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Chronic Exam 3: COPD

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main function of respiratory system

1. ventilation: movement of air in and out of lungs
2. perfusion: exchange of O2 and CO2 at alveolar-capillary level
-ventilation/perfusion must be matched so that adequate O2 and CO2 exchange can occur
-Pneumonia: ventilation problem (fluid in air sacs; air exchange problem)
-P.E.: perfusion problem (clot in the capillary bed of lungs; blood flow problem)


respiratory control mechanisms

1. neural: medulla oblongata
2. chemical
-central: found near the medulla; stimulated by an increase in CO2 or a decrease in pH (acidosis)
-peripheral: located in the carotids and aortic arch; stimulated by an increase in CO2 or a decrease in pH, or hypoxia


respiratory diagnostics

1. Percutaneous Biox (Pulse Oximetry) Capnography
2. X-Ray
3. CT Scan – Helical / Spiral
4. MRI
5. V/Q scan
6. Sputum
7. ABG
8. PFT
9. Bronchoscopy
10. Thoracentesis
11. Lung Biopsy


pulse oximetry

-diagnostic test for respiratory
-Measures oxygen saturation
-Non invasive
-False results: increased bilirubin, dark nail polish/fake nails
-CO poisoning



-diagnostic test for respiratory
-Measures exhaled CO2
-Non invasive
-Usually in ventilated patients
-CO2 level: 35-45


chest x-ray

-diagnostic test for respiratory
-Purpose: detect alterations, determine position of tubes, catheters (chest tube, PICCs, ports), evaluate progress of disease, etc
-Posterior Anterior: taking picture of chest forward
-Lateral: taking picture from side view


CT scan (helical/spiral)

-diagnostic test for respiratory
-3D picture
-gives much better picture than standard x-ray


MRI (magnetic resonance imaging)

-diagnostic test for respiratory
-Anyone with metallic implants cannot have MRI: hip replacements, pace makers, orthopedic fixations, ect.


V/Q scan or lung scan

-diagnostic test for respiratory
-Inhalation or IV injection of radiopaque iodine to detect alterations in patterns of ventilation or perfusion


sputum sample

-diagnostic test for respiratory
-Culture (bacteria that is growing) and sensitivity (whether organism is sensitive to certain antibiotics or not)
-AFB (acid fast bacillus)
-Cytology: study of cells; looking for abnormals
-Collection of 1st sputum in AM is best: secretions are more concentrated



-diagnostic test for respiratory
-Purpose: Identify acid-base imbalances, identify hypoxia
-Drawn from radial or femoral artery


PFTs (pulmonary function tests)

-diagnostic test for respiratory
-Purpose: Assess functional capacity of the lungs; helps evaluate pulmonary disease and response to treatments



-diagnostic test for respiratory
-Used to visualize structures of respiratory tract
-Inserted orally or nasally
-Prep: NPO 8 hrs. prior and consent form (conscious sedation)
-Following: NPO until return of gag. Assess resp. effort/rate. Risk for aspiration



-diagnostic test for respiratory
-Insertion of needle into pleural space (between parietal & visceral pleura) to: remove fluid (from cancer or infection), instill meds, and facilitate breathing


tidal volume (TV)

-volume inspired or expired during spontaneous breath
-Normal: 400-500 cc


inspiratory reserve volume (IRV)

-volume that can be inspired at the end of normal inspiration


expiratory reserve volume (ERV)

-volume that can be expired at the end of normal expiration


residual volume (RV)

-volume of air remaining in lungs after maximal expiration


vital capacity



total lung capacity

Vital Capacity + Residual Volume



-Lower airway disorder resulting in irreversible changes that are chronic and progressive
-Includes: emphysema and chronic bronchitis
-Asthma, unlike emphysema and bronchitis, is a condition of intermittent, reversible airflow obstruction


chronic bronchitis etiology

-Inhalation of physical or chemical irritants, with cigarette smoking most common
-Also implicated: pollutants, chronic resp. infections, genetic predisposition


chronic bronchitis pathophysiology

1. Inflammation
2. hyperplasia of mucus-producing glands
3. excessive mucus production
4. decreased ciliary action
5. airway obstruction
6. hypoxia, hypercapnea, respiratory acidosis
7. PaCO2 decreased, PaCO2 increases
8. polycythemia
9. “blue bloater”: cyanotic

Also: Cor pulmonale may occur: Rt. Sided cardiac hypertrophy as the heart pumps against increased pulmonary vascular resistance


chronic bronchitis assessment findings

-Early: Productive cough on awakening (smoker’s cough)
-Dyspnea, wheezing
-Decreased activity (often subconscious)
-Cyanosis (“Blue Bloater”) or dusky color
-Distended neck veins
-Increased edema
-Appear stout or overweight
-Late: Right sided cardiac failure and respiratory failure
-Diagnostic Results: chronic Hypercapnia (CO2), chronic hypoxia, increased Residual Volume, Decreased Forced Expiratory Volume


emphysema pathophysiology

1. alveolar walls destroyed
2. “air trapping” in alveolar spaces
3. increased dead spaces
4. hyperventilation
5. increased work of breathing
6. weight loss
7. PaO2, PaCO2 normal/low
8. “pink puffer”: working so hard to breathing


emphysema assessment findings

-Dyspnea on exertion (DOE) that progresses to dyspnea at rest
-Cyanosis around lips
-Clubbing of fingers
-ABGS normal until late (compensated resp. acidosis in late stages)
-Decreased Forced Expiratory Flow and Volume


chronic bronchitis vs. emphysema assessment

Chronic bronchitis:
1. barrel chest
2. stout, stocky appearance
3. cyanosis
4. persistent cough
5. copious sputum

1. cachectic (significant nutritional deficiency—malnourishment)
2. accessory muscle use
3. tachypnea, hyperventilation
4. skin-pink
5. shortness of breath
6. exertional dyspnea


chronic bronchitis & emphysema nursing dx

1. impaired gas exchange
2. ineffective airway clearance
3. anxiety
4. activity intolerance
5. imbalanced nutrition- less than body requirements
6. risk of infection
7. decisional conflict r/t smoking cessation
8. interrupted family processes
9. sexual dysfunction
10. disturbed sleep pattern


medical management

1. Improve ventilation
-Mechanical ventilation – CPAP (continuous positive airway pressure), PEEP (positive expiratory end pressure)
2. Remove secretions
-Pulmonary hygiene (Chest Physiotherapy, Postural Drainage)
3. Slow progression
-Aerobic exercise
-Breathing exercises
4. Prevent complications
-Treat edema – Digoxin, diuretics
-Therapeutic phlebotomy (treatment for too many RBCs)
5. Promote health maintenance
-Avoid allergens
-Oxygen therapy


Bronchodilators (Sympathomimetics/ ß2 agonists)

-medication management
-Stimulate beta2 receptors in lungs to cause smooth muscle relaxation with bronchodilation
-Examples: Albuterol (Proventil), Metaproterenol (Alupent)
-both inhalers



-medication management
-Block choinergic receptors located in large airways, producing bronchodilation
-Fewer side effects than that Beta2 agonists
-Atrovent (inhaler)


MDI (meter dosed inhaler)

-medication management
-Clean Mouth piece after use
-Spacer allows large drops to land on walls of spacer as opposed to mouth & vocal chords, while smaller drops disperse more fully into deeper airways


Bronchodilators (MethylXanthines)

-medication management
-Cause bronchodilation, stimulate resp. drive, enhance mucociliary clearance, reduce pulmonary vascular resistance
-Can be given in IV drip or PO
-Monitor theophylline levels (10-20 mcg/ml), can easily become toxic (N/V)


anti-inflammatories (corticosteroids)

-medication management
-Reserved for severe cases
-Given IV, po, or by inhalation


Impaired gas exchange r/t decreased ventilation and mucus plugs

-Goal: Maintain adequate gas exchange
-Nursing Interventions:
1. monitor respiratory parameters
2. administer appropriate O2 (low flow oxygen 1-2L/min)
-RA= 21% O2
-cannula: for every 1L/min increases 2-3% oxygen; bubbler: provides moisture/humidity
-venti/ventura: gives precise percentage of O2 delivery
-non re-breather: has a reservoir, for significant respiratory failure/distress; set flow meter to very top (12-15L/min)
3. positioning: upright
4. administer bronchodilators and watch for side effects
5. administer relaxants, sedative with caution


Ineffective airway clearance r/t excessive secretions and ineffective coughing

-Goal: Improved airway clearance
-Nursing Interventions:
1. monitor lung sounds q4-6h
2. maintain adequate hydration and humidity
3. teach effective coughing techniques
4. incentive spirometry 10 times per hour WA
5. chest PT
6. assess oral mucosa and provide oral care: get rid of secretions


Anxiety r/t difficulty in breathing

-Goal: Anxiety minimized
-Nursing Interventions:
1. be calm, relax
2. calm open environment, use fan
3. encourage relaxation breathing
4. administer sedation with caution
5. guided imagery, music therapy


Activity intolerance

-Goal: Improved activity tolerance
-Nursing Interventions:
1. monitor pulse oximetry (before and after), spirometer post activity
2. monitor respiratory parameters
3. supplemental oxygen
4. schedule exercise after therapy oxygen conserving techniques
-sit at sink for personal care, sitting while ironing, ect.
6. teach breathing techniques: pursed-lip breathing
-inhale through nose with mouth closed
-breath out as if whistling


Imbalanced nutrition – less than body requirements r/t decreased appetite, decreased energy and dyspnea

-Goal: Maintain adequate body weight
-Nursing Interventions:
1. oral care before meals
2. small frequent meals
3. dietician consult for appropriate foods
4. nasal cannula during meals
5. monitor intake and blood levels for Hgb, albumin and prealbumin to determine protein


Risk of infection r/t ineffective pulmonary clearance and steroid therapy

-Goal: Decrease the risk of infection
-Nursing Interventions:
1. Hand washing
2. vaccinations
3. clean respiratory equipment
4. educate s/s of respiratory infections


Decisional conflict r/t smoking cessation

-Goal: Client and family will consider the value to quit smoking
-Nursing Interventions:
1. explain benefit of smoking cessation
2. assess readiness
3. arrange for smoking cessation counseling follow up and pharamacotherapy
4. pharmacologic agents:
-nicotine gum, patches or lozenges: stimulate the release of low levels of dopamine to decrease nicotine cravings
-Chantix: stimulates the release of low levels of dopamine and block nicotine receptor sites in the brain; typically 12 week program


Interrupted family processes r/t chronic illness of family member

1. include family in plan of care
2. family communication: family counseling
3. social support network
4. support groups


Sexual dysfunction r/t dysnea, low energy levels, change in relationships

1. discuss concerns
2. alternative methods
3. sexual activity after treatment or medications
4. professional sex therapist


Disturbed sleep pattern r/t dyspnea

1. environmental control
2. schedule daily care; consistent bedtime
3. avoid stimulants: caffeine
4. high protein snack before bedtime
5. relaxation therapy

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