NURSING PROCESS: THE PATIENT WITH COPD
Assessment involves obtaining information about current symp-toms as well as previous disease manifestations. Chart 24-3 lists sample questions that may be used to obtain a clear history of the disease process. In addition to the history, the nurse also reviews the results of available diagnostic tests.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
· Impaired gas exchange and airway clearance due to chronic inhalation of toxins
· Impaired gas exchange related to ventilation–perfusion inequality
· Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough, broncho-pulmonary infection, and other complications
· Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction, and airway irritants
· Activity intolerance due to fatigue, ineffective breathing patterns, and hypoxemia
· Deficient knowledge of self-care strategies to be performed at home.
· Ineffective coping related to reduced socialization, anxiety, depression, lower activity level, and the inability to work
Based on the assessment data, potential complications that may develop include:
• Respiratory insufficiency or failure
• Pulmonary infection
• Pulmonary hypertension
The major goals for the patient may include smoking cessation, improved gas exchange, airway clearance, improved breathing pattern, improved activity tolerance, maximal self-management, improved coping ability, adherence to the therapeutic program and home care, and absence of complications.
Because smoking has such a detrimental effect on the lungs, the nurse must discuss smoking cessation strategies with patients. Although patients may believe that it is too late to reverse the dam-age from years of smoking and that smoking cessation is futile, they should be informed that continuing to smoke impairs the mechanisms that clear the airways and keep them free of irritants. The nurse should educate the patient regarding the hazards of smoking and cessation strategies and provide resources regarding smoking cessation, counseling, and formalized programs available in the community.
Bronchospasm, which occurs in many pulmonary diseases, re-duces the caliber of the small bronchi and may cause dyspnea, static secretions, and infection. Bronchospasm can sometimes be detected when wheezing or diminished breath sounds are heard on auscultation with a stethoscope. Increased mucus production, along with decreased mucociliary action, contributes to further reduction in the caliber of the bronchi and results in decreased airflow and decreased gas exchange. This is further aggravated by the loss of lung elasticity that occurs with COPD (NIH, 2001).
These changes in the airway require that the nurse monitor the patient for dyspnea and hypoxemia. If bronchodilators or corti-costeroids are prescribed, the nurse must administer the medica-tions properly and be alert for potential side effects. The relief of bronchospasm is confirmed by measuring improvement in expi-ratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) and assessing whether the patient has less dyspnea.
Diminishing the quantity and viscosity of sputum can clear the airway and improve pulmonary ventilation and gas exchange. All pulmonary irritants should be eliminated or reduced, particularly cigarette smoking, which is the most persistent source of pul-monary irritation. The nurse instructs the patient in directed or controlled coughing, which is more effective and reduces the fatigue associated with undirected forceful coughing. Directed coughing consists of a slow, maximal inspiration followed by breath-holding for several seconds and then two or three coughs. “Huff” coughing may also be effective. The technique consists of one or two forced exhalations (“huffs”) from low to medium lung volumes with the glottis open.
Chest physiotherapy with postural drainage, intermittent positive-pressure breathing, increased fluid intake, and bland aerosol mists (with normal saline solution or water) may be use-ful for some patients with COPD. The use of these measures must be based on the patient’s response and tolerance.
Ineffective breathing patterns and shortness of breath are due to the ineffective respiratory mechanics of the chest wall and lung re-sulting from air trapping, ineffective diaphragmatic movement, airway obstruction, the metabolic cost of breathing, and stress. In-spiratory muscle training and breathing retraining may help to im-prove breathing patterns. Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration. Pursed-lip breathing helps to slow expiration, prevents collapse of small airways, and helps the patient to control the rate and depth of respiration. It also promotes relaxation, which enables the pa-tient to gain control of dyspnea and reduce feelings of panic.
Patients with COPD experience progressive activity and exercise intolerance. Education is focused on rehabilitative therapies to promote independence in executing activities of daily living. These may include pacing activities throughout the day or using supportive devices to decrease energy expenditure. The nurse evaluates the patient’s activity tolerance and limitations and teaching strategies to promote independent activities of daily liv-ing. Also, the patient may be a candidate for exercise training to strengthen the muscles of the upper and lower extremities and improve exercise tolerance and endurance. Other health care pro-fessionals (rehabilitation therapy, occupational therapy, physical therapy) may be consulted as additional resources.
In addition to a pulmonary rehabilitation program, the nurse helps the patient manage self-care by emphasizing the importance of setting realistic goals, avoiding temperature extremes, and modifying lifestyle (particularly stopping smoking) as applicable.
A major area of teaching is the importance of setting and accept-ing realistic short-term and long-range goals. If the patient is se-verely disabled, the objectives of treatment are to preserve current pulmonary function and relieve symptoms as much as possible. If the disease is mild, the objectives are to increase exercise toler-ance and prevent further loss of pulmonary function. It is im-portant to plan and share the goals and expectations of treatment with the patient. The patient and those providing care need pa-tience to achieve these goals.
The nurse instructs the patient to avoid extremes of heat and cold. Heat increases the body temperature, thereby raising oxy-gen requirements; cold tends to promote bronchospasm. Air pol-lutants such as fumes, smoke, dust, and even talcum, lint, and aerosol sprays may initiate bronchospasm. High altitudes aggra-vate hypoxemia.
Patients with COPD should adopt a lifestyle of moderate activ-ity, ideally in a climate with minimal shifts in temperature and humidity. As much as possible, the patient should avoid emo-tional disturbances and stressful situations that might trigger a coughing episode. The medication regimen for patients with COPD can be quite complex; patients receiving aerosol medica-tions by an MDI may be particularly challenged. It is crucial to review this material and to have the patient perform a return demonstration before discharge, during follow-up visits to the caregiver’s office or clinic, and during home visits (Chart 24-4).
Smoking cessation goes hand in hand with lifestyle changes, and reinforcement of the patient’s efforts is a key nursing activ-ity. Smoking cessation is the single most important therapeutic intervention for patients with COPD. There are many strategies, including prevention, cessation with or without oral or topical patch medications, and behavior modification techniques.
COPD and its progression promote a cycle of physical, social, and psychological consequences, all which are interrelated. Pa-tients experience depression, altered mood states, social isolation, and altered functional status. The nurse is key to identifying this cycle and promoting interventions for improved physical func-tioning, psychological and emotional stability, and social sup-port. Following the initial assessment of the patient, the nurse may provide referrals to health care professionals in these specific areas.
The nurse caring for the patient with COPD must assess for var-ious complications, such as life-threatening respiratory insuffi-ciency and failure and respiratory infection and atelectasis, which may increase the patient’s risk for respiratory failure. The nurse also monitors for cognitive changes (personality and behavioral changes, memory impairment), increasing dyspnea, tachypnea, and tachycardia, which may indicate increasing hypoxemia and impending respiratory failure.
The nurse monitors pulse oximetry values to assess the pa-tient’s need for oxygen and administers supplemental oxygen as prescribed. The nurse also instructs the patient about signs and symptoms of respiratory infection that may worsen hypoxemia and reports changes in the patient’s physical and cognitive status to the physician. Other activities require assisting with the man-agement of developing complications, with possible intubation and mechanical ventilation.
Bronchopulmonary infections must be controlled to diminish inflammatory edema and to permit recovery of normal ciliary ac-tion. Minor respiratory infections that are of no consequence to the person with normal lungs can be life-threatening to the person with COPD. The cough associated with bronchial infection intro-duces a vicious cycle with further trauma and damage to the lungs, progression of symptoms, increased bronchospasm, and increased susceptibility to bronchial infection. Infection compromises lung function and is a common cause of respiratory failure in patients with COPD.
In COPD, infection may be accompanied by subtle changes. The nurse instructs the patient to report any signs of infection, such as a fever or change in sputum color, character, consistency, or amount. Any worsening of symptoms (increased tightness of the chest, increased dyspnea and fatigue) also suggests infection and must be reported. Viral infections are hazardous to these patients because they are often followed by infections caused by bacterial organisms, such as Streptococcus pneumoniae and Haemophilusinfluenzae.
The nurse should encourage patients with COPD to be im-munized against influenza and S. pneumoniae because these pa-tients are prone to respiratory infection. It is important to caution patients to avoid going outdoors if the pollen count is high or if there is significant air pollution because of the risk of bronchospasm. The patient also should avoid exposure to high out-door temperatures with high humidity.
Pneumothorax is a potential complication of COPD. Patients with severe emphysematous changes can develop large bullae, which may rupture and cause a pneumothorax. The development of a pneumothorax may be spontaneous or related to an activity such as severe coughing or large intrathoracic pressure changes. If the patient develops a rapid onset of shortness of breath, the nurse should quickly evaluate the patient for a potential pneumothorax by assessing the symmetry of chest movement, differences in breath sounds, and pulse oximetry. A pneumothorax is a life-threatening event in the patient with COPD who has minimal pulmonary reserve.
Over time, pulmonary hypertension may occur as a result of chronic hypoxemia. The pulmonary arteries respond to hypox-emia by constriction, thus leading to pulmonary hypertension.The complication may be prevented by maintaining adequate oxygenation through an adequate hemoglobin level, improved ventilation/perfusion of the lungs, or continuous administration of supplemental oxygen (if needed).
Teaching is essential throughout the course of COPD and should be part of the nursing care given to every patient with COPD. Pa-tients’ and family members’ knowledge and comfort level with their knowledge should be assessed and considered when provid-ing instructions about self-management strategies. In addition to the aspects of patient education previously described, patients and family members must become familiar with the medications that are prescribed and knowledgeable about potential side ef-fects. Patients and family members need to learn the early signs and symptoms of infection and other complications so that they seek appropriate health care promptly.
Referral for home care is important to enable the nurse to assess the patient’s home environment and physical and psychological status, to evaluate the patient’s adherence to the prescribed regi-men, and to assess the patient’s ability to cope with changes in lifestyle and physical status. The nurse assesses the patient’s and family’s understanding of the complications and side effects of medications. The home care visit provides an opportunity to re-inforce the information and activities learned in the inpatient or outpatient pulmonary rehabilitation program and to have the pa-tient and family demonstrate correct administration of medications and oxygen, if indicated, and performance of exercises. If the pa-tient does not have access to a formal pulmonary rehabilitation program, it is important for the nurse to provide the education and breathing retraining necessary to optimize the patient’s func-tional status.
The nurse may direct patients to community resources such as pulmonary rehabilitation programs and smoking cessation programs to help improve their ability to cope with their chronic condition and the therapeutic regimen and to give them a sense of worth, hope, and well-being. In addition, the nurse reminds the patient and family about the importance of participating in general health promotion activities and health screening.
Expected patient outcomes may include:
1. Demonstrates knowledge of hazards of smoking
a. Verbalizes willingness/interest to quit smoking
b. Verbalizes information about smoking, risks of contin-uing, benefits of quitting, and techniques to optimize cessation efforts
2. Demonstrates improved gas exchange
a. Shows no signs of restlessness, confusion, or agitation
b. Has stable pulse oximetry or arterial blood gas values (but not necessarily normal values due to chronic changes in the gas exchange ability of the lungs)
3. Achieves maximal airway clearance
a. Stops smoking
b. Avoids noxious substances and extremes of temperature
c. Maintains adequate hydration
d. If indicated, performs postural drainage correctly
e. Knows signs of early infection and is aware of how and when to report them if they occur
f. Performs controlled coughing without experiencing excessive fatigue
4. Improves breathing pattern
a. Practices and uses pursed-lip and diaphragmatic breath-ing
b. Shows signs of decreased respiratory effort (decreased respiratory rate, less dyspnea)
5. Demonstrates knowledge of strategies to improve activity tolerance and maintain maximum level of self-care
a. Performs self-care activities within tolerance range
b. Paces self to avoid fatigue and dyspnea
c. Uses controlled breathing while performing activities
d. Uses devices to assist with activity tolerance and de-crease energy expenditure
6. Demonstrates knowledge of self-care strategies
a. Participates in determining the therapeutic program
b. Understands the rationale for activities and medications
c. Follows the medication plan
d. Uses bronchodilators and oxygen therapy as prescribed
e. Stops smoking
f. Maintains acceptable activity level
7. Uses effective coping mechanisms for dealing with conse-quences of disease
a. Uses self-care strategies to lessen stress associated with disease
b. Verbalizes resources available to deal with psychological burden of disease
c. Participates in pulmonary rehabilitation, if appropriate
8. Uses community resources and home-based care
a. Verbalizes knowledge of community resources (eg, smoking cessation, hospital/community-based support groups)
b. Participates in pulmonary rehabilitation, if appropriate
9. Avoids or reduces complications
a. Has no evidence of respiratory failure or insufficiency
b. Maintains adequate pulse oximetry and arterial blood gas values
c. Shows no signs or symptoms of infection, pneumotho-rax, or pulmonary hypertension
For more information, see Plan of Nursing Care: Care of the Patient With COPD.