What is the most important information for a nurse to teach a client with COPD?

This is an NCLEX review for COPD (chronic obstructive pulmonary disease). Patients who have COPD are experiencing limiting airflow and decrease elasticity of the aveolar sacs. COPD leads to impaired gas, hyperinflation of the lungs, and other complications such as heart failure.

In the previous review, I covered other respiratory disorders of the respiratory system. So, if you are studying for NCLEX or your nursing lecture exams be sure to check out that section.

When taking care of a patient with COPD it is very important the nurse knows how to recognize the typical signs and symptoms seen in this condition, how it is diagnosed, nursing interventions, and patient education.

Don’t forget to take the COPD quiz.

In this NCLEX review for COPD, you will learn the following:

• Definition of COPD
• Types of COPD
• Pathophysiology of COPD
• Complication of COPD
• Signs and Symptoms of COPD
• How COPD is Diagnosed
• Nursing Interventions for COPD
• Medications used to treat COPD

Lecture on COPD (Part 1 and 2)

Definition: pulmonary disease that causes chronic obstruction of airflow from the lungs

Keys Point for COPD:

• Limited Airflow (due to thick and swollen bronchioles that have become deformed with excessive sputum production and this narrows the airways)
• Inability to fully exhale (due to loss of elasticity of the alveoli sacs from damage and the sacs start to develop air pockets)
• Irreversible once developed…cases vary among people from mild to severe…managed with lifestyle changes and medications.
• Happens gradually….most people start to notice signs and symptoms middle-aged and will present with dyspnea with activity they could normally tolerate, recurrent lung infections, chronic cough etc.
• COPD is a term used as a “catch all” for diseases that limit airflow and cause dyspnea.

Types of COPD include:

• Emphysema “pink puffers”
• Chronic bronchitis “blue bloaters”

Pathophysiology of COPD

Normal breathing:

Inhaled oxygen travels down through the trachea which splits at the carina into bronchial tubes starting with the primary bronchus then into smaller airways called secondary and tertiary bronchi which divide into bronchioles and the oxygen goes into the alveolar sacs where gas exchange happens. As the alveoli inflate and deflate with ease, inhaled oxygen attaches to the red blood cells and carbon dioxide enters the respiratory system to be exhaled.

What happens in breathing with COPD?

The name “blue bloaters” is due to cyanosis from “hypoxia” and bloating from edema AND increase in lung volume. The bloating is from the effects of the lung disease on the heart which causes right-sided heart failure.

In chronic bronchitis, the bronchioles become damaged that leads them to be thick and swollen and deformed. This is accompanied by more sputum production. This limits the ability of the person being able to completely exhale the air taken in. So, when they take another breath in, it will increase the air volume even more (because they have retained air from the previous breath), and this leads to hyperinflation.

Also, less oxygen is getting into the blood and more carbon dioxide is staying in the blood. This leads to low blood levels and high carbon dioxide levels. Patients will have cyanosis due to a decreased oxygen level. To compensate, the body increases RBC production and cause blood to shift elsewhere which increases pressure in the pulmonary artery leading to pulmonary hypertension. Pulmonary hypertension leads to right-sided heart failure (which is why you will start to see bloating..edema in the abdomen and legs)

In conditions such as emphysema “pink puffers”:

The name comes from hyperventilation (puffing to breathe) and pink complexion (they maintain a relatively normal oxygen level due to rapid breathing) rather than cyanosis as in chronic bronchitis.

In emphysema, the alveoli sacs lose their ability to inflate and deflate due to an inflammatory response in the body. So, the sac is unable to properly deflate and inflate. Inhaled air starts to get trapped in the sacs and this causes major hyperinflation of the lungs because the patient is retaining so much volume.

Hyperinflation causes the diaphragm to flatten. The diaphragm plays a huge role in helping the patient breathe effortlessly  in and out. Therefore, in order to fully exhale, the patient starts to hyperventilate and use accessory muscles to get the air out now. This leads to the barrel chest look and during inspect it may be noted there is an INCREASED ANTEROPOSTERIOR DIAMETER.

The damage in the sacs cause the body to keep high carbon dioxide levels and low blood oxygen levels. Inhaled oxygen will not be able to enter into the sacs for gas exchange and carbon dioxide won’t leave the cells to be exhaled.

The body tries to compensate by causing hyperventilation (increasing the respiratory rate…hence puffer) and the patient will have less hypoxemia “pink complexion” than chronic bronchitis who have the cyanosis because pink puffers keep their oxygen level just where it needs to be from hyperventilation.

Signs & Symptoms of COPD

Remember: Lung Damage

Lack of energy

Unable to tolerate activity (shortness of breath)

Nutrition poor (weight loss) due to energy used breathing especially with emphysema

Gases abnormal (high PCO2 >45 and low PO2 <90)..respiratory acidosis

Dry or productive cough constant (productive with chronic bronchitis)

Accessory muscle usage during breathing, Abnormal lung sounds: diminished, coarse crackles (chronic bronchitis) or wheezing

Modification of skin color from pink to cyanosis in lips, mucous membranes, nail beds (“blue bloaters”)

Anteroposterior diameter increased (barrel chest)….emphysema  “pink puffers”

Gets in the Tripod Position during dyspnea (stands leaning forward while supporting body with hands on knees or an object)

Extreme dyspnea

In turn over time, people with COPD will be stimulated to breathe due to low oxygen levels RATHER than high carbon dioxide levels.

Complications of COPD

• Heart Disease (remember heart and lungs work together in replenishing the body with oxygen)…heart failure
• Pneumothorax (spontaneous due to forming of air sacs)
• Risk for Pneumonia
• Cancer (especially lung)

How is COPD Diagnosed?

Spirometry: A test where a patient breathes into a tube that measure how much volume the lungs can hold during inhalation and how much and fast air volume is exhaled.

• Measuring the FVC (Forced Vital Capacity): a low reading shows restrictive breathing….it measures the largest amount of air a person exhales after breathing in deeply in one second.
• Forced Expiratory Volume: measures how much air a person can exhale within one second. A low reading shows the severity of the disease.

Nursing Interventions for COPD

Monitor Respiratory System:

• Assess lung sounds (may need suction) and sputum production…obtain a culture if ordered…at risk for pneumonia
• Keep oxygen saturation (88%-93%) why between this range?
  • Patients with COPD are stimulated to breathe due to LOW OXYGEN SATURATION rather than high carbon dioxide levels….which is the opposite for people for healthy lungs. If they are given too much oxygen it will reduce their need to breathe…causing hypoventilation and carbon dioxide levels will increase to toxic levels.
• Given oxygen as prescribed in low amounts 1-2 liters
• Monitor effort of breathing and teach about pursed-lip and diaphragmatic breathing
• Pursed-lip breathing: used for when patient starts to get dyspneic. This technique increases the oxygen level and encourages them to breath out longer (remember these patient don’t fully exhale very well). It is similar to like blowing out a birthday candle.
• Diaphragmatic breathing: uses abdominal muscles for breathing rather than accessory muscles
  • helps make diaphragm stronger which is weak
  • slows down breathing rate to allow breathing to be easier
  • decreases energy used to breathe
  • used along with pursued breathing technique
• Administering breathing treatments as needed: bronchodilators, nebulizer etc. Respiratory therapy helps play a role in this as well  (medications are discussed in more detail below)

Patient Education for COPD

• Nutrition needs: eating high calorie, protein rich meals that are small but frequent and staying hydrated if not contraindicated….avoid large heavy meals due to compression on the lungs from the stomach
• Avoiding sick people, irritants, hot humid (smothering) or very cold weather
• Stop smoking or being around people who smoke
• Vaccination up-to-date: annual flu shot and Pneumovax every 5 years because it is very hard for people with COPD to recover from illnesses
• Pursed lip and diaphragmatic breathing techniques
• Administering medications: be familiar with groups, side effects, and patient teaching

Medication Regime for COPD

Remember the mnemonic: Chronic Pulmonary Medications Save Lungs

Corticosteroids: decreases inflammation and mucous production in airway… given: oral, IV, inhaled and used in combination with bronchodilator like:

• Symbicort: combination of steroid and long acting bronchodilator
• Other corticosteroids: Prednisone, Solu-medrol, Pulmicort
• Side effects: easy bruising, hyperglycemia, risk of infection, bone problems (long term use)
  • Patient education: rinse mouth after using inhaled corticosteroids…can develop thrush, use corticosteroid inhaler AFTER using bronchodilator inhaler

Methylxanthines: Theophylline (most commonly given orally) type of bronchodilator used long term in patients who have severe COPD

• Remember: Narrow therapeutic range of 10 to 20 mcg/mL
• Increases risk for digoxin toxicity and decreases the effects of lithium and Dilantin

Phosphodiestrace-4 inhibitors: “Roflumilast”  used for people who have chronic bronchitis and it works by decreasing COPD exacerbation…not a bronchodilator

• Side effects: can cause suicidal thoughts (remember the word “last” in the drug’s name…it could be the patient’s last days if they are not assessed for this side effect) and can cause weight loss.

Short-acting bronchodilators: relaxes the smooth muscle of the bronchial tubes and are used in emergency situations where quick relief is needed

• Albuterol (beta 2 agonist) and Atrovent (anticholinergic)

Long-acting Bronchodilators: relaxes the smooth muscle of the bronchial tubes (same as short-acting bronchodilators BUT their effects last longer) used over a longer period of time….taken once or twice a day

• Beta 2 agonist: salmeterol, anticholinergics: Spiriva
• Patient education: let them know which drug is short and long-acting, how to use inhaler  and to use bronchodilator inhaler BEFORE steroid inhaler  (wait 5 minutes in between)
  • WHY?  TO OPEN UP THE AIRWAYS SO THE STEROID CAN GET IN THERE AND DO ITS JOB
• Side effects of beta 2 agonist: increased heart rate, urinary retention
• Side effects of anticholinergic: dry mouth, blurred vision

More NCLEX Reviews

References

1. COPD, Treatment Options, NHLBI, NIH. Nhlbi.nih.gov. Retrieved 1 November 2016, from https://www.nhlbi.nih.gov/health/educational/copd/breathing-better/treatment-options.htm
2. What Is COPD? – NHLBI, NIH. (2013). Nhlbi.nih.gov. Retrieved 2 November 2016, from https://www.nhlbi.nih.gov/health/health-topics/topics/copd/