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1 (Relates to Chapter 29, “Nursing Management: Obstructive Pulmonary Diseases,” in the textbook) Focus on Chronic Obstructive Pulmonary Disease (COPD) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. COPD Description Airflow limitation not fully reversible Generally progressive Abnormal inflammatory response of lungs to noxious particles or gases Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2 COPD Description Includes Chronic bronchitis Emphysema Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

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Page 1: Focus on Chronic Obstructive Pulmonary Disease … · Focus on Chronic Obstructive Pulmonary Disease ... Chronic bronchitis ... the pathophysiology of cor pulmonale secondary to chronic

1

(Relates to Chapter 29,  “Nursing Management:  

Obstructive Pulmonary Diseases,”  in the textbook) 

Focus on  Chronic Obstructive Pulmonary Disease 

(COPD) 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

COPD  Description 

 Airflow limitation not fully reversible  Generally progressive  Abnormal inflammatory response of lungs to noxious particles or gases 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

COPD Description 

 Includes  Chronic bronchitis  Emphysema 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

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COPD Significance 

 Fourth leading cause of death in the United States 

 More women die than men  Death rates in Hispanics are lower than in any other ethnic group 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4

COPD Etiology 

 Risk factors  Cigarette smoking  Occupational chemicals and dust  Air pollution 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5

COPD Etiology 

 Risk factors  Infection   Heredity  Aging 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6

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COPD Cigarette Smoking 

 Clinically significant airway obstruction develops in 15% of smokers. 

 80% to 90% of COPD deaths are related to tobacco smoking. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7

COPD Cigarette Smoking 

 Effects of nicotine  Stimulates sympathetic nervous system  Increases HR  Causes peripheral vasoconstriction  Increases BP and cardiac workload 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8

COPD Cigarette Smoking 

 Effects of nicotine  ↓ Amount of functional hemoglobin  ↑ Platelet aggregation  Compounds problems in CAD  

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9

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COPD Cigarette Smoking 

 Effects on respiratory tract  Increased production of mucus  Hyperplasia of mucous glands  Lost or decreased ciliary activity 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10

COPD Cigarette Smoking 

 Carbon monoxide  ↓ O2 carrying capacity  ↑ Heart rate  Impaired psychomotor performance and judgment 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11

COPD Cigarette Smoking 

 Passive smoking (second‐hand smoke)   ↓ Pulmonary function  ↑ Risk of lung cancer  ↑ Respiratory symptoms 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12

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COPD Occupational & 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  

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13

COPD Infection  

 Recurring infections impair normal defense mechanisms. 

 Risk factor for COPD  Intensify pathologic destruction of lung tissue 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14

COPD Heredity 

 α‐Antitrypsin (AAT) deficiency  Genetic risk factor for COPD  Accounts for 3% of COPD 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15

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COPD Aging 

 Some degree of emphysema is common because of physiologic changes of aging lung tissue. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16

COPD Pathophysiology 

 Defining features  Irreversible airflow limitations during forced exhalation due to loss of elastic recoil 

 Airflow obstruction due to mucous hypersecretion, mucosal edema, and bronchospasm 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17

COPD Pathophysiology 

 Primary process is inflammation.  Inhalation of noxious particles  Mediators released cause damage to lung tissue. 

 Airways inflamed  Parenchyma destroyed 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18

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COPD Pathophysiology 

Fig. 29-7 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19

Fig. 29-9. Pathophysiology of COPD.

COPD Pathophysiology 

 Supporting structures of lungs are destroyed.  Air goes in easily, but remains in the lungs. 

 Bronchioles tend to collapse.   Causes barrel‐chest look 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

COPD Pathophysiology 

 Pulmonary vascular changes   Blood vessels thicken.  Surface area for diffusion of O2 decreases. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21

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COPD Pathophysiology 

 Common characteristics  Mucous hypersecretion  Dysfunction of cilia  Hyperinflation of lungs  Gas exchange abnormalities 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22

Pulmonary Blebs and Bullae  

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23

Fig. 29-10. Pulmonary blebs and bullae.

COPD Pathophysiology 

 Commonly, emphysema and chronic bronchitis coexist. 

 Distinguishing symptoms can be difficult with co‐morbidities. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24

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COPD Clinical Manifestations 

 Develops slowly  Diagnosis is considered with  Cough  Sputum production  Dyspnea  Exposure to risk factors 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25

COPD Clinical Manifestations 

 Dyspnea usually prompts medical attention.  Occurs with exertion in early stages  Present at rest with advanced disease 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26

COPD Clinical Manifestations 

 Causes chest breathing  Use of accessory and intercostal muscles 

 Inefficient  

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27

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COPD Clinical Manifestations 

 Characteristically underweight with adequate caloric intake 

 Chronic fatigue 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28

COPD Clinical Manifestations 

 Physical examination findings  Prolonged expiratory phase  Wheezes  Decreased breath sounds  ↑ Anterior‐posterior diameter 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

COPD Clinical Manifestations 

 Bluish‐red color of skin  Polycythemia and cyanosis 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30

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COPD Classification 

 Classified as  Mild  Moderate  Severe  Very severe 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31

Stages of COPD and Therapy 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32

Fig. 29-11. Stages of COPD and therapy by stages.

COPD  Complications 

 Cor pulmonale  Exacerbations of COPD  Acute respiratory failure  Peptic ulcer disease  Depression/anxiety  

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33

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COPD Cor Pulmonale 

 Hypertrophy of right side of heart  Result of pulmonary hypertension  Late manifestation of chronic pulmonary heart disease 

 Eventually causes right‐sided heart failure 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34

Pathophysiology of Cor Pulmonale 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35

Fig. 29-12. Mechanisms involved in the pathophysiology of cor pulmonale secondary to chronic obstructive pulmonary disease.

COPD Cor Pulmonale 

 Dyspnea  Distended neck veins  Hepatomegaly with upper quadrant tenderness 

 Peripheral edema  Weight gain 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 36

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COPD  Exacerbations 

 Signaled by change in usual  Dyspnea  Cough  Sputum 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37

COPD Exacerbations 

 Associated with poorer outcomes  Primary causes  Infection  Air pollution 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 38

COPD Acute Respiratory Failure 

 Caused by  Exacerbations  Cor pulmonale  Discontinuing bronchodilator or corticosteroid medication 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 39

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COPD Acute Respiratory Failure 

 Caused by  Overuse of sedatives, benzodiazepines, and opioids 

 Surgery or severe, painful illness involving chest or abdomen 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 40

COPD Depression/Anxiety 

 Approximately 50% of COPD patients experience depression. 

 If patient become anxious because of dyspnea, teach pursed lip breathing. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 41

COPD Diagnostic Studies 

 Diagnosis confirmed by pulmonary function tests  Chest x‐rays, spirometry, history, and physical examination are also important in the diagnostic workup. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 42

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COPD Diagnostic Studies 

 Spirometry typical findings   Reduced FEV/FVC ratio  Increased residual volume 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 43

COPD Diagnostic Studies 

 ABG typical findings   Low PaO2  ↑ PaCO2  ↓ pH  ↑ Bicarbonate level found in late stages of COPD 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 44

COPD  Diagnostic Studies 

 6‐Minute walk test to determine O2 desaturation in the blood with exercise 

 ECG can show signs of right ventricular failure. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 45

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COPD Collaborative Care 

 Primary goals of care  Prevent progression.  Relieve symptoms.  Prevent/treat complications. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 46

COPD Collaborative Care 

 Primary goals of care  Promote patient participation.  Prevent/treat exacerbations.  Improve quality of life and reduce mortality risk. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 47

COPD Collaborative Care 

 Irritants should be evaluated and avoided. 

 Exacerbations treated promptly 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 48

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COPD Collaborative Care 

 Smoking cessation  Most effective intervention  Accelerated decline in pulmonary function slows and usually improves. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 49

COPD Collaborative Care 

 Drug therapy  Bronchodilators  Relax smooth muscle in the airway  Improve ventilation of the lungs  ↓ Dyspnea and ↑ FEV1  Inhaled route is preferred. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 50

COPD Collaborative Care 

 Drug therapy  Commonly used bronchodilators  β2‐Adrenergic agonists  Anticholinergics  Methylxanthines 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 51

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COPD  Collaborative Care 

 Drug therapy  Long‐acting anticholinergic   Tiotropium (Spiriva) 

 Inhaled corticosteroid therapy  Used for moderate to severe cases 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 52

COPD Collaborative Care 

 O2 therapy is used to  Reduce work of breathing  Maintain PaO2  Reduce workload on the heart 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 53

COPD Collaborative Care 

 Long‐term O2 therapy improves  Survival  Exercise capacity  Cognitive performance  Sleep in hypoxemic patients 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 54

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Methods of Oxygen Administration 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 55

Pendant‐Type Oxygen‐Conserving Cannula 

Fig. 29-11 A Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 56

Unn. Fig. 29-2. Methods of Oxygen Administration: Low-Flow Delivery Devices: Nasal Cannula.

Unn. Fig. 29-3. Methods of Oxygen Administration: Low-Flow Delivery Devices: Simple Face Mask.

Unn. Fig. 29-4. Methods of Oxygen Administration: Low-Flow Delivery Devices: Partial and Non-Rebreathing Masks.

Pendant‐Type Oxygen‐Conserving Cannula (cont’d) 

Fig. 29-11 A Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 57

Unn. Fig. 29-5. Methods of Oxygen Administration: Low-Flow Delivery Devices: Oxygen-Conserving Cannula.

Unn. Fig. 29-6. High-Flow Delivery Devices: Tracheostomy Collar.

Unn. Fig. 29-7. High-Flow Delivery Devices: Venturi Mask.

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Helios Liquid Portable Oxygen System 

Fig. 29-11 B Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 58

Fig. 29-14. A portable liquid O2 unit can be refilled from a liquid O2 reservoir unit.

COPD Collaborative Care 

 O2 delivery systems are high or low flow.  Low flow is most common.  Low flow is mixed with room air, and delivery is less precise than high flow. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 59

COPD Collaborative Care 

 Humidification   Used because O2 has a drying effect on the mucosa 

 Supplied by nebulizers, vapotherm, and bubble‐through humidifiers 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 60

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COPD Collaborative Care 

 Complications of oxygen therapy  Combustion   CO2 narcosis  O2 toxicity  Absorption atelectasis  Infection 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 61

COPD Collaborative Care 

 Chronic O2 therapy at home improves  Prognosis  Mental acuity  Exercise intolerance 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 62

COPD Collaborative Care 

 Chronic O2 therapy at home reduces  Hematocrit  Pulmonary hypertension 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 63

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COPD Collaborative Care 

 Chronic O2 therapy at home  Periodic reevaluations are necessary to determine duration of use. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 64

COPD Collaborative Care 

 Surgical therapy  Lung volume reduction surgery  Remove diseased lung to enhance performance of remaining tissue 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 65

COPD Collaborative Care 

 Surgical therapy  Bullectomy  Used for emphysema  Large bullae are resected to improve lung function. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 66

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COPD Collaborative Care  Surgical therapy  Lung transplantation  Single lung—Most common because of donor shortages 

 Prolongs life  Improves functional capacity  Enhances quality of life 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 67

COPD Collaborative Care 

 Respiratory and physical therapy  Breathing retraining  Effective coughing  Chest physiotherapy  Percussion  Vibration  Postural drainage 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 68

COPD Collaborative Care 

 Respiratory and physical therapy  Airway clearance devices  High‐frequency chest wall oscillation 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 69

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COPD Collaborative Care 

 Breathing retraining  Decreases dyspnea, improves oxygenation, and slows respiratory rate  Pursed lip breathing 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 70

COPD Collaborative Care 

 Pursed lip breathing  Prolongs exhalation and prevents bronchiolar collapse and air trapping 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 71

COPD Collaborative Care 

 Effective coughing  Main goals  Conserve energy.  Reduce fatigue.  Facilitate removal of secretions. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 72

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COPD Collaborative Care 

 Chest physiotherapy indicated for  Excessive, difficult‐to‐clear bronchial secretions 

 Retained secretions in artificial airway  Lobular atelectasis from mucous plug 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 73

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 74

COPD  Collaborative Care 

 Postural drainage  Gravity assists in bronchial drainage.  Techniques are individualized according to patient’s pulmonary condition and response to initial treatment. 

 Commonly ordered 2 to 4 times per day 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 75

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COPD Collaborative Care 

 Percussion  Hands in a cuplike position to create an air pocket 

 Air‐cushion impact facilitates movement of thick mucus. 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 76

Cupped‐Hand Position 

Fig. 29-16 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 77

Fig. 29-15. Cupped-hand position for percussion. The hand should be cupped as though scooping up water.

COPD Collaborative Care 

 No percussion over  Kidneys   Sternum   Spinal cord  Bony prominences  Tender or painful area 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 78

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COPD Collaborative Care 

 Vibration  Facilitates movement of secretions to larger airways 

 Mild vibration tolerated better than percussion 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 79

COPD Collaborative Care 

 Flutter mucus clearance device  Produces vibration in lungs to loosen mucus for expectoration  

 Hand‐held device 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 80

Flutter Mucus Clearance Device 

Fig. 29-18

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 81

Fig. 29-16. Flutter mucus clearance device is a small hand-held device that provides positive expiratory pressure (PEP) therapy. It is used to facilitate removal of mucus from the lungs. A, It consists of a hard plastic mouthpiece, a plastic perforated cover, and a high-density stainless steel ball resting in a circular cone. B, The Flutter effects occur during expiration. Before exhalation, the ball blocks the conical canal of the Flutter. During exhalation, the position of the ball is the result of an equilibrium between the pressure of the exhaled air, the force of gravity on the ball, and the angle of the cone where contact with the ball occurs. As the steel ball rolls and moves up and down, it creates an opening and closing cycle that repeats itself many times throughout each exhalation. The net result is that vibrations occur in the airways resulting in the “fluttering” sensation. C, These vibrations loosen mucus from the airway walls and facilitate their movement up the airways.

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COPD Collaborative Care 

 High‐frequency chest wall oscillation  Inflatable vest that vibrates the chest  Works on all lobes  More effective than CPT 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 82

COPD Collaborative Care 

 Acapella  Vibrates lungs to shake free mucous plugs 

 Improves clearance of secretions  Faster and more tolerable than CPT 

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 83

Acapella 

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Fig. 29-17. Acapella.

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COPD Collaborative 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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COPD Collaborative Care 

 Nutritional therapy  To decrease dyspnea and conserve energy  Rest at least 30 minutes before eating.  Use bronchodilator.  Prepare foods in advance. 

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COPD Collaborative Care 

 Nutritional therapy  Eat five to six small meals to avoid bloating and early satiety. 

 Cold foods may cause less fullness than hot foods. 

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COPD Collaborative 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 Management Nursing Assessment 

 Obtain complete health history and conduct a complete physical assessment.  See Table 29‐24 in textbook for COPD‐specific information. 

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Nursing Management Nursing Diagnoses 

 Ineffective airway clearance  Impaired gas exchange  Imbalanced nutrition: Less than body requirements 

 Risk for infection  Insomnia 

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Nursing Management Planning 

 Goals  Prevention of disease progression  Ability to perform ADLs  Relief from symptoms  No complications related to COPD 

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Nursing Management Planning 

 Goals  Knowledge and ability to implement long‐term regimen 

 Overall improved quality of life 

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Nursing Management Nursing Implementation 

 Health promotion   Abstain from or stop smoking.  Avoid or control exposure to occupational and environmental pollutants and irritants. 

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Nursing Management Nursing Implementation 

 Health promotion   Early detection of small‐airway disease  Early diagnosis and treatment of respiratory tract infection 

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Nursing Management Nursing Implementation 

 Health promotion   Awareness of family history of COPD and AAT deficiency 

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Nursing Management Nursing 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 Management Nursing Implementation 

 Ambulatory and home care  Most important aspect is teaching.  Pulmonary rehabilitation  Activity considerations  Sexual activity  Sleep  Psychosocial considerations 

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Nursing Management Nursing Implementation 

 Pulmonary rehabilitation  Increase exercise performance.  Reduce dyspnea.  Improve quality of life. 

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Nursing Management Nursing 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 Management Nursing Implementation  Activity considerations  Modify ADLs to conserve energy.  Walk 15 to 20 minutes a day at least  3 times a week with gradual increases.  Adequate rest should be allowed. 

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Nursing Management Nursing Implementation  Activity considerations  Exercise‐induced dyspnea should return to baseline within 5 minutes after exercise. 

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Nursing Management Nursing Implementation  Sexual activity  Plan when breathing is best.  Use slow, pursed lip breathing.  Refrain after strenuous activity.  Do not assume dominant position or prolong foreplay. 

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Nursing Management Nursing 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 Management Nursing Implementation  Psychosocial considerations  Healthy coping is difficult.   May feel guilt, depression, anxiety, social isolation, denial, and dependence 

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Nursing Management Evaluation  Expected outcomes  Normal breath sounds  Effective coughing  Return of PaO2 to normal range for patient 

 Improved mental status 

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Nursing Management Evaluation  Expected outcomes  Maintenance of normal body weight  Normal serum protein levels  Feeling of being rested  Improvement in sleep pattern 

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Nursing Management Evaluation  Expected outcomes  Awareness of need to seek medical attention 

 Behaviors minimizing risk of infection  No infection 

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