COPD

COPD Chronic Obstructive Pulmonary Disease Pathophysiology | Care Plan for Nursing Students

Chronic obstructive pulmonary disease | COPD

Chronic obstructive pulmonary disease (COPD) is a long-term lung disease that involves the obstruction of airflow due to an inflammation of the lungs. COPD further branches into three specific lung conditions: emphysema, chronic bronchitis, and refractory asthma.

Emphysema occurs when the air sacs in the lungs called alveoli become damaged, causing them to have destroyed walls. Eventually, the tiny alveoli merge into one big air sac. As a result, the alveolar walls are unable to absorb oxygen normally, which then affects the oxygen level of the blood. In addition to this, the lungs lose their springiness. This traps the air inside the lungs, making it difficult for the patient to breathe.

Chronic bronchitis happens when the hair-like fibers (cilia) lining your bronchial tubes are lost. This reduces the ability to move the mucus out of the lungs. Coughing and shortness of breath are the physical signs related to this. Eventually, the coughing mechanism triggers the lungs to produce more mucus, causing the patient to try and expectorate more of it.

Refractory asthma is a severe type of asthma that is non-reversible and does not respond to usual medical treatments for asthma. It is characterized by low lung function, frequent asthma attacks, and persistent symptoms.

Chronic obstructive pulmonary disease | COPD
Chronic Obstructive Pulmonary Disease : COPD – Pulmonary Emphysema disease. Emphysema infographics elements. health and medical concept vector cartoon.

Signs and Symptoms of COPD

  • Shortness of breath – this becomes more severe upon physical exertion
  • Chest tightness
  • Wheeze (emphysema), crackles (bronchitis), or absent breath sounds (refractory asthma)
  • Chronic productive cough
  • Phlegm – can be white, clear, greenish or yellowish and can last for months or years
  • Fatigue

In the long run, COPD patients may show unexplained weight loss and may have frequent respiratory infections, as well as swelling of the limbs. They are also prone to worsening of the above signs and symptoms for several days. This episode is called COPD in Exacerbation.

Causes of COPD

  1. Tobacco smoking: Most COPD cases in developed countries are caused by smoking. Although there is a big risk, not all smokers suffer from COPD. Second hand smoking, marijuana smoking, and pipe smoking can also cause COPD.
  2. Exposure to fumes: In developing countries, people still burn fuel to cook and to heat their homes. This creates fumes which are harmful when inhaled. Some occupations also involved being exposed to chemical vapors and fumes.
  3. Alpha-1-antitrypsin deficiency: A small number of COPD patients has this genetic disorder where in there is a deficiency of the AAt, a protein that the liver secretes to the bloodstream and goes to the lungs to help protect these organs.

Complications of COPD

  1. Higher risk of recurrent respiratory infections: COPD patients are highly vulnerable to bacteria and viruses that may cause infection. The frequent infections may cause more damage to the tissues of the lungs, making it more difficult to breathe.
  2. Pulmonary hypertension: COPD may increase the blood pressure in the arteries that carry blood to the lungs.
  3. Lung cancer: The study by Durham and Adcock in 2015 showed the relationship between COPD and lung cancer. COPD can contribute to the development of lung cancer as it increases oxidative stress, which causes DNA damage and increase in cellular proliferation.
  4. Cardiac issues: COPD may increase the risk for cardiovascular disease, particularly myocardial infarction. The connection between COPD and cardiac problems has not been fully studied.

Diagnostic Tests

  • Medical history taking – especially tobacco use, family history, occupation, and exposure to lung irritants
  • Arterial blood gas (ABG) analysis – to measure the gas exchange in the lungs
  • Pulmonary function tests – to measure the level of air during inhalation and exhalation. The most common one is spirometry. Other tests include pulse oximetry and six-minute walk test.
  • Imaging – chest x-ray and/or CT scan
  • Genetic testing for AAt deficiency – if the patient has a family history of COPD

Treatments for COPD

COPD is generally irreversible, but through proper treatment, therapy, and lifestyle changes, the patient can have better pulmonary function and thus, experience partial recovery and optimal quality of life. These treatments include:

  1. Smoking cessation: Quitting smoking is one of the crucial steps to combat COPD. This also includes avoiding second-hand smoking.
  2. Medications: Bronchodilators such as Ventolin and Ipratropium (Atrovent) work by relaxing the muscles of the airways, making breathing much easier. These usually come in the form of inhalers. On the other hand, inhaled corticosteroids such as Budesonide and Fluticasone alleviate inflammation in the airways, which effectively prevent exacerbation episodes. There are also inhalers that combine bronchodilators and steroids, such as Combivent and Bevespi. During acute or severe exacerbations, patients may be prescribed a short course of oral steroids. Antibiotics may be prescribed for pulmonary infections which may worsen the symptoms of a patient with COPD.
  3. Oxygen therapy: Supplemental oxygen may be needed if there is a low level of oxygen in the blood. It is normal for most COPD patients to have an oxygen level between 88 to 92% via pulse oximetry. Oxygen therapy may be required if the patient’s SpO2 drops to less than 88%.
  4. Pulmonary rehabilitation program: A healthcare plan for exercise, nutrition advice, counselling, and education need to be customised for each COPD patient.
  5. Bilevel Positive Airway Pressure (BiPAP): This is a non-invasive, in-home ventilation therapy that comes with a mask and helps improve breathing as well as reduce hypercapnia (the retention of carbon dioxide in the lungs).
  6. Surgical intervention: Lung volume reduction surgery, lung transplant, bullectomy (removal of bullae or large air spaces) are the most common surgical procedures performed to treat COPD.

Nursing Care Plans for of COPD

  1. Ineffective Airway Clearance related to COPD and pneumonia as evidenced by shortness of breath, wheeze, SpO2 level of 85%, productive cough, difficulty to expectorate greenish phlegm

Desired Outcome: The patient will be able to maintain airway patency and improved airway clearance as evidenced by being able to expectorate phlegm effectively, respiratory rates between 12 to 20 breaths per minutes, oxygen saturation between 88 to 92%, and verbalize ease of breathing.

InterventionsRationales
Assess the patient’s vital signs and characteristics of respirations at least every 4 hours. Assess breath sounds via auscultation.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. Breath sounds are important signs of COPD: wheeze (emphysema), crackles (bronchitis), or absent breath sounds (refractory asthma)
Suction secretionsTo help clear thick phlegm that the patient is unable to expectorate.
Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.To increase the oxygen level and achieve an SpO2 value within the target range of 88 to 92%.
Administer the prescribed COPD medications (e.g. bronchodilators, steroids, or combination inhalers / nebulizers) and antibiotic medications.Bronchodilators: To dilate or relax the muscles on the airways.
Steroids: To reduce the inflammation in the lungs.
Antibiotics: To treat bacterial infection, which may trigger exacerbation of COPD.
Elevate the head of the bed and assist the patient to assume semi-Fowler’s position.Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively.
  • Nursing Diagnosis: Ineffective Breathing Pattern related to COPD and pneumonia as evidenced by shortness of breath, SpO2 level of 85%, productive cough, and greenish phlegm

Desired Outcome: The patient will achieve effective breathing pattern as evidenced by respiratory rates between 12 to 20 breaths per minutes, oxygen saturation between 88 to 92%, and verbalize ease of breathing.

InterventionsRationales
Assess the patient’s vital signs and characteristics of respirations at least every 4 hours.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment
Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.To increase the oxygen level and achieve an SpO2 value within the target range of 88 to 92%.
Administer the prescribed COPD medications (e.g. bronchodilators, steroids, or combination inhalers / nebulizers) and antibiotic medications.Bronchodilators: To dilate or relax the muscles on the airways.
Steroids: To reduce the inflammation in the lungs.
Antibiotics: To treat bacterial infection, which may trigger exacerbation of COPD.
Elevate the head of the bed. Assist the patient to assume semi-Fowler’s position.Head elevation and semi-Fowler’s position help improve the expansion of the lungs, enabling the patient to breathe more effectively.
Perform chest physiotherapy such as percussion and vibration, if not contraindicated. Nebulization using sodium chloride (NaCl) may also be done, as ordered by the physician. Steam inhalation may also be performedTo facilitate clearance of thick airway secretions.

Other possible nursing diagnoses:

  • Impaired Gas Exchange
  • Activity Intolerance
  • Anxiety related to COPD in Exacerbation
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Anna C. RN-BC, BSN, PHN, CMSRN Anna began writing extra materials to help her BSN and LVN students with their studies. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process. She is a clinical instructor for LVN and BSN students along with a critical care transport nurse.

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