• Dyspnea usually prompts medical
attention• Occurs with exertion in early stages• Present at rest with advanced disease
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COPDClinical Manifestations
• Causes chest breathing• Use of accessory and intercostal
muscles• Inefficient
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COPDClinical Manifestations
• Characteristically underweight with adequate caloric intake• Chronic fatigue
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COPDClinical Manifestations
• Physical examination findings• Prolonged expiratory phase• Wheezes• Decreased breath sounds• ↑ Anterior-posterior diameter
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COPDClinical Manifestations
• Bluish-red color of skin• Polycythemia and cyanosis
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COPD Complications
• Cor pulmonale• Exacerbations of COPD• Acute respiratory failure• Peptic ulcer disease• Depression/anxiety
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COPDDiagnostic Studies
• Diagnosis confirmed by pulmonary function tests• Chest x-rays, spirometry, history, and
physical examination are also important in the diagnostic workup
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COPDDiagnostic Studies
• Spirometry typical findings • Reduced FEV/FVC ratio• Increased residual volume
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COPDDiagnostic Studies
• ABG typical findings• Low PaO2
• ↑ PaCO2
• ↓ pH• ↑ Bicarbonate level found in late stages
COPD
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COPD Diagnostic Studies
• 6-Minute walk test to determine O2
desaturation in the blood with exercise• ECG can show signs of right
ventricular failure
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COPDCollaborative Care
• Primary goals of care• Prevent progression• Relieve symptoms• Prevent/treat complications
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COPDCollaborative Care
• Primary goals of care• Promote patient participation• Prevent/treat exacerbations• Improve quality of life and reduce
mortality risk
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COPDCollaborative Care
• Irritants should be evaluated and avoided• Exacerbations treated promptly
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COPDCollaborative Care
• Smoking cessation• Most effective intervention• Accelerated decline in pulmonary
function slows and usually improves
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COPDCollaborative Care
• Drug therapy• Bronchodilators• Relaxes smooth muscle in the airway• Improves ventilation of the lungs• ↓ Dyspnea and ↑ in FEV1
• Inhaled route is preferred
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COPDCollaborative Care
• Drug therapy• Commonly used bronchodilators
•Β2-Adrenergic agonists• Anticholinergics• Methylxanthines
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COPD Collaborative Care
• Drug therapy• Inhaled corticosteroid therapy• Used for moderate-to-severe cases• Not for long-term use
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COPDCollaborative Care
• O2 therapy is used to• Reduce work of breathing• Maintain PaO2
• Reduce workload on heart
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COPDCollaborative Care
• Long-term O2 therapy improves• Survival• Exercise capacity• Cognitive performance• Sleep in hypoxemic patients
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COPDCollaborative Care
• Humidification • Used because O2 has a drying effect on
the mucosa• Supplied by nebulizers, vapotherm,
and bubble-through humidifiers
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COPDCollaborative Care
• Complications of oxygen therapy• Combustion • CO2 narcosis• O2 toxicity• Absorption atelectasis• Infection
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COPDCollaborative Care
• Chronic O2 therapy at home improves• Prognosis• Mental acuity• Exercise intolerance
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COPDCollaborative Care
• Surgical therapy• Lung volume reduction surgery• Remove 30% of most diseased lung to
enhance performance of remaining tissue
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COPDCollaborative Care
• Surgical therapy• Bullectomy• Used for emphysema• Large bullae are resected to improve lung
function
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COPDCollaborative Care
• Breathing retraining• Decreases dyspnea, improves
oxygenation, and slows respiratory rate• Pursed-lip breathing
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COPDCollaborative Care
• Pursed-lip breathing• Prolongs exhalation and prevents
bronchiolar collapse and air trapping
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COPDCollaborative Care
• Effective coughing• Main goals• Conserve energy• Reduce fatigue• Facilitate removal of secretions
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COPDCollaborative Care
• Nutritional therapy • Weight loss and malnutrition are
common• Pressure on diaphragm from a full
stomach causes dyspnea• Difficulty breathing while eating leads to
inadequate consumption
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COPDCollaborative Care
• Nutritional therapy• To decrease dyspnea and conserve
energy• Rest at least 30 minutes prior to eating• Use bronchodilator• Prepare foods in advance
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COPDCollaborative Care
• Nutritional therapy• Eat 5 to 6 small meals to avoid bloating
and early satiety• Cold foods may cause less fullness than
hot foods
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COPDCollaborative Care
• Nutritional therapy• Avoid • Foods that require a great deal of chewing• Exercises and treatments 1 hour before
and after eating• Gas-forming foods
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COPD Collaborative Care
• Nutritional therapy• High-calorie, high-protein diet is
recommended• Fluids (intake of 3 L/day) should be
taken between meals
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Nursing ManagementNursing Assessment
• Obtain complete health history and conduct a complete physical assessment• See Table 29-27 in textbook for COPD
specific information
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Nursing ManagementNursing Diagnoses
• Ineffective airway clearance• Impaired gas exchange• Imbalanced nutrition: Less than
body requirements• Risk for infection• Insomnia
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Nursing ManagementPlanning
• Goals• Prevention of disease progression• Ability to perform ADLs• Relief from symptoms• No complications related to COPD
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Nursing ManagementPlanning
• Goals• Knowledge and ability to implement
long-term regimen• Overall improved quality of life
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Nursing ManagementNursing Implementation
• Health promotion • Abstain from or stop smoking• Avoid or control exposure to
occupational and environmental pollutants and irritants
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Nursing ManagementNursing Implementation
• Health promotion • Early detection of small-airway disease• Early diagnosis and treatment of
respiratory tract infections
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Nursing ManagementNursing Implementation
• Health promotion • Awareness of family history of COPD
and AAT deficiency
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Nursing ManagementNursing Implementation
• Acute intervention • Required for pneumonia, cor
pulmonale, or acute respiratory failure• Degree and severity of underlying
respiratory problem should be assessed
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Nursing ManagementNursing Implementation
• Ambulatory and home care• Most important aspect is teaching• Pulmonary rehabilitation• Activity considerations• Sexual activity• Sleep• Psychosocial considerations
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Nursing ManagementNursing Implementation
• Pulmonary rehabilitation• Increase exercise performance• Reduce dyspnea• Improved quality of life
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Nursing ManagementNursing Implementation
• Activity considerations • Exercise training leads to energy
conservation• In upper extremities it may improve
muscle function and reduce dyspnea
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Nursing ManagementNursing Implementation
• Activity considerations• Modify ADLs to conserve energy• Walk 15 to 20 minutes a day at least
three times a week with gradual increases• Adequate rest should be allowed
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Nursing ManagementNursing Implementation
• Sleep• Can be difficult because of
medications, postnasal drip, or coughing• Nasal saline sprays, decongestants, or
nasal steroid inhalers can help
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Nursing ManagementNursing Implementation
• Psychosocial considerations• Healthy coping is difficult • Depression affects 40% as severity and
chronicity are realized
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Nursing ManagementNursing Implementation
Ambulatory and home care• Psychosocial considerations• Denial• Dependence• Use relaxation techniques and support
groups
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Nursing ManagementEvaluation
• Expected outcomes• Normal breath sounds• Effective coughing• Return of PaO2 to normal range for
patient• Improved mental status
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Nursing ManagementEvaluation
• Expected outcomes• Maintenance of normal body weight• Normal serum protein levels• Feeling of being rested• Improvement in sleep pattern
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Nursing ManagementEvaluation
• Expected outcomes• Awareness of need to seek medical
attention• Behaviors minimizing risk of infection• No infection