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COPDIt Takes Your Breath Away
Patti J. Pagel, RN, BSNAlverno CollegeMSN Program
April, [email protected]
Self-Study Tutorial GuideInstruction Page Click on to go back to previous slide Click on to go to the next slide Click on to return to objectives Click on True/False and learn the correct
answer when presented in a slide Click on Answer for multiple choice to check
for correct answer Click here to go back to review slides Click on website link for further information
Welcome!Main MenuClick on subject to navigate to:
Or click on forward arrow to go to next slide
ObjectivesObjectivesNursingNursing
OutcomesOutcomes
RespiratoryRespiratoryReviewReview
PathophysiologyPathophysiology
RespiratoryRespiratoryQuizQuiz
Patho QuizPatho Quiz
Signs & SymptomsSigns & Symptoms
Interventions
Case StudyCase Study
ReferencesReferences
Intended Audience
This self-study tutorial on Chronic Obstruction Pulmonary Disease is intended for the following people:
Registered Nurses Medical Assistants Anyone interested in learning
about COPD
Tutorial Objectives
Review respiratory system anatomy. Increase understanding of the
pathophysiology of COPD. Recognize signs and symptoms of COPD. Identify treatment options:
Non-pharmaceutical nursing interventions
Pharmaceutical interventions
Nursing Outcomes:
Respiratory Status: Ventilation
- movement of air in and out of lungs Respiratory Status: Airway Patency
- open, clear tracheobronchial passages
Knowledge: Medications
- extent of understanding conveyed about the safe use of medicationSource: (Moorhead et al 2004)
Microsoft clipart
Let’s Review: Respiratory Anatomy
Upper Respiratory Tract:Mouth, nose, throat (pharynx),
larynx, trachea Lower Respiratory Tract:
Lungs, bronchi, alveoli Medulla Oblongata
Controls inspiration/expiration
Microsoft clipart
Respiratory ReviewLet’s Take a Breath Together: Air is warmed and humidified. Cilia filter out dust particles. Macrophages destroy germs. Air goes to L and R bronchi. Then to the bronchioles. Through to the Alveoli. Oxygen and CO2 exchange takes place.Used with permission: Jensen M.S., Webanatomy 2007
Respiratory Review:Now your Breath is…
Alveoli fill with air. Oxygen diffuses thru alveoli walls. Oxygen diffuses to Capillaries and bloodstream. Hemoglobin for transport of
oxygen. Oxygen to the heart and
to the body.
Used with permission: Jensen, M.S., Webanatomy (2007).
Respiratory ReviewLet your air out…
Hemoglobin frees oxygen. O2 to cells.
CO2 is the waste product.
Veins return CO2 to heart.
Heart pumps CO2 to lungs.
CO2 passes alveoli to be exhaled
Use with permission: Jensen, M.S., Webanatomy (2007)
Respiratory Quiz
Respiratory Assessment:
Understanding the anatomy of the lungs, where does the exchange of oxygen and CO2 occur:
A. Bronchioles
B. Aveoli
C. Bronchial Tubes
Click on underlined best answer.
Respiratory Quiz:
Respiratory Assessment:
What part of the body controls inspiration and expiration?
A. Pituitary Gland
B. Sympathetic Nervous System
C. Medulla Oblongata
Click on underlined best answer.
What is COPD?Chronic Obstructive Pulmonary Disease
COPD is a group of respiratory disorders characterized by chronic, recurrent, irreversible obstruction of airflow in the pulmonary airways not fully reversible with inhaled bronchodilators.
(Porth, 2005) (Punturieli, 2007)
Chronic Obstructive Pulmonary Disease (COPD)
FACTS YOU SHOULD KNOW:
FOURTH leading cause of death in United States. COPD refers to two lung diseases:
Chronic Bronchitis & Emphysema. Smoking is a primary risk factor. Air pollution, second-hand smoke, history of childhood respiratory
infections and heredity are other causes. Female smokers are almost 13 times as likely to die from COPD than
women who have never smoked. 11.4 million U.S. adults affected. $37.2 billion cost to nation. Important cause of hospitalization in our aged population.
Source:American Lung Association Fact Sheet August 2006
Chronic Obstructive Pulmonary DiseaseFact you might not know…
COPD patients most likely have been smoking 20 cigarettes per day for 20 or more years before they even get symptoms (Snider, 2006).
Microsoft clipart
What Causes COPD?
What do you think are the two causes of COPD?
Find the two causes- click on word
Cigarette Smoking Factory WorkObesity Cancer Diabetes Stroke Alcohol Abuse InactivityCoronary Heart DiseaseAlpha1-antitripsin DeficiencyClick HERE to learn more about COPD.
Pathogenesis of COPD
Inflammation bronchial walls Cause
airway
Fibrous bronchial walls obstruction &
problems
Hypertrophy of submucosal glands with
ventilation
Hypersecretion of mucus &
perfusion
Loss of elastic lung fibers and alveoli tissue
(Porth, 2005)
Types of COPD:
Chronic Bronchitis ----- -Obstruction of small airway-Inflammation of major & small airways
Emphysema-Enlargement of air spaces-Destruction of tissues
Alpha1- antitrypsin deficiency-inherited disorder-protective material produced in liver and transported to lungs to help combat inflammation-leads to destruction of alveoli
(Porth, 2005)
Characteristics of: Chronic Bronchitis Cough with phlegm Shortness of breath Exercise Intolerance Expiratory phase of respiration long Wheezes and Crackles on auscultation Inability to maintain stable arterial blood
gases Hypoxemia
(Porth, 2005)
Characteristics of:Chronic Bronchitis
Doesn’t strike suddenly Damage occurs before patients seek
treatment Pulmonary hypertension Right heart failure with peripheral edema
(Porth, 2005)
Chronic Bronchitis Diagnosis
Mucus producing cough most days of the month, three months of a year for two consecutive years (ALA).
Microsoft Clipart
Characteristics: Emphysema
Dyspnea, slowly progressive Abnormal Arterial Blood Gases Use accessory muscles Weight loss Sputum production in morning, scant Cough- minimal Loss of lung elasticity Destruction of alveoli walls and capillary beds
(Porth, 2005)
Emphysema Diagnosis
Careful history and physical examinationPulmonary function studiesForced Expiratory Volumes
Chest radiographsLaboratory tests
Microsoft clipart
COPD- Let’s Review
COPD is the fourth leading cause of death in the United States.
TRUE
FALSE
Heredity is the most common cause of COPD
TRUE
FALSE
Click here to proceed to next slide
PathophysiologyAutonomic Nervous System
Respiratory Centers:
MEDULLARY &
PONSVentilation
Central Chemoreceptor
PeripheralChemoreceptor
Respond to Arterial PCO2
Respond to Arterial
PO2 & PCO2
Stretch Receptors
IrritantReceptors
Monitor Stretch
ofLungs &
Chest Wall
InvolvedWith
ReflexesCausing
Coughing &Sneezing
(Freudenrich, 2007)
Factors that Influence the Respiratory Centers:
Craig C. Freudenrich, Ph.D.. "How Your Lungs Work". October 06, 2000 http://health.howstuffworks.com/lung.htm (April 12, 2007)
Oxygen:Peripheral Receptor
Monitors O2 concentrationof blood
Carbon Dioxide:Central Receptor
Monitors CO2
Concentration in CSF
Hydrogen Ion (pH):
Peripheral & Central
Sensitive to pH ofBlood and CSF
oxygen Concentration= Rate and Depth
Breathing
CO2 = Rate and Depth
Breathing
Hydrogen Ion= Rate and Depth
Breathing
The single most important driver of ventilation is CO2
But can be deadly for the COPD Patient
Microsoft clipart
CO2
CO2
CO2
CO2
CO2
CO2CO2
CO2
CO
2
Example of receptors at work:
You administer high flow supplemental oxygen to a patient with COPD and the patient stops breathing.
What Happened to your patient?
You removed his drive to breathe!
Specifically, patients with COPD retain CO2 chronically. Administering oxygen removes the central
chemoreceptor drive to breathe. The central chemoreceptor is not sensitive to small oxygen changes like when a person breathes deep but high flow oxygen administration extinguished the stimulus to breathe.
Arterial Blood Gases (ABG’s) SNAP SHOT OF YOUR PATIENT”S OXYGEN STATUS
COPD PATIENT- 3L O2
Normal ABG Results Abnormal ABG ResultspH 7.35-7.45 pH 7.32PaCO2 35-45 PaCO2 69HCO3 22-26 HCO3 32PaO2 80-100 PaO2 86
The abnormal ABG finding indicates your patient is retaining CO2.What we don’t know just from the ABG result is if your patientis compensating or uncompensated. A complete history needs tobe obtained.
(Perry & Potter, 2006)
Pathophysiology COPD
Emphysema type of COPD: Walls between many of the air sacs
are destroyed leading to few large air sacs.
These large air sacs have less surface area for O2 and CO2 exchange.
Poor exchange of O2 and CO2 causes
shortness of breath.
Pathophysiology COPD
Bronchitis type of COPD: Airways inflamed and thickened Increase number & size of mucus
producing cells Excessive mucus production Coughing to remove mucus Difficulty getting air in & out
Used with permission: Jensen, M.S., Webanatomy (2007).
Pathophysiology COPD
Take a look at the next slide and note where the oxygen exchange takes place in the lungs.
With permission Copyright 2007 American Lung AssociationFor more information about the American Lung AssociationAssociation or to support the work it does, call 1-800-LUNG-USA (1-800-586-4872) or log on to www.lungusa.org.
Pathophysiology COPD
Probably a good time to share with you the…
WISCONSIN TOBACCO
QUIT LINE:
1-800-QUIT-NOW (1-800-784-8669)
(UW WI Madison, 2005) Microsoft clipart
Pathophysiology QuizLet’s see how you are doing-
Which type of COPD leads to destruction of the surface area of the alveoli?
Chronic Bronchitis or
Emphysema
Pathophysiology Quiz
What causes the central chemoreceptor in the medulla to signal the respiratory center to increase the rate and depth of respirations?
A. Low oxygen in blood
B. High oxygen in blood
C. High CO2 level in blood
D. Gee, I need to review. CLICK HERE
Just checking in with you-
How are you doing? Need to review more?
Ready to move on?
You are doing very well.We’re almost finished!
Microsoft clipart
COPD- Signs and SymptomsReview…
Chronic Cough- Major Factor in seeking care.
Exercise intolerance- Fatigue
Shortness of breath- At rest or activity
(Kessenich & Dayer-Berenson, 2007)
What happens when your patient has an Exacerbation of COPD?
These patients have sustained worsening of their usual state of health. They will exhibit:
Worsening breathlessness
Increased coughIncreased sputum production (to yellow/green)
(Bellamy, D. 2006)
COPD Patients PINK PUFFER: early disease Emphysema
Over ventilate to maintain relatively normal ABG’s until late in disease
Red face
BLUE BLOATER: Chronic Bronchitis Bronchial secretions and airway obstruction cause poor
ventilation and perfusion; unable to compensate leading to hypoxia and cyanosis
Clubbing Circumoral cyanosis
(Porth, 2005)
Microsoft Clipart
Barrel Chest- What’s this?
COPD patients chest often looks barrel shaped.
Why?These patients have a loss of lung elasticity. Airways collapse during expiration because pressure in lung tissue exceeds airway pressure. Air gets trapped causing increase in anteroposterior dimensions of the chest (Porth, 2005).
Simply:
Their lungs are chronically over inflated with air.
Microsoft clipart
Pursed Lip Breathing- What’s this?
COPD patients purse their lips to breath.
WHY?
Pursing your lips increases the resistance to the outflow of air. It helps to prevent airway collapse by increasing pressure (Porth, 2005).
Simply:
Pucker up.
Try to blow air out.
Feel the resistance?
Microsoft clipart
Signs and Symptoms of CO2 RETAINERS
Labored Breathing
Feeling of Air Hunger
Nausea
Confusion
Dizziness
Headache
Nursing InterventionsNon Pharmaceutical
SMOKING CESSATION
AVOID EXPOSURE TO RESPIRATORY INFECTIONS
ENCOURAGE FLU & PNEUMOCOCCAL VACCINES
Microsoft clipart
Nursing InterventionsNon Pharmaceutical
POSITIONING: Sit patient on side of bed with bed side
table.BREATHING:
Encourage pursed lip breathing.Incentive Spirometry
DIET:Small frequent nutritious meals
Easily swallowed food
Microsoft clipart
Nursing InterventionsNon Pharmaceutical
PULMONARY REHABILITATION
PHYSICAL CONDITIONING
SUPPORTIN PATIENT CARE
COMMUNITY CARE
Microsoft clipart
Nursing InterventionsPharmaceutical
OXYGEN IS a drug not just something that
sometimes makes the patient breathe better.
Keep oxygen saturation above 90%.
Follow physician order.
Monitor ABG’s as ordered by physician.
Dangerous side effects:Atelectasis
Oxygen toxicity
CO2 retention (Perry & Potter, 2005)
Nursing InterventionsPharmaceuticalBRONCHODILATORS
Inhaled B2-adrenergic antagonists
Anticholinergic agents- long and short acting
Inhaled corticosteroidsOral corticosteroidsIV corticosteroids
Dangerous side effects:Monitor blood sugarsCan increase heart ratePatients with fungal infections should use with caution
(Perry & Potter, 2005)
Nursing InterventionsPharmaceutical- In patient careGIVING SOLUMEDROL: Methylprednisolone Sodium
Succinate
INDICATION FOR COPD:
Inflammation
DOSING:
40mg-125mg q 6-8 hours IV
NURSING CONSIDERATION:
Give IV slow, over one minute
Don’t discontinue abruptly
Monitor for fungal infection
Monitor blood glucose
(Perry & Potter, 2005)
Nursing InterventionsPharmacologic
ANTIBIOTICSCan be used to treat an acute
exacerbation of COPD due to bacterial infections.
No evidence to support prophylactic use to prevent COPD exacerbation.
Nursing:
Check for patient allergies before administering antibiotic therapy.
Patient education to take all medication is important.
(Porth, 2005)
Nursing InterventionsPharmaceutical
Anti-anxiety Medication
COPD patients tend to become very anxious during an exacerbation. Collaborate with the physician to assess appropriate medication for your patient.
This aspect of patient care is often times overlooked.
Microsoft clipart
Nursing InterventionIn Patient Care
Often times the physician will order Solumedrol intravenously. Can you tell me what the normal dosing schedule would be for giving this drug on your unit?
A. IV Solumedrol 300mg every 2 hoursB. IV Solumedrol 60 mg every 8 hoursC. IV Solumedrol 2gm every 6 hours for 72 hoursD. IV Solumedrol 3gm every 8 hours for 48 hours
Click here to go to next slide.
Nursing InterventionIn Patient Care
Complete Respiratory AssessmentAssess Co-morbidities
Confirm allergiesReview medications
Monitor lab values: CBC, ABG’s, LytesCollaborate with physician
Educate patient and familyAdminister IV medications as ordered
EVALUATE RESPONSE TO TREATMENT
Case Study Mr. Sigh A. NosisMr. Nosis is a 64 year-old- male who presents to the ER
with complaints of SOB, wheezing and fatigue. His past medical history indicates a 32-year history of smoking two packs of cigarettes a day. With only this information, what can you anticipate the ER physicians orders to include?
A. Chest x-ray, Ct scan and lasix
B. Chest x-ray, ABG’s, IV access
C. Chest x-ray, ABG’s, exercise stress test
Case Study:Mrs. Bronk I. TisMrs.Tis comes to the clinic today for a follow up
post hospital visit with acute exacerbation of COPD. She is a widow, elderly, frail looking woman. Which of the following concerns you?
A. Oxygen saturation is 92% after a walk in the hall with you on room air.
B. A weight loss of six pounds since her discharge four weeks ago.
This concludes the COPD Tutorial
I hope you have enjoyed and learned about COPD. You can make an impact in the lives of the patients you care for with this disabling but many times preventable disease.
Patti Pagel RN BSN
Alverno College
References American Lung Association. (2006). Chronic obstructive pulmonary
disease fact sheet. Retrieved February 16, 2007 from http://lungusa.org.
Anugwom, C., & Dachs, R. (2006). Beta-blocker use in patients with COPD. American Family Physician. (74)11., p1858.
Bay Area Medical Information. (2006). Overview of the respiratory system. Retrieved March 7, 2007 from http://www.bami.us/Resp/COPD2.html.
Bellamy, D., (2006). COPD exacerbations. Practice Nurse (32)6., p35-42. Retrieved February 15, 2007 from http://web.ebscohost.com/ehost/delivery?vid=4&hid=7&sid=cef94c21-be5a-4615-a3a7-33.
Freudnenrich, C.C., (2007). How your lung works. Retrieved April 13, 2007 from http://health.howstuffworks.com/lung.htm/printable.
Goldsmith, C., (2007). Fighting for breath with COPD. Nurseweek. Retrieved March 1, 2007 from http://www.nurseweek.net.
References continued
Kessenich, C.R., & Dayer-Berenson, L., (2007). Polypharmacy in the elderly. Nurseweek. Retrieved March 1, 2007 from http://www.nurseweek.net
Moorhead, S., Johnson, M., & Maas, M., (2004). Nursing outcomes classification. Iowa outcome project (3rd ed.). St Louis, MO: Mosby.
Nova. How the body uses O2. Retrieved on March 19, 2007 from http://www.pbs.org/wgbh/nova/everest/exposure/body.htm.
Porth, C. M., (2005). Pathophysiology: Concepts of altered health states. (7th ed. ). Philadelphia: Lippincott, Williams & Wilkins.
Perry, A.G., & Potter, P. A., (2006). Clinical nursing skills and techniques. (6th ed.). St. Louis, MO: Mosby, Elsevier.
Punturieri, A., Croxton, T., Weinman, G., & Kiley, J.P., (2007). The changing face of COPD. American Academy of Family Physicians. (75)3., February 1, 2007.
Snider, G.L., (2006). Diagnosis of chronic obstructive pulmonary disease. Uptodate. Retrieved February 12, 2007 from http://www.utdol.com.
University Wisconsin Madison (2005). Report: State tobacco quit line saves millions in health care costs. Retrieved April 16, 2007 from http://www.news.wisc.edu/11228.html.
Illustration References:
American Lung Association website. Retrieved March 22, 2007 from www.lungusa.org.
Jensen, M., website. Retrieved April 12, 2007 from
http://www.msjensen.gen.umn.edu/webanatomy/default.htm. Microsoft Corp. (2006). Microsoft clipart. Retrieved February 26,
2007 from www.microsoftclipart.com. Nova website. Retrieved April 9, 2007 from
http://ww.pbs.org/nova/teachers. Rose, L., website. Retrieved March 18, 2007 from
http://webschoolsolutions.com/patts/systems/ lungs.htm.