CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Chronic Obstructive Pulmonary Disease (COPD), or also known as Chronic

Obstructive Lung Disease (COLD) and Chronic Obstructive Airway Disease (COAD)
is a broad classification that includes a group of conditions associated with chronic
obstruction of airflow entering or leaving the lungs. Airway obstruction is diffuse
airway narrowing, causing increased resistance to airflow. Most people with Chronic
Bronchitis have COPD.
Basically, the person with COPD has (1) excessive secretion of mucus within
the airways not owing to specific causes (bronchitis), (2) an increase in the size of
the air spaces distal to the terminal bronchioles with loss of alveolar walls and
elastic recoil of the lungs (emphysema), and (3) narrowing of the bronchial airways
that varies in severity (asthma). As a result there is a subsequent derangement of
airway dynamics------ for example, loss of elasticity and obstruction to airflow. There
is often an overlap of these conditions.
COPD is a type of obstructive lung disease in which chronic incompletely
reversible poor airflow (airflow limitation) and inability to breathe out fully (air
trapping) exist. The poor airflow is the result of breakdown of lung tissue and small
airways disease known as obstructive bronchiolitis.

Risk Factors:

Genetics
Smoking cigarettes (Most common cause of COPD)
Air pollution
Occupational exposures
Poverty
Infectious diseases

Signs and Symptoms

Cough (first symptom to occur)

Shortness of breath
Productive cough
Barrel chest
Crackles
Tachypnea
Tachycardia
Diaphoresis

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Precipitating Factors:
Smoking
Passive Smoking
Exposure to indoor and
outdoor air pollution
Prolonged
and
intense
exposure to occupational
dusts and chemicals
HIV infection
Recurrent
respiratory
function

Predisposing Factors:

Age
Allergies
Deficiency
of
Alpha1 Antitrypsin
Alpha1 Antitrypsin
(hereditary)

Chronic irritation to the

airflows of the lungs

Infiltration of lymphocytes,
macrophages, and
polymorphonuclear leukocytes
in the mucosal areas

The elastin and fiber network

of the alveoli are broken

Vasodilation, congestion, and

edema of the bronchial
mucosa

As a compensatory
mechanism, the alveoli
enlarge but the walls are
damaged

Thickening due to excessive

mucus plug formation and
rigidity of bronchi

Consistent destruction of the

alveoli and alveolar walls

Narrowing of air passages

Enlargement of acini

Reduction in the alveolar

diffusing space and some
tissue changes

Chronic Bronchitis
Pulmonary Emphysema

Chronic Obstructive
Pulmonary Disease

Assessment

If the person is on the emphysematous end of the spectrum, she will

tend to be thin and have a wide, barrel-shaped chest. She will always
feel out of breath. When she coughs, she will not produce much sputum.

On chest examination, this persons breath sounds will be distant and

relatively clear.
If the person is on the chronic bronchitis end of the spectrum, she will
tend to be of normal weight or overweight. She will cough frequently and
will bring up sputum. A cough that will last at least three months a year
for two consecutive years. On chest examination, her breath sounds will
include rales (dry crackles), rhonchi (harsh, wet sounds), and wheezes. A
COPD patient with chronic bronchitis will get more respiratory infections
than normal.
Other signs and symptoms of COPD include:

Shortness of breath, especially during physical activities

Wheezing

Chest tightness

Having to clear your throat first thing in the morning, due to excess mucus in
your lungs

A chronic cough that produces sputum that may be clear, white, yellow or
greenish

Blueness of the lips or fingernail beds (cyanosis)

Frequent respiratory infections

Lack of energy

Unintended weight loss (in later stages)

Laboratory Tests
Routine lab tests are often done on individuals who have been diagnosed with
COPD. These tests include what is known as the Complete Blood Count (CBC) and a
basic chemistry profile.
Complete Blood Count
A complete blood count (CBC) provides information about the different
types of blood cells. In a person with chronic obstructive pulmonary disease
(COPD), the CBC may show:
An increased number of red blood cells (erythrocytosis). This
occurs when the person has had low oxygen levels in the blood (hypoxemia) for
a long period of time. Red blood cells carry oxygen in the blood. Because of
damage to the lungs, a person with COPD often cannot get enough air. The
body reacts by producing more red blood cells to try to increase the amount of
oxygen in the blood.
An increase in the white blood cells that fight infection (neutrophils)
may mean that the person has an infection. An increase in the white blood
cells that may be produced during an allergic reaction (eosinophils) may mean
that a condition such as asthma is causing the symptoms.
An increase in neutrophils can also occur in response to using oral or
intravenous (IV) corticosteroids.
Arterial Blood Gases
ABGs determine how well the lungs are getting oxygen into the blood and
carbon dioxide out of the blood. A sample of blood is drawn from an artery, most
often near the wrist. The most important measurements in the blood gas sample
are the acid/base balance (pH), the carbon dioxide level (PaCO2), the oxygen
level (PaO2) and oxygen saturation (SaO2).

pH is a measurement of the acid/base balance of the body. A pH below 7.35

indicates "acidosis". A pH above 7.45 indicates "alkalosis.
PaCO2 measures the pressure of carbon dioxide in the arterial blood. This
pressure is related to the amount of carbon dioxide in the blood.
PaO2 measures the pressure of oxygen in the arterial blood. It is based on the
PaO2, the number of red blood cells in your blood, the amount of hemoglobin in
each red blood cell and the ability of hemoglobin to carry oxygen. Hemoglobin is
a protein in the red blood cells that carries oxygen throughout the body. The
PaO2 number decreases somewhat as we get older. A low number may mean
abnormal lung function.

SaO2 measures what percent of the hemoglobin in your red blood cells is
carrying oxygen.
Result: For COPD patients, the PaO2 can drop below 60 mm Hg. This level
signals respiratory distress to the brain and it strongly activates the respiratory
centers. When the PaO2 is below 60 mm Hg, a person hyperventilates in an
attempt to reverse the hypoxemia by breathing in more air. Unfortunately,
hyperventilation due to hypoxemia expels too much carbon dioxide from the
bloodstream and causes respiratory alkalosis, a pH imbalance in the blood.
Hypoxemia with alkalosis is found in the middle phase of the course of COPD.
In later stages of COPD, hypoxemia is accompanied by hypercapnia (excess
blood carbon dioxide), and the patient develops chronic respiratory acidosis,
an ominous sign. Hypoxemia with acidosis is found in the late phase of the
course of COPD.

Diagnostic Exams
Pulmonary function tests
As the name implies, pulmonary function tests (PFTs) measure how well
the lungs are moving air in and out. They also measure how well the lungs
are moving oxygen to the blood. Most are done by blowing into a tube while
you sit in a chair.
Individuals with COPD often have abnormal PFT results which suggest airway
blockage and air trapping. Similar changes can be seen in some other lung
conditions, such as asthma. If the lung function testing includes a diffusing
capacity (DLCO) test, a low value suggests emphysema.
Many factors can affect the results of these tests. These include the
current health of your lungs, the skill of the person testing you, your effort
and the type of equipment used. PFTs are helpful in measuring the effects of
lung medicines on lung function. They can also determine how serious are
the disorders affecting the airways or other lung tissue. PFTs are helpful when
preparing for lung surgery.
Spirometry
Spirometry measures how much air you can breathe in and out, how
fast you can breathe out that volume of air and how fast you can breathe out
that volume of air.
Forced Vital Capacity (FVC) measures the amount of air you can breathe
out in one complete breath. You will hold a clean tube up to your mouth, often
using a mouthpiece. You will be asked to breathe in as fully as you can. And
then immediately blow out as hard and fast as you can, until you feel you
cannot blow any longer. You will do this with your nose pinched closed. A new
version of this test, called the "Six-Second Forced Expiratory Volume (FEV6).
Result: There is likely to be a reduction in FVC in patients with moderate-tosevere COPD, which is caused by the alveolar damage and coalescence,
together with loss of elasticity of the lung tissue.
Forced Expiratory Volume in the first second (FEV1) measures how
much of the air you blew out was breathed out during the first second.
Result: A decrease in the FEV1 may mean there is blockage to the flow of air
out of your lungs. Obstructive pulmonary diseases, such as emphysema,
asthma or chronic bronchitis, can cause reduced FEV1 values. This value is
often the most important value followed over time in COPD patients.
The Ratio describes what percentage of your total breath was breathed out
during the first second of your FVC test. The normal adult can breathe out 60-

90 percent of their breath during the first second. This percent often
decreases with age.
Result: In obstructive lung diseases, the FEV1/FVC ratio is lower than the
normal range. If you have both a low FEV1 and a low FVC, this value can help
in understanding the type of lung disease you have.
Chest X-rays
Chest x-rays are used to rule out other causes of airway obstruction,
such as mechanical obstruction, tumors, infections, effusions, or interstitial
lung diseases. In acute exacerbations of COPD, chest x-rays are used to
look for pneumothorax, pneumonia, and atelectasis (collapse of part of a
lung).

Results: When COPD includes significant emphysema, the chest is

widened, the diaphragm is flattened, and the lung fields have fainter and
fewer vascular markings. Emphysema can make the heart look long,
narrow, and vertical, and the airspace behind the heart can be enlarged.
When COPD includes significant chronic bronchitis, chest x-rays have a
dirty look. There are more vascular markings and more nonspecific
bronchial markings, and the walls of the bronchi look thicker than normal
when viewed end-on. Often, the heart appears enlarged.
Computed Tomography Scans
A CT scan of your lungs can help detect emphysema and help
determine if you might benefit from surgery for COPD. CT scans can also be
used to screen for lung cancer, which is more common among people with
COPD than it is among those who smoked but didn't develop COPD.

Result: Findings of COPD may be seen in a variety of CT studies, in chronic

bronchitis, bronchial wall thickening may be seen in addition to enlarged
vessels. Repeated inflammation can lead to scarring with bronchovascular
irregularity and fibrosis.

Emphysema is diagnosed by alveolar septal destruction and airspace

enlargement, which may occur in a variety of distributions. Centrilobular
emphysema is predominantly seen in the upper lobes with panlobular
emphysema predominating in the lower lobes. Paraseptal emphysema tends
to occur near lung fissures and pleura. Formation of giant bullae may lead to
compression of mediastinal structures, while rupture of pleural blebsmay
produce spontaneous pneumothorax/pneumomediastinum.

References:
http://www.webmd.com/lung/copd/diagnostic-tests?page=2
http://www.patient.co.uk/doctor/spirometry-pro#
http://radiopaedia.org/articles/chronic-obstructive-pulmonary-disease-1
http://www.nursingceu.com/courses/405/index_cm.html

Medical Management
Risk Reduction

Smoking cessation is the single most cost-effective intervention to

reduce the risk of developing COPD and to stop its progression. However,
smoking cessation is difficult to achieve and even more difficult to sustain in
the long term.

Pharmacologic Therapy
Bronchodilators
Bronchodilators relieve bronchospasm by altering smooth muscle tone
and reduce airway obstruction by allowing increased oxygen distribution
throughout the lungs and improving alveolar ventilation. Although regular use
of bronchodilators that act primarily on the airway smooth muscle does not
modify the decline of function or the prognosis of COPD, their use is central in
the management of COPD (GOLD, 2008). These agents can be delivered
through a metered-dose inhaler or other type of inhaler, by nebulization, or
via the oral route in pill or liquid form. Bronchodilators are often administered
regularly throughout the day as well as on an as-needed basis. 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.

AEROSOL DELIVERY DEVICES

Devices
Drugs
1. Metered-dose inhaler (MDI)
Beta2-agonists
Corticosteroids
Cromolyn sodium
Anticholinergics
2. Breath-actuated MDI
Beta2-agonists
3. Dry powder inhaler (DPI)
Beta2-agonists
Corticosteroids
Anticholinergics
4. Spacer or valved-holding chamber
(VHC)
5. Nebulizer
Beta2-agonists
Corticosteroids
Cromolyn sodium
Anticholinergics

COMMON TYPES OF BRONCHODILATOR MEDICATIONS FOR COPD

Drug Classification
1. Beta2-Adrenergic Agonist Agents

2. Anticholinergic Agents
3. Combination Short-Acting Beta-2
Adrenergic Agonist and
Anticholinergic Agents
4. Methylxanthines

Generic/Trade Name
salbutamol, albuterol (Proventil,
Ventolin)
fenoterol (Alupent, Isuprel)
terbutaline (Brethine)
formoterol (Foradil)
salmeterol (Serevent Diskus)
Ipratropium bromide (Atrovent)
fenoterol/ipratropium (Duovent)
salbutamol/ipratropium (Combivent)
aminophylline (Phyllocontin, Truphylline)
theophylline (Theo-Dur, Slo-Bid)

Corticosteroids
Although inhaled and systemic corticosteroids may improve the
symptoms of COPD, 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
with oral corticosteroids is not recommended in COPD and can cause steroid
myopathy, leading to muscle weakness, decreased ability to function, and, in
advanced disease, respiratory failure
Other Medications
Other pharmacologic treatments that may be used in COPD include
alpha1-antitrypsin augmentation therapy, antibiotic agents, mucolytic
agents, antitussive agents, vasodilators, and narcotics. Vaccines may also be
effective. Influenza vaccines can reduce serious morbidity and death in
patients with COPD by approximately 50% . It is recommended that people
limit their risk through influenza vaccination and smoking cessation.
Pneumococcal vaccination also reduces the incidence of pneumonia.
Oxygen Therapy
Oxygen therapy can be administered as long-term continuous therapy,
during exercise, or to prevent acute dyspnea during an exacerbation. The
goal of supplemental oxygen therapy is to increase the baseline resting
partial arterial pressure of oxygen (PaO2) to at least 60 mm Hg at sea level
and an arterial oxygen saturation (SaO2) at least 90%. Long-term oxygen
therapy (more than 15 hours per day) has also been shown to improve
quality of life, reduce pulmonary arterial pressure and dyspnea, and improve
survival. Long-term oxygen therapy is usually introduced in very severe
COPD, and indications generally include a PaO2 of 55 mm Hg or less or
evidence of tissue hypoxia and organ damage such as cor pulmonale,
secondary polycythemia, edema from right-sided heart failure, or impaired
mental status. For patients with exercise-induced hypoxemia, oxygen
supplementation during exercise may improve performance.

Surgical Management
During the past few decades multiple surgical interventions have been
suggested to improve symptoms in patients with COPD. These include bullectomy,
lung volume reduction surgery and lung transplantation.

Bullectomy
Outcomes: Bullectomy appears to be of benefit in highly selected patients,
resulting in short-term improvements in airflow obstruction, lung volumes,
hypoxaemia and hypercapnia, exercise capacity, dyspnoea, and health-related
quality of life.
Surgical mortality ranges from 0-22.5%. Long-term follow-up data are more
limited with 1/3-1/2 of patients maintaining benefits for ~5 years.
Patient selection: Based on the presumption that improvement is
dependent on relief of compressed normal lung, most investigators have attempted
to identify optimal surgical candidates on the basis of pulmonary function and
radiographic features.

Lung Volume Reduction Surgery

Outcomes: LVRS results in short-term improvements in spirometry, lung
volumes, exercise tolerance, dyspnoea and health-related quality of life, and

potentially long-term improvement in survival.

LVRS using resection of lung tissue has significantly better results than laser
treatment of the lung.
Bilateral LVRS shows greater improvements compared to unilateral LVRS
among similar patients.
Patient selection: Selection criteria for LVRS remain controversial.
A systematic review proposed the following features, as determined by expert
opinion, to be associated with better outcomes: smoking-related emphysema,
heterogeneous emphysema with surgically accessible "target" areas, bilateral
surgery, good general fitness/condition and thoracic hyperinflation. The National
Emphysema Treatment Trial (NETT) suggests that upper lobe predominance of
emphysema on high resolution computed tomography of the chest and low post
rehabilitation exercise capacity measured while breathing 30% inspiratory oxygen
fraction on a cycle ergometry are predictive of the best chance of post-surgical
improvement.

Spirometry: The mean improvement from baseline in FEV1 ranges from 596%, although 20-50% of patients show little spirometric improvement after LVRS.
Lung volume: Lung volume changes include a mean decrease in total lung
capacity from baseline varying from 1-23% and residual volume ranging from 346%.
Exercise tolerance: Improved timed walk distance, ranging a mean of 7103%, and an increase in maximal work load, oxygen uptake and minute ventilation
have been reported after LVRS.
Dyspnea and health-related quality of life: Improved dyspnea and
health-related quality of life has been reported after LVRS
Mortality: Mortality following LVRS varies greatly among centres. The NETT
Research Group documented a 90-day surgical mortality of 7.9% in all randomised
patients, compared to 1.3% in a comparable medically treated arm; much of this
mortality was accounted for by high-risk patients in whom the 90-day surgical
mortality was 28.6%, as compared to 0% in the respective medical arm. In non-high
risk patients, the 90-day surgical mortality was 5.2%, as compared to 1.5% in the
medically treated patients.
In the NETT study, baseline patient characteristics were found to predict longterm mortality risks. In patients with upper lobe predominant emphysema on highresolution computed tomography and a low postrehabilitation, maximal-achieved
cycle ergometry work load, there was an improved long-term (mean follow-up 29
months) survival in patients undergoing bilateral LVRS compared to those treated
with medical therapy (risk ratio 0.47, p=0.005). Early higher mortality in patients
treated surgically was compensated for by lower mortality risk in LVRS patients
during long-term follow-up. In patients with nonupper lobe predominant
emphysema and a higher post-rehabilitation cycle ergometry work load, surgically
treated patients experienced a higher mortality than comparable, medically treated
patients (risk ratio 2.06, p=0.02). The other two sub-groups experienced no
mortality difference with LVRS.
Long-term results: Few studies have reported long-term results, but they
suggest widely varying long-term morbidity and mortality among centres, return of
spirometric function and lung volumes towards preoperative baseline and worsening

dyspnoea over time. There appears to be slower loss of 6-min walk distance after
LVRS than of other functional measures.

Lung transplantation
Lung transplantation should be considered in selected patients with advanced
COPD. COPD is the most common indication for lung transplantation (UNOS on-line
data base). The choice of single lung transplantation (SLT) or bilateral lung
transplantation (BLT) for COPD remains controversial.
Outcomes: Lung transplantation results in improved pulmonary function,
exercise capacity and quality of life. However, its effect on survival remains
controversial.
Patient selection: In selecting candidates, several issues must be
considered, including the patients pulmonary disability, projected survival without
transplantation, comorbid conditions and patient preferences. To optimise results of
transplantation, the procedure must be carefully timed such that transplantation is
performed when the patient is neither "too healthy" nor "too ill". Selection criteria
for COPD patients are shown in tables 6 and 7.
General selection guidelines for candidate selection for lung
transplantation in COPD patients
Relative
contraindicatio
ns

Age limits
Heart-lung transplants ~55 yrs
Double lung transplant ~60 yrs
Single lung transplant ~65 yrs
Symptomatic osteoporosis
Oral corticosteroids >20 mgday-1 prednisone
Psychosocial problems
Requirement for invasive mechanical ventilation
Colonisation with fungi or atypical mycobacteria

Absolute
contraindicatio
ns

Severe musculoskeletal disease affecting the thorax

Substance addiction within previous 6 months
Dysfunction of extrathoracic organ, particularly renal
dysfunction
HIV infection
Active malignancy within 2 yrs except basal or squamous cell
carcinoma of skin
Hepatitis B antigen positivity
Hepatitis C with biopsy-proven evidence of liver disease

Disease-specific guidelines for candidate selection for lung transplantation

in COPD patients.
FEV1 25% pred (without reversibility) and/or
Resting, room air Pa,CO2 >7.3 kPa (55 mmHg) and/or
Elevated Pa,CO2 with progressive deterioration requiring long-term oxygen
therapy
Elevated pulmonary artery pressure with progressive deterioration.

Pulmonary function: Following SLT for COPD, FEV1 is expected to rise to

~50% of the predicted normal value and FVC to ~70% of the predicted normal
value.
Exercise capacity: Despite the differential improvements in spirometry,
peak exercise capacity is similar between SLT and BLT.
Quality of life: Quality of life following lung transplantation improves
dramatically, in particular for those patients who do not develop chronic rejection.
Only a minority of patients return to full-time work.
Survival: Average actuarial survival following lung transplantation for
recipients with COPD is 81.7, 61.9 and 43.4% at 1, 3 and 5 yrs (UNOS online data
base).
Compared to patients with other cardiopulmonary diseases, patients with
emphysema exhibit the best overall survival after transplantation.
By 5 yrs following lung transplantation, the prevalence of chronic allograft
rejection (obliterative bronchiolitis), the leading cause of long-term morbidity and
mortality, is as high as 50-70% among survivors.

Nursing Management
Patient with chronic obstructive pulmonary disease (COPD) requires astute
nursing care to avoid the complications of reduced respiratory function and the
stresses and anxieties of dealing with a life-threatening illness.

Ineffective Airway Clearance

Nursing Interventions
Auscultate breath
sounds. Note adventitious
breath sounds, e.g.,
wheezes, crackles,
rhonchi.
Assess/ monitor
respiratory rate. Note
inspiratory/ expiratory
ratio.
Assist patient to assume
position of comfort, e.g.,
elevate head of bed, have

Rationale
Some degree of bronchospasm is present with
obstructions in airway and may/may not be
manifested in adventitious breath sounds, e.g.,
scattered, moist crackles (bronchitis); faint sounds,
with expiratory wheezes (emphysema); or absent
breath sounds (severe asthma).
Tachypnea is usually present to some degree and
may be pronounced on admission or during stress/
concurrent acute infectious process. Respirations
may be shallow and rapid, with prolonged expiration
in comparison to inspiration.
Elevation of the head of the bed facilitates
respiratory function by use of gravity; however,
patient in severe distress will seek the position that

patient lean on overbed

table or sit on edge of
bed.
Keep environmental
pollution to a minimum,
e.g., dust, smoke, and
feather pillows, according
to individual situation.
Encourage/ assist with
abdominal or pursed-lip
breathing exercises.
Observe characteristics
of cough, e.g., persistent,
hacking, moist. Assist with
measures to improve
effectiveness of cough
effort.
Increase fluid intake to
3000 mL/day within
cardiac tolerance. Provide
warm/ tepid liquids.
Recommend intakeof
fluids between, instead of
during, meals.
Monitor/ graph serial
ABGs, pulse oximetry,
chest x-ray.

most eases breathing. Supporting arms/legs with

table, pillows, and so on helps reduce muscle fatigue
and can aid chest expansion.
Precipitators of allergic type of respiratory reactions
that can trigger/ exacerbate onset of acute episode.

Provides patient with some means to cope with/

control dyspnea and reduce air-trapping.
Cough can be persistent but ineffective, especially if
patient is elderly, acutely ill, or debilitated. Coughing
is most effective in an upright or in a head-down
position after chest percussion.

Hydration helps decrease the viscosity of secretions,

facilitating expectoration. Using warm liquids may
decrease bronchospasm. Fluids during meals can
increase gastric distension and pressure on the
diaphragm.

Establishes baseline for monitoring progression/

regression of disease process and
complications. Note: Pulse oximetry readings detect
changes in saturation as they are happening, helping
to identify trends before patient is symptomatic.
However, studies have shown that the accuracy of
pulse oximetry may be questioned if patient has
severe peripheral vasoconstriction.

Impaired Gas Exchange

Nursing Interventions
Assess respiratory rate, depth.
Note use of accessory muscles,
pursed-lip breathing, and
inability to speak / converse.
Elevate head of bed, assist
patient to assume position to
ease work of breathing. Include
periods of time in prone
position as tolerated.
Encourage deep-slow or
pursed-lip breathing as
individually needed/ tolerated.
Assess/ routinely monitor skin
and mucous membrane color.

Rationale
Useful in evaluating the degree of respiratory
distress and/or chronicity of the disease process.

Encourage expectoration of
sputum; suction when
indicated.

Thick, tenacious, copious secretions are a major

source of impaired gas exchange in small
airways. Deep suctioning may be required when
cough is ineffective for expectoration of
secretions.
Breath sounds may be faint because of
decreased airflow or areas of consolidation.
Presence of wheezes may indicate

Auscultate breath sounds,

noting areas of decreased
airflow and/or adventitious

Oxygen delivery may be improved by upright

position and breathing exercises to decrease
airway collapse, dyspnea, and work of
breathing. Note: Recent research supports use
of prone position to increase Pao2.

Cyanosis may be peripheral (noted in nailbeds)

or central (noted around lips/or earlobes).
Duskiness and central cyanosis indicate
advanced hypoxemia.

sounds.

Palpate for fremitus.

Monitor level of consciousness/
mental status. Investigate
changes.

Evaluate level of activity

tolerance. Provide calm, quiet
environment. Limit patients
activity or encourage bed/chair
rest during acute phase. Have
patient resume activity
gradually and increase as
individually tolerated.
Evaluate sleep patterns, note
reports of difficulties and
whether patient feels well
rested. Provide quiet
environment, group care/
monitoring activities to allow
periods of uninterrupted sleep;
limit stimulants.
Monitor vital signs and cardiac
rhythm.

bronchospasm/ retained secretions. Scattered

moist crackles may indicate interstitial fluid/
cardiac decompensation.
Decrease of vibratory tremors suggests fluid
collection or air-trapping.
Restlessness and anxiety are common
manifestations of hypoxia. Worsening ABGs
accompanied by confusion/ somnolence are
indicative of cerebral dysfunction due to
hypoxemia.
During severe/ acute/ refractory respiratory
distress, patient may be totally unable to
perform basic self-care activities because of
hypoxemia and dyspnea. Rest interspersed with
care activities remains an important part of
treatment regimen. An exercise program is
aimed at increasing endurance and strength
without causing severe dyspnea and can
enhance sense of well-being.
Multiple external stimuli and presence of
dyspnea may prevent relaxation and inhibit
sleep.

Tachycardia, dysrhythmias, and changes in BP

can reflect effect of systemic hypoxemia on
cardiac function.

Imbalanced Nutrition: Less than body requirements

Nursing Interventions
Assess dietary habits,
recent food intake. Note
degree of difficulty with
eating. Evaluate weight
and body size (mass).

Auscultate bowel
sounds.

Give frequent oral care,

remove expectorated
secretions promptly,
provide specific container
for disposal of secretions
and tissues.
Encourage a rest period
of 1 hr before and after
meals. Provide frequent
small feedings.
Avoid gas-producing
foods and carbonated
beverages.
Avoid very hot or very

Rationale
Patient in acute respiratory distress is often anorectic
because of dyspnea, sputum production, and
medications. In addition, many COPD patients
habitually eat poorly, even though respiratory
insufficiency creates a hypermetabolic state with
increased caloric needs. As a result, patient often is
admitted with some degree of malnutrition. People
who have emphysema are often thin with wasted
musculature.
Diminished/ hypoactive bowel sounds may reflect
decreased gastric motility and constipation (common
complication) related to limited fluid intake, poor food
choices, decreased activity, and hypoxemia.
Noxious tastes, smells, and sights are prime
deterrents to appetite and can produce nausea and
vomiting with increased respiratory difficulty.

Helps reduce fatigue during mealtime, and provides

opportunity to increase total caloric intake.

Can produce abdominal distension, which hampers

abdominal breathing and diaphragmatic movement
and can increase dyspnea.
Extremes in temperature can precipitate/ aggravate

cold foods.
Weigh as indicated.

Administer supplemental
oxygen during meals as
indicated.

coughing spasms.
Useful in determining caloric needs, setting weight
goal, and evaluating adequacy of nutritional
plan. Note: Weight loss may continue initially, despite
adequate intake, as edema is resolving.
Decreases dyspnea and increases energy for eating,
enhancing intake.

Risk for Infection

Nursing Interventions
Monitor temperature.
Review importance of breathing exercises,
effective cough, frequent position changes,
and adequate fluid intake.
Observe color, character, odor of sputum.

Demonstrate and assist patient in disposal

of tissues and sputum. Stress proper
handwashing (nurse and patient), and use
gloves when handling/ disposing of tissues,
sputum containers.
Monitor visitors; provide masks as indicated.

Encourage balance between activity and

rest.

Discuss need for adequate nutritional

intake.
Recommend rinsing mouth with water and
spitting, not swallowing, or use of spacer on
mouthpiece of inhaled corticosteroids.
Obtain sputum specimen by deep coughing
or suctioning for Grams stain, culture/
sensitivity.
Administer antimicrobials as indicated.

Rationale
Fever may be present because of
infection and/or dehydration.
These activities promote
mobilization and expectoration of
secretions to reduce risk of
developing pulmonary infection.
Odorous, yellow, or greenish
secretions suggest the presence of
pulmonary infection.
Prevents spread of fluid-borne
pathogens.

Reduces potential for exposure to

infectious illnesses, e.g., upper
respiratory infection (URI).
Reduces oxygen consumption/
demand imbalance, and improves
patients resistance to infection,
promoting healing.
Malnutrition can affect general
well-being and lower resistance to
infection.
Reduces localized
immunosuppressive effect of drug
and risk of oral candidiasis.
Done to identify causative
organism and susceptibility to
various antimicrobials.
May be given for specific
organisms identified by culture and
sensitivity, or be given
prophylactically because of high

risk.

Knowledge Deficit
Nursing Interventions
Explain/reinforce explanations of
individual disease process.
Encourage patient/SO to ask
questions.
Instruct/reinforce rationale for
breathing exercises, coughing
effectively, and general conditioning
exercises.

Stress importance of oral care/

dental hygiene.
Discuss importance of avoiding
people with active respiratory
infections. Stress need for routine
influenza/ pneumococcal
vaccinations.
Discuss individual factors that may
trigger or aggravate condition, e.g.,
excessively dry air, wind,
environmental temperature
extremes, pollen, tobacco smoke,
aerosol sprays, air pollution.
Encourage patient/ SO to explore
ways to control these factors in and
around the home and work setting.
Review the harmful effects of
smoking, and advise cessation of
smoking by patient and/or SO.

Provide information about activity

limitations and alternating activities

Rationale
Decreases anxiety and can lead to
improved participation in treatment plan.

Pursed-lip and abdominal/ diaphragmatic

breathing exercises strengthen muscles of
respiration, help minimize collapse of small
airways, and provide the individual with
means to control dyspnea. General
conditioning exercises increase activity
tolerance, muscle strength, and sense of
well-being.
Decreases bacterial growth in the mouth,
which can lead to pulmonary infections.
Decreases exposure to and incidence of
acquired acute URIs.

These environmental factors can induce/

aggravate bronchial irritation, leading to
increased secretion production and airway
blockage.

Cessation of smoking may slow/ halt

progression of COPD. Even when patient
wants to stop smoking, support groups and
medical monitoring may be
needed. Note:Research studies suggest
that side-stream or second-hand
smoke can be as detrimental as actually
smoking.
Having this knowledge can enable patient
to make informed choices/ decisions to

with rest periods to prevent fatigue;

ways to conserve energy during
activities (e.g., pulling instead of
pushing, sitting instead of standing
while performing tasks); use of
pursed-lip breathing, side-lying
position, and possible need for
supplemental oxygen during sexual
activity.
Discuss importance of medical
follow-up care, periodic chest x-rays,
sputum cultures.
Review oxygen requirements/
dosage for patient who is discharged
on supplemental oxygen. Discuss
safe use of oxygen and refer to
supplier as indicated.
Instruct patient/SO in use of NIPPV
as appropriate. Problem-solve
possible side effects and identify
adverse signs/ symptoms, e.g.,
increased dyspnea, fatigue, daytime
drowsiness, or headaches on
awakening.
Instruct asthmatic patient in use of
peak flow meter, as appropriate.

Provide information/ encourage

participation in support groups, e.g.,
American Lung Association, public
health department.

Refer for evaluation of home care if

indicated. Provide a detailed plan of
care and baseline physical
assessment to home care nurse as
needed on discharge from acute
care.
Discuss respiratory medications,
side effects, adverse reactions.

Demonstrate technique for using a

metered-dose inhaler (MDI), such as
how to hold it, taking 25 min
between puffs, cleaning the inhaler.
Devise system for recording

reduce dyspnea, maximize activity level,

perform most desired activities, and
prevent complications.

Monitoring disease process allows for

alterations in therapeutic regimen to meet
changing needs and may help prevent
complications.
Reduces risk of misuse (too little/too
much) and resultant complications.
Promotes environmental/ physical safety.

NIPPV may be used at night/ periodically

during day to decrease CO2 level, improve
quality of sleep, and enhance functional
level during the day. Signs of increasing
CO2 level indicate need for more
aggressive therapy.
Peak flow level can drop before patient
exhibits any signs/ symptoms of asthma
during the first time after exposure to a
trigger. Regular use of the peak flow meter
may reduce the severity of the attack
because of earlier intervention.
These patients and their SOs may
experience anxiety, depression, and other
reactions as they deal with a chronic
disease that has an impact on their desired
lifestyle. Support groups and/ or home
visits may be desired or needed to provide
assistance, emotional support, and respite
care.
Provides for continuity of care. May help
reduce frequency of rehospitalization.

Frequently these patients are

simultaneously on several respiratory
drugs that have similar side effects and
potential drug interactions. It is important
that patient understand the difference
between nuisance side effects (medication
continued) and untoward or adverse side
effects (medication possibly discontinued/
dosage changed).
Proper administration of drug enhances
delivery and effectiveness.

Reduces risk of improper use/ overdosage

prescribed intermittent drug/ inhaler

usage.
Recommend avoidance of sedative
antianxiety agents unless
specifically prescribed/ approved by
physician treating respiratory
condition.

of prn medications, especially during acute

exacerbations, when | cognition may be
impaired.
Although patient may be nervous and feel
the need for sedatives, these can depress
respiratory drive and protective cough
mechanisms. Note: These drugs may be
used prophylactically when patient is
unable to avoid situations known to
increase stress/ trigger respiratory
response.

References:
http://nurseslabs.com/5-chronic-obstructive-pulmonary-disease-copd-nursing-careplans/
http://www.nursingceu.com/courses/405/index_cm.html
http://www.coursewareobjects.com/objects/evolve/E2/book_pages/monahan/pdfs/Nu
rsingManagement.pdf