Download Pagel, P., 2007. COPD - it Takes Your Breath Away

COPD
It Takes Your Breath Away
Patti J. Pagel, RN, BSN
Alverno College
MSN Program
April, 2007
[email protected]
Self-Study Tutorial Guide
Instruction 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 Menu
Click on subject to navigate to:
Objectives
Nursing
Outcomes
Pathophysiology
Interventions
Respiratory
Review
Patho Quiz
Case Study
Respiratory
Quiz
Signs & Symptoms
References
Or click on forward arrow to go to next slide
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 medication
Source: (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
Anatomy Review
Respiratory Review
Let’s Take a Breath Together:
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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 Review
Let 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:
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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 Disease
Fact 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 Work
Obesity
Cancer
Diabetes
Stroke
Alcohol Abuse
Inactivity
Coronary Heart Disease
Alpha1-antitripsin Deficiency
Click HERE to learn more about COPD.
Pathogenesis of COPD
Inflammation bronchial walls
Fibrous bronchial walls
Hypertrophy of submucosal glands
Hypersecretion of mucus
Cause
airway
obstruction &
problems
with
ventilation
&
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
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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 examination
Pulmonary function studies
Forced Expiratory Volumes
Chest radiographs
Laboratory tests
Microsoft clipart
COPD- Let’s Review
 COPD is the fourth
leading cause of death
in the United States.
 Heredity is the most
common cause of
COPD
TRUE
TRUE
FALSE
FALSE
Click here to proceed to
next slide
Pathophysiology
Autonomic Nervous System
Respiratory Centers:
MEDULLARY
&
PONS
Stretch
Receptors
Monitor
Stretch
of
Lungs &
Chest Wall
Irritant
Receptors
Involved
With
Reflexes
Causing
Coughing &
Sneezing
Ventilation
Central
Chemoreceptor
Respond to
Arterial PCO2
Peripheral
Chemoreceptor
Respond to
Arterial
PO2 & PCO2
(Freudenrich, 2007)
Factors that Influence the
Respiratory Centers:
Oxygen:
Peripheral Receptor
Monitors O2 concentration
of blood
 oxygen
Concentration=
 Rate and Depth
Breathing
Carbon Dioxide:
Central Receptor
Monitors CO2
Concentration in CSF
 CO2 =
 Rate and Depth
Breathing
Hydrogen Ion (pH):
Peripheral & Central
Sensitive to pH of
Blood and CSF
 Hydrogen Ion=
 Rate and Depth
Breathing
Craig C. Freudenrich, Ph.D.. "How Your Lungs Work". October 06,
2000 http://health.howstuffworks.com/lung.htm (April 12, 2007)
The single most important
driver of ventilation is CO2
But can be deadly for the COPD Patient
CO2
CO2
CO2
CO2
CO2
CO2
Microsoft clipart
CO2
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
pH
7.35-7.45
PaCO2
35-45
HCO3
22-26
PaO2
80-100
Abnormal ABG Results
pH
7.32
PaCO2
69
HCO3
32
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 patient
is compensating or uncompensated. A complete history needs to
be 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.
O2 and CO2 Exchange
Used with permission: http://www.pbs.org/wgbh/nova/everest/exposure/body.html
Pathophysiology COPD
Now take a look at the comparison of a healthy
lung and a COPD emphysema lung.
With permission Copyright 2007 American Lung Association
For more information about the American Lung Association 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 Quiz
Let’s see how you are doingWhich 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 youHow 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 Symptoms
Review…
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 cough
Increased sputum production (to yellow/green)
(Bellamy, D. 2006)
What triggers a COPD Exacerbation?
INFECTION
AIR POLLUTION
COLD WEATHER
Weakened Immune System
COPD Patients
 PINK PUFFER: early disease Emphysema
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Over ventilate to maintain relatively normal ABG’s until late
in disease
Red face
 BLUE BLOATER: Chronic Bronchitis
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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 Interventions
Non Pharmaceutical
SMOKING CESSATION
AVOID EXPOSURE TO RESPIRATORY
INFECTIONS
ENCOURAGE FLU & PNEUMOCOCCAL
VACCINES
Microsoft clipart
Nursing Interventions
Non 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 Interventions
Non Pharmaceutical
PULMONARY REHABILITATION
PHYSICAL CONDITIONING
SUPPORT
IN PATIENT CARE
COMMUNITY CARE
Microsoft clipart
Nursing Interventions
Pharmaceutical
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 Interventions
Pharmaceutical
BRONCHODILATORS
Inhaled B2-adrenergic antagonists
Anticholinergic agents- long and short
acting
Inhaled corticosteroids
Oral corticosteroids
IV corticosteroids
Dangerous side effects:
Monitor blood sugars
Can increase heart rate
Patients with fungal infections should use with caution
(Perry & Potter, 2005)
Nursing Interventions
Pharmaceutical- In patient care
GIVING 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 Interventions
Pharmacologic
ANTIBIOTICS
Can 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 Interventions
Pharmaceutical
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 Intervention
In 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.
B.
C.
D.
IV Solumedrol 300mg every 2 hours
IV Solumedrol 60 mg every 8 hours
IV Solumedrol 2gm every 6 hours for 72 hours
IV Solumedrol 3gm every 8 hours for 48 hours
Click here to go to next slide.
Nursing Intervention
In Patient Care
Complete Respiratory Assessment
Assess Co-morbidities
Confirm allergies
Review medications
Monitor lab values: CBC, ABG’s, Lytes
Collaborate with physician
Educate patient and family
Administer IV medications as ordered
EVALUATE RESPONSE TO TREATMENT
Case Study
Mr. Sigh A. Nosis
Mr. 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. Tis
Mrs.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
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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., p3542. Retrieved February 15, 2007 from
http://web.ebscohost.com/ehost/delivery?vid=4&hid=7&sid=cef94c2
1-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
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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
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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.
Special thank you…
To everyone who supported the time, ideas, energy,
frustrations, excitement, & trial runs to the
completed project.
I sincerely thank you.
Roger
Pam
Christine David(s)
Elizabeth Paula Georgia
Kim
Nicholas Vicki
Patti
Debbie
Mom
Kathy(s) Susanne Linda
Randy
Marcia
Jeanine Pat
Kris