COPD

Question 1

It is caused by chronic bronchitis and emphysema.

→ is a term used to describe a group of progressive lung diseases that lead to airflow obstruction.

Answer 1

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Question 2

PATHOPHYSIOLOGY COPD

Answer 2

→ Exposure to irritants such as smoking, dust, pollen, etc., irritates the goblet cells and these cells respond by increasing sputum production thereby causing an obstruction on the bronchi causing a productive cough and if this last for more than 3 months for 2 consecutive years this is now known as chronic bronchitis. This inflammation can reach the alveoli, wherein it causes alveolar wall destruction called as emphysema. These two conditions obstruct the airway and contribute to Chronic Obstructive Pulmonary Disease

Question 3

➢ presence of cough and sputum production for at least 3 months in each of 2 consecutive years

→ It is characterized by a productive cough lasting 3 or more months in 2 consecutive years.

Answer 3

CHRONIC BRONCHITIS (CB)

Question 4

is a major factor implicated in the development of CB.

Answer 4

Cigarette smoke

Question 5

the initial symptom of CB

Answer 5

Productive cough due to increased sputum production

Question 6

In COPD remember there are 2 things to remember, Chronic Bronchitis and Emphysema

*In chronic bronchitis - bronchi is affected
**If bronchi affected in COPD,
**Goblet cell - seen in bronchi

manifestation? sputum production

that will have PRODUCTIVE COUGH

———————-

emphysema - alveoli affected

*150 million alveoli each lungs and surfactant - seen in alveoli
1. decrease surface tension - decrease attractiveness of water
2. so alveoli will not collapsed

**alveoli collapsed - manifestation? DYSPNEA

Answer 6

TO KNOW

Question 7

In COPD remember there are 2 things to remember, Chronic Bronchitis and Emphysema

(EXPLAIN NA)

Answer 7

*In chronic bronchitis - bronchi is affected
**If bronchi affected in COPD,
**Goblet cell - seen in bronchi

manifestation? sputum production

that will have PRODUCTIVE COUGH

———————-

emphysema - alveoli affected

*150 million alveoli each lungs and surfactant - seen in alveoli
1. decrease surface tension - decrease attractiveness of water
2. so alveoli will not collapsed

**alveoli collapsed - manifestation? DYSPNEA

Question 8

CHRONIC BRONCHITIS
→ 3 Laboratory Studies

Answer 8

▪ Arterial Blood Gases
▪ Pulse Oximetry
▪ Sputum Culture & Sensitivity

Question 9

CHRONIC BRONCHITIS
→ Laboratory Studies
Sputum Culture and Sensitivity

(Define and Nursing Intervention)

Answer 9

– for rapid identification and treatment of pulmonary infection.

✓ Give the patient a sterile sputum container.

✓ Best done in the morning, before eating or drinking.

✓ Chest Physiotherapy combined with Nebulization help loosen secretions for expectoration.

✓ Difficult in producing sputum, give nebulizer with saline for 15-30mins to soften and loosen sputum to help expectorate

✓ Collect at least 1tsp of sputum.

✓ Brushing the teeth and rinsing the mouth is recommended, to reduce contamination of the sputum.

✓ Let the patient cough after taking several deep breaths.

Question 10

→ It is characterized by destruction of the wall of the alveoli with resulting enlargement of abnormal air spaces.

Answer 10

EMPHYSEMA

Question 11

→ _____ is strongly implicated as a
causative factor of Emphysema

Answer 11

Cigarette smoking

Question 12

→ Two Major Changes that occur with
emphysema:

Answer 12

▪ Loss of lung elasticity
▪ Hyperinflation of the lung

Question 13

→ _______ is the initial symptom of Emphysema

Answer 13

Dyspnea

Question 14

Emphysema - Explain:

Hyperinflation

Barrel Chest

Answer 14

✓ Hyperinflation is an excessive expansion of the alveoli due to loss of lung elasticity. This results in larger but less efficient air sacs. As the bronchi are obstructed, patients have difficulty exhaling CO2, which results in elevated levels of CO2 in the bloodstream.

▪ Barrel chest is primarily caused by the loss of lung elasticity and hyperinflation of the alveoli, which results in the chest taking on a more expanded shape

Question 15

EMPHYSEMA - EXPLAIN

E-cigarettes or vaping are devices used to inhale an aerosol, which typically contains nicotine (though not always).

Answer 15

▪ It inactivates the cilia, which are responsible for removing microorganisms. With the cilia not working effectively, it becomes easier for microorganisms to enter the trachea, potentially causing lung infections.

▪ It produces carbon monoxide, wherein hemoglobin is more attracted to this type of gas therefore decreasing the carrier for oxygen.

▪ It causes vasoconstriction which increases blood pressure and delays wound healing.

Question 16

➢ Surfactant is being produced by the type 2 alveolar cells.

(Surfactant is needed to ______________)

Answer 16

prevent the attraction of water molecules to each other thus preventing the collapse of the alveoli

Question 17

❖ RISK FACTORS OF EMPHYSEMA

Answer 17

→ Cigarette Smoking (most common)

→ Environmental Pollutants

→ Genetic because there is a deficiency of alpha antitrypsin, an enzyme that is produce by the lungs, so that if viruses enters, this enzyme will protect the lining of the alveoli.

→ Age – the lungs weakens as we age

→ Exposure to secondhand smoke - there will be irritating lungs and air sacs -> they lose their elasticity -> diminish antitrypsin -> Protein destroying enzymes will destroy collagen and elastin -> dilated and accumulation of Carbon dioxide in the Alveoli)

Question 18

PHYSICAL ASSESSMENT OF EMPHYSEMA

Answer 18

㾎 Inspection
㾎 Percussion
㾎 Palpation
㾎 Auscultation

Question 19

PHYSICAL ASSESSMENT OF EMPHYSEMA

㾎 Inspection

→ Barrel Chest
→ Prominent Sternocleidomastoid Muscle
→ Decreased appetite
→ Lose Weight
→ Mouth Breather
→ Tripod Position

Answer 19

→ Barrel Chest
*because of accumulated co2 in the alveoli
**(AP Diameter > Lateral Diameter)

**results of loss of lung elasticity
**chronic air trapping.
***chest wall expansion with chest rigidity

Accessory muscles of respiration are used for
breathing

→ Prominent Sternocleidomastoid Muscle
→ Decreased appetite
→ Lose Weight

→ Mouth Breather – They breathe through their mouth because they are having a hard time exhaling the excess CO2 that has accumulated.

→ Tripod Position – upper extremity is supported by a table; they do this because the lungs is occupied with CO2 and they are having dyspnea; this position pulls the shoulder up allowing more space for the lungs to expand.

Question 20

PHYSICAL ASSESSMENT OF EMPHYSEMA

㾎 Percussion

Hyper resonant

Answer 20

– signifies that there is increased lung inflation from air tapping

Question 21

PHYSICAL ASSESSMENT OF EMPHYSEMA

㾎 Palpation

Decreased Fremitus

Answer 21

done by vibration through asking the patient to say tres,tres or 99

transmission of vibration is obstructed

Question 22

PHYSICAL ASSESSMENT OF EMPHYSEMA

㾎 Auscultation

Breath Sounds

Answer 22

Breath Sounds are reduced

Crackles and wheezes can be heard as air passes through the fluid.

Question 23

Clubbing of Nails
▪ It results from chronic oxygen deprivation in the tissue beds.

▪ It will take years for clubbing to develop.

▪ Normal: diamond shape is present

▪ Commonly seen in association with: Hypoxemia and Polycythemia

Answer 23

to know

Question 24

▪ It results from chronic oxygen deprivation in the tissue beds.

Answer 24

Clubbing of Nails

Question 25

Clubbing of Nails

Normal Finger angle:

Clubbed Finger angle:

Answer 25

160

> 180

Question 26

➢ Usually called “PINK PUFFERS” because they can compensate for the ABG is within normal limit -> plus not all the alveoli is damaged so they can maintain their acid base balance.

Answer 26

EMPHYSEMA

Question 27

➢ Usually called “Blue Bloaters” because of cyanosis. (If there is obstruction in the bronchi, which is the passage of Oxygen and Carbon Dioxide, Oxygen cannot pass causing Cyanotic)

Answer 27

CHRONIC BRONCHITIS

Question 28

SYMPTOMS:
Chronic
Productive Cough
Purulent Sputum
Hemoptysis
Mild Dyspnea
Cyanosis (due to hypoxemia)
Peripheral Edema (due to cor pulmonale)
Crackles, wheezes
Prolonged expiration
Obese

Answer 28

CHRONIC BRONCHITIS

Question 29

COMPLICATIONS

*Secondary polycythemia vera due to hypoxemia

• Pulmonary Hypertension due to reactive vasoconstriction from hypoxemia
• Cor Pulmonale from chronic pulmonary hypertension

Answer 29

CHRONIC BRONCHITIS

Question 30

SYMPTOMS
Dyspnea
Minimal Cough
Increased minute ventilation
Pink skin
Pursed-lip breathing
Accessory muscle use
Cachexia
Hyperinflation
Barrel Chest
Decreased breath sound
Tachypnea

Answer 30

EMPHYSEMA

Question 31

COMPLICATION
*Pneumothorax due to bullae
*Weigh loss due to work of breathing

Answer 31

EMPHYSEMA

Question 32

_______: obstructed bronchi = cyanotic

_______: they can compensate even in the last stage of COPD

Answer 32

Blue Bloater

Pink Puffer

Question 33

❖ COMPLICATIONS OF COPD

→ Respiratory insufficiency and failure are major life-threatening complications.

→ Pneumonia, chronic atelectasis,pneumothorax.

→ Cor Pulmonale (Right Sided Heart Failure)

Answer 33

TO KNOW

Question 34

❖ COMPLICATIONS OF COPD

Answer 34

▪ COPD is due to emphysema and chronic bronchitis. In which, alveoli are destroyed due to emphysema while in chronic bronchitis there is an increased production of mucus by the goblet cells and these actions led to obstruction of the bronchi which lessens the passageway for the gases. Due to less oxygen in the lungs, the smooth muscles will contract causing bronchoconstriction. This can increase pressure in the lungs (Pulmonary Hypertension) and the right ventricle now is having a hard time pushing blood against the pulmonary valve and this can increase the workload of the heart leading to enlargement of the right ventricle known as Right Ventricular Hypertrophy.

▪ Another cause of Right Ventricular Hypertrophy is a lack of oxygen. In response, the body compensates by increasing the production of red blood cells (RBCs), a condition known as polycythemia vera. The consequence is that an excess of RBCs thickens the blood. When the heart has to pump thickened blood, it adds to the workload of the right ventricle, leading to its enlargement.

▪ Cor Pulmonale is the term used if the etiology is pulmonary caused.

Question 35

→ In patients with COPD, the most prominent palpable impulse or PMI may be in the ___ or ___ as a result of ______

▪ Normal RV: ____

▪ Enlarge RV: ____

Answer 35

Xiphoid or Epigastric Area

Right Ventricular Hypertrophy

4th ICS

xiphoid process or epigastric area

Question 36

▪ Cor Pulmonale is the term used if the etiology is _____ caused.

Answer 36

pulmonary

Question 37

❖ TYPE OF POLYCYTHEMIA VERA

▪ The cause is unknown.

▪ The bone marrow keeps on producing RBCS resulting to increased BP and blood viscosity.

Answer 37

→ Primary Polycythemia Vera

Question 38

❖ TYPE OF POLYCYTHEMIA VERA

▪ The bone marrow is producing RBCs to compensate.

Answer 38

→ Secondary Polycythemia Vera

Question 39

❖ TYPE OF POLYCYTHEMIA VERA

→ Secondary Polycythemia Vera

Examples

Answer 39

✓ A patient with COPD has a chronic obstruction of airways, therefore, less blood is being circulated. The body will compensate by stimulating the bone marrow to produce more RBCs.

✓ A person living in Baguio has rosy cheeks because there is less oxygen in higher places, so the body compensates by stimulating the bone marrow to produce more RBCs

Question 40

❖ WHY DOES A PATIENT WITH COPD RECEIVES LESS OXYGEN?

Answer 40

The central chemoreceptors found in the medulla oblongata is stimulated due to the presence of CO2 causing inhalation and exhalation. However, patients with COPD, the alveoli are completely dilated, there will be accumulation of CO2 in the lungs, and these can narcotize the medulla oblongata which makes it not responsive or sensitive to CO2.

Therefore, the body will compensate in which Peripheral chemoreceptors (found at carotid and aortic bodies) will take over. These chemoreceptors are only stimulated when there is low oxygen, and this is called Hypoxic Drive. That is why a patient with COPD despite the difficulty of breathing receives lesser than 2L/min of oxygen via venturi mask.

Question 41

❖ TYPE OF POLYCYTHEMIA VERA

→ Secondary Polycythemia Vera

EXPLAIN

Answer 41

– chronic hypoxemia – body will compensate – stimulate bone marrow to release RBC – plenty of RBC (primary polycythemia vera) – secondary – response on the abnormality of the body – chronic hypoxia – increase RBC – increase viscosity – RV have a hard time pushing high viscosity blood because it requires more effort – Cor pulmonale – COPD

Question 42

❖ MEDICAL MANAGEMENT

→ If hypercapnic, administer oxygen via nasal cannula at ____ to ___ lpm.
▪ best to target oxygen sat at ___ to ___

HYPERCAPNIC - when you have too much carbon dioxide (CO2) in your blood

Answer 42

0.5-1.5

90% to 92%

Question 43

❖ MEDICAL MANAGEMENT

→ Ipratropium Bromide and Salbutamol (Combivent or Duavent)

Answer 43

▪ It is a potent bronchodilator, a combination of these drugs produces a greater bronchodilator effect than when either
drug is used alone.

Question 43

❖ MEDICAL MANAGEMENT

㾎 Tiotropium Bromide – Spiriva (18mcg – a long acting inhaled anticholinergic agent)

Answer 43

o Given once a day
o Given with hand inhaler device.

Question 44

❖ MEDICAL MANAGEMENT

o Acetylcysteine – Fluimucil (Melt In a glass of water) 200 mg sachet BID - TID

o Erdosteine - Ectrin 300 mg cap (1 cap BID-TID)

Answer 44

㾎 For Thick and voluminous mucous secretion

Question 45

❖ MEDICAL MANAGEMENT

㾎 Oxygen Therapy

o Keep PaO2 below 60 mmhg and PaCO2 at a level to maintain pH

o Venturi mask is used for it to be précised. (Explain)

Answer 45

Venturi Mask

▪ Humidification usually isn’t needed because the mask entrains a much greater flow of room air.

▪ The mixture of gas delivered to the patient approaches room air humidity.

Question 46

❖ MEDICAL MANAGEMENT

____ and ____ therapy have been shown to prolong life.

Answer 46

Smoking cessation and home oxygen

Question 47

❖ MEDICAL MANAGEMENT

→ Antibiotics are indicated when the patient is having COPD symptoms with signs of infection such as:

Answer 47

▪ increased dyspnea, sputum volume, &
sputum purulence

Question 48

→ Improves airway clearance by removing bronchial secretions, improve ventilation, and increase the efficiency of the respiratory muscles.

Answer 48

❖ CHEST PHYSIOTHERAPY (CPT)

Question 49

▪ It allows the force of gravity to assist in the removal of bronchial secretions

Answer 49

→ Postural Drainage

Question 50

In Postural Drainage, the secretions drain from the affected bronchioles into the bronchi and trachea and are removed by ___ or ____

▪ Each position contributes to effective drainage of a different lobe of the lungs;

___ and ___ lobe bronchi drain more effectively when the head is _____,

whereas the ____ lobe bronchi drain more effectively when the head is ____.

Answer 50

coughing or suctioning.

lower and middle - down

upper - up

Question 51

In Postural Drainage,

▪ _____ before and after the procedure to identify the areas that need drainage.

▪ Advise to perform this procedure ____ meals to prevent ___, ___, and ____.

▪ Take prescribed __________ before postural drainage to ___ the bronchioles, _____ bronchospasm, and ____ the thickness of mucus.

Answer 51

Auscultate

before

nausea, vomiting, and aspiration

bronchodilators, water, or saline

dilate - reduce - decrease

Question 52

EXPLAIN

→ Postural Drainage

Answer 52

▪ It allows the force of gravity to assist in the removal of bronchial secretions.

▪ The secretions drain from the affected bronchioles into the bronchi and trachea and are removed by coughing or suctioning.

▪ Each position contributes to effective drainage of a different lobe of the lungs; lower and middle lobe bronchi drain more effectively when the head is down, whereas the upper lobe bronchi drain more effectively when the head is up

▪ Auscultate before and after the procedure to identify the areas that need drainage.

▪ Advise to perform this procedure before meals to prevent nausea, vomiting, and aspiration.

▪ Take prescribed bronchodilators, water, or saline before postural drainage to dilate the bronchioles, reduce bronchospasm, and decrease the thickness of mucus.

Question 53

❖ NURSING MANAGEMENT

→ Ineffective Airway Clearance

Answer 53

▪ Chest Physiotherapy and Postural Drainage
✓ To loosen secretions and helps move secretions into central airways.

▪ Encourage Fluid Intake of at least 2L to 2.5L daily because adequate fluid intake helps keep the mucous secretions thin.

▪ Place patient in a high fowler’s or orthopneic position to promote lung expansion.

▪ Turn patient every 2 hours to help mobilize the mucus.

▪ Encourage coughing and deep breathing at least every 2 hours while awake to promote lung expansion and mobilization of mucus; and advise the patient to do this in a seated upright position while leaning forward to increase the effectiveness of coughing

Question 54

❖ NURSING MANAGEMENT

→ Ineffective Breathing Pattern

Answer 54

▪ Advise patient to do pursed-lip breathing because it delays small-airway collapse, thereby reducing air trapping that occurs with forced expiration.
▪ Pursed-lip breathing involves prolonging the exhalation because it helps remove trapped CO2 from the lungs.

Question 55

❖ NURSING MANAGEMENT

→ Energy Conservation Techniques

Answer 55

▪ Plan and pace daily activities, rest periods are paced between activities.

▪ Use assistive devices such as grabber or reacher, long shoehorn.

▪ Avoid working with the arms raised.

▪ Avoid breath-holding while performing any activity.

▪ Wear slip-on shoes and use long shoehorn to reduce the labor.

▪ While showering, sit on a stool instead of standing.

▪ Work at waist level when possible, avoiding extended reaches from the floor or above the shoulder.

Question 56

❖ NURSING MANAGEMENT

→ Imbalanced Nutrition: less than body requirements

Answer 56

▪ A diet high in proteins and fats without excess carbohydrates to minimize carbon dioxide production during metabolism.

▪ Glucerna or Ensure – high in proteins
✓ given to postop patients or aged due to lack of appetite
✓ Ensure (low protein, more glucose)
✓ Glucerna (high protein, low glucose)

Question 57

❖ NURSING MANAGEMENT

→ Risk reduction: Preventing further lung injury

Answer 57

▪ Smoking Cessation

▪ Avoid lung irritants, such as secondhand smoke and fumes from cars.

▪ Wear mask

▪ Avoid people who are sick

▪ Hand Hygiene

▪ Annual flu vaccination and pneumonia vaccination

Question 58

❖ NURSING MANAGEMENT

→ Dyspnea is the most common problem related to eating.

Answer 58

▪ Rest before meals.

▪ 4 to 6 small meals a day to prevent the stomach from pushing up the diaphragm.

▪ Use bronchodilator 30 minutes before a meal to reduce dyspnea due to bronchospasm.

▪ Give foods that are easy to chew and not gas forming.
✓ Avoid dry foods because it can stimulate coughing.
✓ Avoid milk and chocolate because it can thicken the mucus.
✓ Avoid caffeinated beverages because these act as a mild diuretic and can result to dehydration making the mucus thick.

▪ Place seated or in high fowler’s position for meals.

▪ Eat meals when energy levels are at their highest (usually MORNING).

▪ Eat slowly and avoid swallowing air.

▪ Limit salt intake as this can cause fluid retention, making breathing more difficult.

▪ Avoid fluids prior to meals to avoid bloating.

▪ Drink fluids at the end of the meal.

▪ Wear a nasal cannula while eating to optimize oxygen intake, required for food metabolism.