Chronic Obestractive Pulmonary diseases
Nursing Assessment
1. Determine smoking history, exposure history, positive family history of respiratory disease, onset of dyspnea.
2. Note amount, color, and consistency of sputum.
3. Inspect for use of accessory muscles of respiration and use of abdominal muscles during expiration; note increase of anteroposterior diameter of chest.
4. Auscultate for decreased/absent breath sounds, *****les, decreased heart sounds.
5. Determine level of dyspnea, how it compares to patient's baseline.
6. Determine oxygen saturation at rest and with activity.

Nursing Diagnoses
1. Ineffective Airway Clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection
2. Ineffective Breathing Pattern related to chronic airflow limitation
3. Risk for Infection related to compromised pulmonary function, retained secretions, and compromised defense mechanisms
4. Impaired Gas Exchange related to chronic pulmonary obstruction, [V with dot above]/[Q with dot above] abnormalities due to destruction of alveolar capillary membrane
5. Imbalanced Nutrition: Less Than Body Requirements related to increased work of breathing, air swallowing, drug effects with resultant wasting of respiratory and skeletal muscles
6. Activity Intolerance related to compromised pulmonary function, resulting in shortness of breath and fatigue
7. Disturbed Sleep Pattern related to hypoxemia and hypercapnia
8. Ineffective Coping related to the stress of living with chronic disease, loss of independence


Nursing Interventions
Improving Airway Clearance
1. Eliminate pulmonary irritants, particularly cigarette smoking.
A) Cessation of smoking usually results in less pulmonary irritation, sputum production, and cough, and may slow progression of COPD.
B) Keep patient's room as dust-free as possible.
C) Add moisture (humidifier, vaporizer) to indoor environment, if appropriate.
2. Administer bronchodilators to control bronchospasm and dyspnea and assist with raising sputum.
A) Assess for adverse effects—tremulousness, tachycardia, cardiac dysrhythmias, CNS stimulation, hypertension.
B) Auscultate the chest after administration of aerosol bronchodilators to assess for improvement of aeration and reduction of adventitious breath sounds.
C) Observe if patient has reduction in dyspnea.
D) Monitor serum theophylline level, as ordered, to ensure therapeutic level and prevent toxicity.
3. Use postural drainage positions to aid in clearance of secretions, if mucopurulent secretions are responsible for airway obstruction (see page 230).
4. Use controlled coughing (see page 231).
5. Keep secretions liquid.
A) Encourage high level of fluid intake (8 to 10 glasses; 2 to 2آ½qt [2 to 2.5 L] daily) within level of cardiac reserve.
B) Give continuous aerolized sterile water or nebulized normal saline to humidify bronchial tree and liquefy sputum if appropriate.
C) Avoid dairy products if these increase sputum production.

Improving Breathing Pattern
1. Teach and supervise breathing retraining exercises to strengthen diaphragm and muscles of expiration to decrease work of breathing
A) Teach diaphragmatic, lower costal, and abdominal breathing, using a slow and relaxed breathing pattern to reduce respiratory rate and decrease energy cost of breathing.
B) Use pursed-lip breathing at intervals and during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination. Diaphragmatic and pursed-lip breathing should be practiced for 10 breaths four times daily before meals and before sleep. Inspiratory to expiratory ratio should be 1:2.
2. Discuss and demonstrate relaxation exercises to reduce stress, tension, and anxiety.
3. Encourage patient to assume position of comfort to decrease dyspnea. Positions might include leaning trunk forward with arms supported on a fixed object.

Controlling Infection
1. Recognize early manifestations of respiratory infection—increased dyspnea, fatigue; change in color, amount, and character of sputum; nervousness; irritability; low-grade fever.
2. Obtain sputum for Gram stain and culture and sensitivity.
3. Administer prescribed antimicrobials to control secondary bacterial infections in the bronchial tree, thus clearing the airways.

Improving Gas Exchange
1. Watch for and report excessive somnolence, restlessness, aggressiveness, anxiety, or confusion; central cyanosis; and shortness of breath at rest, which is commonly caused by acute respiratory insufficiency and may signal respiratory failure.
2. Review ABG levels; record values on a flow sheet so comparisons can be made over time.
3. Monitor oxygen saturation and give supplemental oxygen as ordered to correct hypoxemia in a controlled manner. Monitor and minimize CO2 retention. Patients that experience CO2 retention may need lower oxygen flow rates.
4. Be prepared to assist with noninvasive ventilation or intubation and mechanical ventilation if acute respiratory failure and rapid CO2 retention occur.

Improving Nutrition
1. Take nutritional history, weight, and anthropometric measurements.
2. Encourage frequent small meals if patient is dyspneic; even a small increase in abdominal ****************************s may press on diaphragm and impede breathing. Encourage snacking on high-calorie, high-protein snacks, such as cheese, nuts.
3. Offer liquid nutritional supplements to improve caloric intake and counteract weight loss.
4. Avoid foods producing gas and abdominal discomfort.
5. Employ good oral hygiene before meals to sharpen taste sensations.
6. Encourage pursed-lip breathing between bites if patient is short of breath; rest after meals.
7. Give supplemental oxygen while patient is eating to relieve dyspnea as directed.
8. Monitor body weight.

Increasing Activity Tolerance
1. Reemphasize the importance of graded exercise and physical conditioning programs (enhances delivery of oxygen to tissues; allows a higher level of functioning with greater comfort). This may be part of a formalized pulmonary rehabilitation program or a referral to physical or occupational therapy.
A) Discuss walking, stationary bicycling, swimming.
B) Encourage use of portable oxygen system for ambulation for patients with hypoxemia.
2. Encourage patient to carry out regular exercise program 3 to 7 days per week to increase physical endurance.
3. Train patient in energy conservation techniques.

Improving Sleep Patterns
1. Maintain a balanced schedule of activity and rest.
2. Use nocturnal oxygen therapy when appropriate.
3. Avoid use of sedatives that may cause respiratory depression.

Enhancing Coping
1. Understand that the constant shortness of breath and fatigue make the patient irritable, apprehensive, anxious, and depressed, with feelings of helplessness and hopelessness.
2. Assess the patient for reactive behaviors (anger, depression, acceptance).
3. Demonstrate a positive and interested approach to the patient.
A) Be a good listener and show that you care.
B) Be sensitive to patient's fears, anxiety, and depression; may provide emotional relief and insight.
C) Provide patient with control of as many aspects of care as possible.
4. Strengthen the patient's self-image.
5. Allow the patient to express feelings. Be aware that (within a controlled degree) the mechanisms of denial and repression may be useful defense mechanisms.
6. Be aware that sexual dysfunction is common in patients with COPD. Encourage discussion of concerns and fears, and clarify misunderstandings. Encourage patient to use a bronchodilator and secretion clearance techniques before sexual activity, plan for sexual relations at time of day when patient has highest level of energy, use supplemental oxygen if needed, and consider alternative displays of affection to loved one.
7. Support spouse/family members. Refer to local or national support groups (American Lung Association 1-800-LUNG USA; http://www.lungusa.org).

Community and Home Care Considerations
1. Encourage patient to live within the limitations that emphysema imposes.
2. Help to relax and work at a slower pace. Obtain occupational therapy consult to help employ work simplification techniques such as sitting for tasks, pacing activities, using dressing aids (grabber, sock aid, long-handled shoe horn), shower bench, and handheld shower head.
3. Encourage enrollment in a pulmonary rehabilitation program where available and Better Breathers club or other support group found through the American Lung Association or the American Association for Cardiovascular and Pulmonary Rehabilitation at 312-321-5146 or http://www.aacvpr.org/. Components include breathing retraining techniques, proper use of medications and inhalers, secretion clearance techniques, prevention and management of respiratory infection, panic control, controlling dyspnea with ADLs and stair climbing, control of pulmonary irritants, monitored and supervised exercise, proper use of oxygen systems, and group support.
4. Suggest vocational counseling to help patient maintain gainful employment within his physical limits for as long as possible.
5. Warn patient to avoid excessive fatigue, which is a factor in producing respiratory distress.
6. Advise to adjust activities per individual fatigue patterns.
7. Advise to try to cope with emotional stress as positively as possible. Such stress triggers attacks of dyspnea. Teach coping strategies, such as relaxation techniques, meditation, guided imagery.
8. Stress that progression of worsening lung function may be slowed through close medical follow-up for rest of life.

Patient Education and Health Maintenance General Education
1. Give the patient a clear explanation of the disease, what to expect, how to treat and live with it. Reinforce by frequent explanations, reading material, demonstrations, and question and answer sessions. (See Patient Education Guidelines .
2. Review with the patient the objectives of treatment and nursing management.
3. Work with the patient to set goals (eg, stair climbing, return to work).
4. Encourage patient involvement in disease self-management techniques, such as identification and prompt reporting of respiratory infection or respiratory deterioration. Encourage patient to have open communication and partnership with primary care provider.

Avoid Exposure to Respiratory Irritants
1. Advise patient to stop smoking and avoid exposure to second-hand smoke.
2. Advise patient to avoid sweeping, dusting, and exposure to paint, aerosols, bleaches, ammonia, and other respiratory irritants.
3. Advise patient to keep entire house well-ventilated.
4. Warn patient to stay out of extremely hot/cold weather to avoid bronchospasm and dyspnea.
A) Keep a warm mask or scarf over nose and mouth, and drink a warm beverage to warm inspired air in cold weather.
B) Stay indoors with air conditioning when air pollution level is high.
C) Try to avoid abrupt environmental changes.
D) Shower in warm water.
5. Instruct patient to humidify indoor air in winter; maintain 30% to 50% humidity for optimal mucociliary function.
6. Suggest the use of a HEPA air cleaner to remove dust, pollen, and other particulates; this is controversial as to the benefit to the patient.

Prevent and Treat Respiratory Infections
1. Warn against exposure to people with respiratory infections; a respiratory infection makes symptoms worse and can produce further irreversible damage.
2. Advise patient to avoid crowds and areas with poor ventilation.
3. Stress the importance of obtaining influenza vaccine (annual) and pneumococcal vaccine to decrease likelihood of developing these infections.
4. Teach patient how to recognize and report evidence of respiratory infection promptly—changes in character of sputum (amount, color, or consistency—becoming purulent), increasing cough, wheezing, increasing shortness of breath, fever, chills, increasing difficulty in raising sputum, chest pain.
5. Instruct patient to discuss with health care provider taking prescribed antimicrobial at first sign of infection and adding oral corticosteroids for exacerbation of COPD.

Reduce Bronchial Secretions
1. Advise patient to maintain an adequate fluid intake (8 to 10 glasses daily); mark down the amount of liquid consumed daily.
2. Encourage use of bronchodilators as directed.
3. Teach postural drainage exercises as prescribed.
A) Stay in each position 5 to 15 minutes as tolerated.
B) Use controlled cough after each position.
4. Use other secretion clearance techniques, such as PEP valve, flutter valve, huff cough and, possibly, chest percussion if needed for enhanced secretion clearance.

Improve Airflow
1. Teach the proper technique for inhalation of medication to maximize aerosol deposition in the bronchial tree.
A) Use spacer device, breathe out normally; place MDI (attached to spacer device) in mouth, make tight seal around mouthpiece (if not using spacer device: place inhaler 1 inch [2.5 cm] in front of open mouth).
B) Actuate cartridge to release spray and inhale slowly over 5 seconds.
Pause, holding breath for about 10 seconds; exhale slowly.
2. Encourage routine use of a spacer device or holding chamber to allow easier inhalation of bronchodilator medication and enhanced medication deposition. Follow manufacturer's instructions for use of holding chambers.
3. If using a dried powder inhaler, instruct in proper use according to manufacturer's instructions. Spacer devices are not necessary.

Breathing Exercises
1. Explain that goal is to strengthen and coordinate muscles of breathing to lessen work of breathing and help lung empty more completely.
2. Stress the importance of controlled breathing.
3. Teach diaphragmatic breathing and pursed-lip breathing for episodes of dyspnea and stress.
4. Encourage muscle toning by regular exercise.

General Health
1. Teach good habits of well-balanced, nutritious intake.
2. Encourage high-protein diet with adequate mineral, vitamin, and fluid intake.
3. Advise against excessive hot or cold fluids and foods, which may provoke an irritating cough.
4. Advise to avoid hard-to-chew foods (causes tiring) and gas-forming foods, which cause distention and restrict diaphragmatic movement.
5. Encourage five to six small meals daily to ease shortness of breath during and after meals.
6. Suggest rest periods before and after meals if eating produces shortness of breath.
7. Warn against potassium depletion. Patients with COPD tend to have low potassium levels; also, patient may be taking diuretics.
A) Watch for weakness, numbness, tingling of fingers, leg cramps.
B) Encourage foods high in potassium include bananas, dried fruits, dates, figs, orange juice, grape juice, milk, peaches, potatoes, tomatoes.
8. Advise patient on restricting sodium as directed.
9. Limit carbohydrates if CO2 is retained by patient, because they increase CO2.
10. Use community resources, such as Meals On Wheels or a home care aide if energy level is low.


Evaluation: Expected Outcomes
1. Coughs up secretions easily; decreased wheezing and *****les
2. Reports less dyspnea; effectively using pursed-lip breathing
3. No fever or change in sputum
4. ABG levels and/or Spo2 improved on low-flow oxygen
5. Tolerates small, frequent meals; weight stable
6. Reports walking longer distances without tiring
7. Sleeping in 4- to 6-hour intervals; uses low-flow oxygen at night
8. Demonstrates more effective coping; expresses feelings; seeks support group