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02.03 COPD (Chronic Obstructive Pulmonary Disease)

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Overview

Chronic obstruction of airflow due to emphysema and chronic bronchitis

Nursing Points

General

  1. Emphysema
    1. Destruction of alveoli due to chronic inflammation
    2. Decreased surface area for gas exchange
  2. Chronic Bronchitis
    1. Chronic airway inflammation with productive cough
    2. Excessive sputum production

Assessment

  1. Barrel chest – expanded rib cage due to ↑ work of breathing and air trapping.
  2. Accessory muscle use
  3. Adventitious breath sounds
    1. Diminished
    2. Crackles
    3. Wheezes
  4. Congestion on Chest X-ray
  5. ABG → ↓ pH, ↑ pCO2, ↓ PaO2

Therapeutic Management

  1. Do NOT give O2 > 2 lpm
    1. Stimulus to breathe = ↓ O2
  2. Chest Physiotherapy (CPT)
    1. Loosen secretions
  3. Increase fluid intake (3 L / day)
    1. Thin secretions
  4. Medications
    1. Bronchodilators
    2. Corticosteroids

Nursing Concepts

  1. Oxygenation
    1. Listen to lungs
    2. Monitor SpO2 (88-92%)
    3. Caution with supplemental O2 – Do not give excessive supplemental O2 – aim for SpO2 88-92% only
  2. Gas Exchange
    1. Monitor ABG
    2. Monitor for s/s CO2 toxicity
      1. ↓ LOC
      2. ↓ RR
  3. Comfort
    1. Encourage position of comfort

Patient Education

  1. Smoking Cessation
  2. Small, frequent meals
  3. Identify and avoid triggers
  4. Pursed lip breathing – helps complete expiration

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Video Transcript

In this lesson we’re going to cover one of the most common chronic lung diseases you’ll see. There are also some things about taking care of COPD patients that some nursing schools aren’t teaching so we’re going to make sure you know this because it’s super important and you WILL see it on the NCLEX.

In this lesson we’re going to cover one of the most common chronic lung diseases you’ll see. There are also some things about taking care of COPD patients that some nursing schools aren’t teaching so we’re going to make sure you know this because it’s super important and you WILL see it on the NCLEX.

So COPD stands for Chronic Obstructive Pulmonary Disease. So it’s a chronic, meaning greater than 6 months, disease of the lungs (pulmonary), caused by obstruction. So we see chronic obstruction of air flow and gas exchange in the lungs – caused by either emphysema or chronic bronchitis. So let’s look at both of these. Emphysema is when there is so much inflammation that the alveoli themselves get destroyed. Remember from the gas exchange lesson that this is where all the gas exchange happen. So if they are destroyed, we seriously limit our ability for gas exchange. The second condition is chronic bronchitis. This is airway inflammation plus excessive sputum that causes them to have a productive cough. and of course the more they cough, the more it irritates and causes more inflammation. So the air passages themselves are narrowed and filled with mucus. So, again, the ability to get oxygen in is severely compromised. BUT, so is the ability to get carbon dioxide out. So in both cases, we see patients essentially trapping CO2 in their systems because their lungs just won’t allow for proper gas exchange.

Now here’s where the problem comes in. This is something that a lot of nursing schools aren’t teaching and a lot of new nurses don’t know. It can cause huge problems for your patient so make sure you get what we’re about to tell you. You should NOT be giving a COPD patient supplemental oxygen greater than 2 liters per minute. What? Why? What’s happening? They have poor gas exchange like we just talked about, so their O2 levels drop, their CO2 levels rise. And you’re thinking – okay – aren’t we supposed to give oxygen when their O2 levels drop? Here’s the issue. This is a chronic condition – and COPD patients’ bodies will accommodate to these changes. We call it the “50-50” club. Their PaO2 will be 50 (where it should be 60-100) and their pCO2 will also be about 50 (where it should be 35-45). And this is where they live – this is what they’re used to. So in a normal person, our stimulus to breathe is a high CO2 level. If you hold your breath, CO2 levels will rise until your brain tells your lungs they HAVE to take another breath. That’s our normal stimulus. So in someone with COPD who has these chronically high CO2 levels, and their body has gotten used to that – their stimulus to breathe is no longer a high CO2, but instead it becomes a low oxygen level that stimulates them to breathe.

So here you are with your COPD patient whose sats are 88%. You think, I’ll give them some oxygen – and you put them on 2 liters nasal cannula – their sats come up to 91% and you think, you know what – more is better, right? So you bump them up to 4 liters. Now, in the short-term, you’ve fixed that problem – now their sats are 96% and you’re feeling good about yourself. Here’s the problem – now we’ve started to decrease their respiratory drive. Their respiratory rate will drop. Their CO2 levels will begin to rise even higher because now they’re not breathing much. And that can lead to CO2 toxicity – sometimes called CO2 narcosis – their LOC will drop dramatically, they’ll struggle to protect their airway, and they can die. Here at NRSNG, we LOVE you guys and we want to see you advocating for these patients and keeping them out of harms’ way – so do NOT give more than 2 liters of O2 to this patient without talking to the provider. In fact, many times we’ll see doctors actually order to “keep sats between 88-92%” so that we don’t over oxygenate them. If you remember nothing else about caring for a COPD patient – please remember this!

Okay – so your little 60 year old man with COPD comes into the emergency room – what are you gonna see? Well you’ll probably see some accessory muscle use – he’ll be using his abdomen, shoulders, neck, and those intercostal muscles to get good deep breaths. You’ll hear adventitious breath sounds – they could be diminished, crackles, or even wheezes. You’ll see a barrel chest this is classic – that’s when the rib cage expands over time because of the patient trying to take deep breaths and all of the air trapping that’s happening. You can see here how the front of this person’s chest is expanded out like a barrel. You’ll also see some congestion on the x-ray, like what you see here. And you’ll see that increased pCO2 on an ABG. And you’ll see their pH decreased because a high pCO2 is acidic. Make sure you check out the ABG lesson if you need a review on this.

So what do we do for them – well just like with Asthma, we’re going to give bronchodilators, then corticosteroids – again bronchodilators first to make sure the airways are open enough to receive the steroids. We’re going to monitor their SpO2 and ABG, remembering that their baseline might be abnormal – and we usually keep sats between 88-92%. We can do Chest Physiotherapy or CPT to mobilize those secretions to help clear the airways. We’ll have them increase their fluid intake to upwards of 3 liters per day, assuming it’s not contraindicated (like in heart or kidney failure), because that can help to thin out the secretions and make them easier to get out. And then we’ll focus on patient education. They can use pursed lip breathing techniques – that can help them to get full expiration and deeper breaths. Now, a lot of times patients find it hard to eat a big meal or things that require a lot of chewing – they kind of have to choose between eating or breathing. So if they eat smaller, more frequent meals, this can help them to avoid breathing problems, but still get adequate nutritional intake. And then, of course, they need to learn to identify their triggers or allergens and avoid them if at all possible. The most important thing here is Smoking cessation and avoiding secondhand smoke – COPD patients should NEVER smoke. Some of them will be on home oxygen and if there is smoking in the home, that can cause a huge fire hazard. You’d be shocked – patients will be on oxygen and still light up a cigarette – and they show up with crazy facial burns in the emergency room because it blew up in their face.

So our priority nursing concepts for patients with COPD are pretty obvious, I think. Of course, oxygenation and gas exchange – being careful that we don’t over-oxygenate the patient and put them at risk for CO2 toxicity. And then patient education is important to teach them how to manage their symptoms, use their inhalers, and safety precautions, especially if they are on home oxygen. Make sure you check out the care plan and the case study attached to this lesson to see more details about nursing interventions and what it’s like to care for a patient with COPD.

So remember that COPD is chronic obstruction of the airways caused by either emphysema or chronic bronchitis. Emphysema is destruction of the alveoli due to chronic inflammation. Chronic bronchitis is inflammation and excessive sputum production that obstructs airways and impairs gas exchange. COPD patients often live with a low O2 and a high CO2 level – their bodies accommodate to this and their drive to breathe shifts. Instead of a high CO2 stimulus, they now have a low O2 stimulus – so we have to be cautious giving supplemental oxygen. We have to encourage the patient to use pursed-lip breathing, stop smoking, identify and avoid their triggers, increase their fluid intake if they can, and to eat smaller, more frequent meals to make sure they get the nutrition they need. And, our main nursing priorities are oxygenation, gas exchange, and patient education.

Okay guys – we hope we’ve given you the most important things you need to know about COPD – don’t forget to check out the resources attached to this lesson to learn more. Now, go out and be your best selves today. And, as always, happy nursing!

  • Question 1 of 10

A client with COPD is being seen in the primary care clinic for evaluation. During the assessment, the nurse asks the client medical history questions. Which of the following would most likely reveal whether a client is behaving in a way that works against the client’s treatment plan?

  • Question 2 of 10

A nurse is working in the emergency room and receives report on 4 clients. The nurse knows to see the client with which of the following first?

  • Question 3 of 10

A multidisciplinary team is working together to help a client who has decreased pulmonary function as a result of COPD. The team members perform a functional assessment on the client. Which action would be a component of this assessment?

  • Question 4 of 10

A 60-year-old client is going through pulmonary rehabilitation for COPD. The nurse understands that an expected outcome of pulmonary rehabilitation is which of the following?

  • Question 5 of 10

The nurse is caring for a client with COPD. Which of the following are appropriate inhalation drugs to reduce inflammation? Select all that apply.

  • Question 6 of 10

The nurse is completing a home visit for a client diagnosed with chronic obstructive pulmonary disease (COPD). The nurse understands that which of the following environmental factors could have contributed to this diagnosis?

  • Question 7 of 10

The nurse is caring for a client with COPD who is admitted with pneumonia. Which of the following nursing considerations is most appropriate for this client?

  • Question 8 of 10

A client with COPD has developed malnutrition and weight loss since his diagnosis 8 years ago. Which describes the most likely reason why a COPD client is at higher risk of malnutrition?

  • Question 9 of 10

A client with COPD is receiving care at the primary provider’s clinic with worsening of symptoms of emphysema. The provider orders an outpatient chest x-ray to determine if there have been any changes in lung structure. Which best describes what would show on a chest x-ray in the later stages of emphysema?

  • Question 10 of 10

The nurse is assessing a client in the emergency department who states, “I have COPD and usually require 2L of oxygen. I was eating yesterday and choked on a piece of ham and have been coughing ever since, like it’s stuck in my throat. Now I feel like I have been needing more oxygen, so I have turned my tank up to 5L.” Which part of this statement is priority and needs to be immediately investigated?

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