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(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
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COPD Description
Includes Chronic bronchitis Emphysema
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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
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COPD Etiology
Risk factors Cigarette smoking Occupational chemicals and dust Air pollution
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COPD Etiology
Risk factors Infection Heredity Aging
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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.
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COPD Cigarette Smoking
Effects of nicotine Stimulates sympathetic nervous system Increases HR Causes peripheral vasoconstriction Increases BP and cardiac workload
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COPD Cigarette Smoking
Effects of nicotine ↓ Amount of functional hemoglobin ↑ Platelet aggregation Compounds problems in CAD
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COPD Cigarette Smoking
Effects on respiratory tract Increased production of mucus Hyperplasia of mucous glands Lost or decreased ciliary activity
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COPD Cigarette Smoking
Carbon monoxide ↓ O2 carrying capacity ↑ Heart rate Impaired psychomotor performance and judgment
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COPD Cigarette Smoking
Passive smoking (second‐hand smoke) ↓ Pulmonary function ↑ Risk of lung cancer ↑ Respiratory symptoms
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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
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COPD Infection
Recurring infections impair normal defense mechanisms.
Risk factor for COPD Intensify pathologic destruction of lung tissue
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COPD Heredity
α‐Antitrypsin (AAT) deficiency Genetic risk factor for COPD Accounts for 3% of COPD
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COPD Aging
Some degree of emphysema is common because of physiologic changes of aging lung tissue.
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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
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COPD Pathophysiology
Primary process is inflammation. Inhalation of noxious particles Mediators released cause damage to lung tissue.
Airways inflamed Parenchyma destroyed
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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
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COPD Pathophysiology
Pulmonary vascular changes Blood vessels thicken. Surface area for diffusion of O2 decreases.
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COPD Pathophysiology
Common characteristics Mucous hypersecretion Dysfunction of cilia Hyperinflation of lungs Gas exchange abnormalities
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Pulmonary Blebs and Bullae
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Fig. 29-10. Pulmonary blebs and bullae.
COPD Pathophysiology
Commonly, emphysema and chronic bronchitis coexist.
Distinguishing symptoms can be difficult with co‐morbidities.
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COPD Clinical Manifestations
Develops slowly Diagnosis is considered with Cough Sputum production Dyspnea Exposure to risk factors
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COPD Clinical Manifestations
Dyspnea usually prompts medical attention. Occurs with exertion in early stages Present at rest with advanced disease
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COPD Clinical Manifestations
Causes chest breathing Use of accessory and intercostal muscles
Inefficient
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COPD Clinical Manifestations
Characteristically underweight with adequate caloric intake
Chronic fatigue
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COPD Clinical Manifestations
Physical examination findings Prolonged expiratory phase Wheezes Decreased breath sounds ↑ Anterior‐posterior diameter
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COPD Clinical Manifestations
Bluish‐red color of skin Polycythemia and cyanosis
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COPD Classification
Classified as Mild Moderate Severe Very severe
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Stages of COPD and Therapy
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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
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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
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Pathophysiology of Cor Pulmonale
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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
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COPD Exacerbations
Signaled by change in usual Dyspnea Cough Sputum
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COPD Exacerbations
Associated with poorer outcomes Primary causes Infection Air pollution
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COPD Acute Respiratory Failure
Caused by Exacerbations Cor pulmonale Discontinuing bronchodilator or corticosteroid medication
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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
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COPD Depression/Anxiety
Approximately 50% of COPD patients experience depression.
If patient become anxious because of dyspnea, teach pursed lip breathing.
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COPD Diagnostic Studies
Diagnosis confirmed by pulmonary function tests Chest x‐rays, spirometry, history, and physical examination are also important in the diagnostic workup.
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COPD Diagnostic Studies
Spirometry typical findings Reduced FEV/FVC ratio Increased residual volume
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COPD Diagnostic Studies
ABG typical findings Low PaO2 ↑ PaCO2 ↓ pH ↑ Bicarbonate level found in late stages of COPD
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COPD Diagnostic Studies
6‐Minute walk test to determine O2 desaturation in the blood with exercise
ECG can show signs of right ventricular failure.
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COPD Collaborative Care
Primary goals of care Prevent progression. Relieve symptoms. Prevent/treat complications.
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COPD Collaborative Care
Primary goals of care Promote patient participation. Prevent/treat exacerbations. Improve quality of life and reduce mortality risk.
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COPD Collaborative Care
Irritants should be evaluated and avoided.
Exacerbations treated promptly
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COPD Collaborative Care
Smoking cessation Most effective intervention Accelerated decline in pulmonary function slows and usually improves.
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COPD Collaborative Care
Drug therapy Bronchodilators Relax smooth muscle in the airway Improve ventilation of the lungs ↓ Dyspnea and ↑ FEV1 Inhaled route is preferred.
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COPD Collaborative Care
Drug therapy Commonly used bronchodilators β2‐Adrenergic agonists Anticholinergics Methylxanthines
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COPD Collaborative Care
Drug therapy Long‐acting anticholinergic Tiotropium (Spiriva)
Inhaled corticosteroid therapy Used for moderate to severe cases
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COPD Collaborative Care
O2 therapy is used to Reduce work of breathing Maintain PaO2 Reduce workload on the heart
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COPD Collaborative Care
Long‐term O2 therapy improves Survival Exercise capacity Cognitive performance Sleep in hypoxemic patients
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Methods of Oxygen Administration
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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.
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COPD Collaborative Care
Humidification Used because O2 has a drying effect on the mucosa
Supplied by nebulizers, vapotherm, and bubble‐through humidifiers
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COPD Collaborative Care
Complications of oxygen therapy Combustion CO2 narcosis O2 toxicity Absorption atelectasis Infection
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COPD Collaborative Care
Chronic O2 therapy at home improves Prognosis Mental acuity Exercise intolerance
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COPD Collaborative Care
Chronic O2 therapy at home reduces Hematocrit Pulmonary hypertension
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COPD Collaborative Care
Chronic O2 therapy at home Periodic reevaluations are necessary to determine duration of use.
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COPD Collaborative Care
Surgical therapy Lung volume reduction surgery Remove diseased lung to enhance performance of remaining tissue
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COPD Collaborative Care
Surgical therapy Bullectomy Used for emphysema Large bullae are resected to improve lung function.
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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
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COPD Collaborative Care
Respiratory and physical therapy Breathing retraining Effective coughing Chest physiotherapy Percussion Vibration Postural drainage
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COPD Collaborative Care
Respiratory and physical therapy Airway clearance devices High‐frequency chest wall oscillation
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COPD Collaborative Care
Breathing retraining Decreases dyspnea, improves oxygenation, and slows respiratory rate Pursed lip breathing
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COPD Collaborative Care
Pursed lip breathing Prolongs exhalation and prevents bronchiolar collapse and air trapping
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COPD Collaborative Care
Effective coughing Main goals Conserve energy. Reduce fatigue. Facilitate removal of secretions.
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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
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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
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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.
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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
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COPD Collaborative Care
Vibration Facilitates movement of secretions to larger airways
Mild vibration tolerated better than percussion
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COPD Collaborative Care
Flutter mucus clearance device Produces vibration in lungs to loosen mucus for expectoration
Hand‐held device
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Flutter Mucus Clearance Device
Fig. 29-18
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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
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COPD Collaborative Care
Acapella Vibrates lungs to shake free mucous plugs
Improves clearance of secretions Faster and more tolerable than CPT
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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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