1. NURSING MANAGEMENT OF COPD

2. Physiology  Respiratory System Upper Tract & Lower Tract  Goal is to transfer oxygen and carbon dioxide

3. Disorders Associated Respiratory Alterations  Pneumonia  Pulmonary edema  Pulmonary emboli  Heart failure  CNS depression  Neuromuscular disease  Acute Asthma  COPD  Chest trauma  pneumo-hemothorax, tension pneumothorax  High spinal cord injury HypoxemicHypercapnic

4. Etiology  Cigarette smoking is the main precipitating factor  3 rd leading cause of death  Upwards of 5.4 million people died in 2005 and it is estimated to grow to 8.3 million deaths/year in 2030 (World Health Organization)  Greater risk population:  Women, whites, age 65-74, lower economic status, current or former smokers, history of asthma http://www.nhlbi.nih.gov/health/health-topics/topics/copd/causes http://www.cdc.gov/copd/index.html

5. Pathophysiology  Progressive destruction of alveoli related to chronic inflammation  Alveoli collapse  The cause related to air trapping in respiratory bronchioles, alveoli, and alveolar ducts  The gas exchange (oxygen  carbon dioxide) that normally occurs has been impaired due to the alveoli destruction over time

6. Pathophysiology-COPD

7. Pathophysiology AVEOLIBRONCHI

8. Pathophysiology Map

9. Complications of COPD  Pneumothorax  Pleural effusion  Atelectasis  Pneumonia  Heart failure (Cor Pulmonale)  Lung Cancer  Polycythemia

10. Arterial Blood Gas interpretation pH Acidosis  7.35 - 7.45  Alkalosis pH PaCO2 45 – 35 HCO3 22 – 26  pH = 7.35-7.45 (normal range)  PaCO2 = 45-35 (normal range)-respiratory  HCO3 = 22-26 (normal range)-metabolic  pO2 = 80-100  Oxygen Saturation = 95 – 100 %

11. ABG Interpretation ACIDOTIC (Respiratory)NORMALALKALOTIC (Metabolic) 1.What is the pH? acidosis, normal, or alkalosis 2.What is the PaCO2? acidosis, normal or alkalosis 3.What is the PaHCO3? acidosis, normal or alkalosis 4.Is this patient in a compensated or uncompensated state? Partially Compensated Respiratory Acidosis Acidosis Compensated Acidosis alkalosis pH: 7.32 (7.35-7.45) PaCO2: 48 (45-35) PaHCO3: 30 (22-26) 7.32 pH  48 PaCO2  30 PaHCO3  Don’t forget to look at the PaO2 (80-100)!!! Anything less than 60 is acute respiratory failure! 35 PaHCO3 fully compensated 21 HCO3  uncompensated

12. Assessment Focus  Dyspnea  “Pink puffer” is a clinical description of barrel chest caused by pursed lip breathing (caused by forced exhalation), use of accessory muscles, and underweight appearance  Exertional dyspnea progresses with disease  Tachycardia related to inadequate oxygenation  Lung sounds: diminished, wheezes and/or crackles

13. Problems with COPD  Impaired gas exchange  Ineffective breathing pattern  Ineffective airway clearance  Imbalanced nutrition  Activity intolerance  Fatigue Chronic hypoxia over time = clubbed fingers

14. Plan of Care  The client will have adequate oxygenation and ventilation

15. Interventions  Promotion of Oxygenation & Ventilation  Positioning (  HOB)  Apply oxygen and titrate to keep oxygen sats > 93%  Cough & deep breathing exercises (teaching)  Purse lip breathing (teaching)  Incentive spirometer (teaching)

16. Interventions-Medication Use  Inhaled Bronchodilators  Short-acting (albuterol) and long-acting (salmeterol, iprotropium, spiriva)  Relax the muscle, open bronchioles  Inhaled Corticosteroids  Reduce inflammation  Flovent, Pulmicort (bedesonide)  Combination inhalers  Symbicort (Budesonide/formoterol)  Advair (fluticasone/salmeterol)  Methylxanthines  Theophyline  Phosphodiesterase-4 (PDE-4) Inhibitors (roflumilast) improve quality of life  Antibiotics for infections  Oral and or IV corticosteroids – only used for acute exacerbations (prednisone, methylprednisone)  Oxygen therapy (for home)  Vaccines http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699952/

17. Education on Meter-Dose Inhalers (MDIs)

18. Inhaler with Spacer

19. Interventions-cont.  Pulmonary rehabilitation (PR)  exercise, diet  Patient teaching  Smoking cessation  Corticosteroid use Weight gain-water retention Immunosuppression Increased glucose levels Rinse mouth after use of inhaler (increase risk of thrush) insomnia  Bronchodilators Increased heart rate, jitteriness

20. Evaluation of the Interventions  Focus your attention on the interventions  Reassess and adjust according to the evaluation  Lung sounds  Patient complaints and ability to function with the disease

21. Patient Education  Pneumococcal Vaccine  Influenza Vaccine  Pneumococcal Vaccine  Influenza Vaccine  Oxygen Therapy  Flammable Acute exacerbation - HospitalChronic Disease – Home Care

22. References  Ignatavicius, D. D. & Workman, M. L. (2010). Medical-surgical nursing: patient-centered collaborative care (6 th ed.). St. Louis, MO: Saunders Elsevier.  Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., & Bucher, L. (2014). Medical-surgical nursing: Assessment & management of client problems (9 th ed.). St. Louis, MO: Mosby  Hogan, M., Dentlinger, N.C., & Ramdin, V. (2014). Medical-surgical: nursing pearson nursing reviews and rationales (3 rd ed.). Boston, MA: Pearson.