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Chronic Obstructive Pulmonary Disease Cydney FongCalifornia State University, Chico Nursing 307P: Nursing Portfolio IJennifer Lillibridge, RN, PhDJune 20, 2011Pathophysiology & Related Nursing CareHave you ever tried to breathe through a straw? Try it. It is rather hard, and yet people who suffer from chronic obstructive pulmonary disease feel like they are breathing out of a straw every day. As time goes on their overall health usually deteriorates further. COPD, which encompasses chronic bronchitis and emphysema, is the 4th leading cause of mortality in the United States with approximately 16 million people affected and an annual expenditure of $32.1 billion annually according to (Smeltzer, Bare, Hinkle, & Cheever, 2008). The airway obstruction is caused by a hyperactive inflammatory response to irritants. The most common irritant is tobacco smoke, which accounts for about 80-90% of COPD cases, with a history of smoking at least 20 pack years (Barnett, 2007 & Smeltzer et al., 2008). Occupational exposures such as coalmine, silica dusts, and metal fumes also contribute to this suffocating disease process (Greener, 2011). This progressive and irreversible disease occurs all throughout the victim’s airways, parenchyma, and pulmonary vasculature. The airway becomes increasingly narrow over time and with repeated abuse or exposure. Patients often don’t become symptomatic until the middle adult years. The narrowing of the lumen is caused by inflammation from the irritant, scar tissue formation from the bodies attempt to heal itself, an increase in the number of mucus glands, and an excess of mucus production (Smeltzer et al., 2008). Looking more specifically at chronic bronchitis, it is defined as a chronic cough and sputum production and must be present for at least 3 months in each of two consecutive years. Smoke and other environmental irritants cause an increase production of secretions and inflammation. Continuous exposure to the irritants further increases the production of mucoid sputum, ciliary function is diminished, which causes extra mucus production. The additional secretions heighten the possibility of the airways to become plugged. Bronchial walls become thickened, narrowing the small airways even more. This causes airway resistance and fibrosis. These patients are more susceptible to respiratory infection because their macrophages are constantly working, cleaning up the damage (Smeltzer et al., 2008). Additional signs and symptoms these patients may experience are dyspnea, wheezing, fatigue, and hypoxemia (Higginson, 2010).The other type of COPD is emphysema which is a result of impaired gas exchange caused by destruction of the walls of permanent over distended alveoli. Patients have a difficult time completely exhaling leading to air trapping and thus hyperinflation (Fairclough & Burns, 2009). Recurrent infections continually destroy the alveoli and cause an increase in dead space over time. In earlier stages, patients have a difficult time oxygenating which leads to hypoxemia. In later stages, patients have a difficult time eliminating carbon dioxide which leads to hypercapnia and respiratory acidosis (Smeltzer et al., 2008). Naturally dyspnea is also seen with these individuals. Barrel chest from their hyper-inflated lungs, tachypnea, pursed lip breathing, and a tripod stance are other signs and symptoms noted which may help contribute to an improvement of their oxygenation status (Higginson, 2010).An inherited deficiency of alpha-1 antitrypsin affects 1-2% of emphysema cases. This enzyme inhibitor protects the lung parenchyma from injury. Genetically susceptible people are sensitive to environmental factors, even if they do not smoke. Screening for the lack of this enzyme is usually done on patients younger than 45 years and who also have a prominent family history of COPD (Higginson, 2010, Smeltzer et al., 2008).A complication of emphysema is right sided heart failure. This occurs because there is resistance to pulmonary blood flow. The right ventricle maintains a higher blood pressure to overcome this resistance. Signs and symptoms that right sided heart failure is developing are congestion, dependent edema, and distended neck veins (Higginson, 2010 & Smeltzer et al., 2008).Whether patients are diagnosed with chronic bronchitis or emphysema, they both are a form of COPD. COPD is classified into five stages depending on the severity of the symptoms that the patients have. A patient’s stage of COPD is based on different characteristics such as normal spirometry, cough and sputum production, forced expiratory volume (FEV), and if they are presenting with chronic symptoms. Stage zero puts patients at an “at risk” stage. Stage one marks patients as having mild COPD. Moderate COPD is marked at being in stage two. Severe COPD cases are at stage three of the disease process. Stage four covers the very severe patients. Determining factors of survival for patients with COPD include history of cigarette smoking, passive smoking exposure, age, rate of decline of FEV, hypoxemia, pulmonary artery pressure, resting heart rate, weight loss, and reversibility of airflow obstruction (Smeltzer et al., 2008).The most important nursing role for these patients is education. Zakrisson & Hagglund, (2009) define patient education as “a planned process of activities designed to enable people to improve knowledge, to acquire skills and to facilitate voluntary adaptation of behaviors in order to restore, maintain and improve health”. According to Wilson, Ross, Goodridge, Davis, Landerville, Roebuck, (2008) patients strive for “self-reliance, and independence through adaptation, stable health with maintenance, and living with constraints.” Fraser, Page, & Skingley, (2011) makes a good point that “information is the key to self-management, which in turn is an essential component of disease management.” As nurses, we can provide patient education on the anatomy and physiology of COPD, medications, oxygen, nutrition, respiratory therapy treatment, smoking cessation, coping strategies, communicating effectively with the health care team, and planning for the future (Smeltzer et al., 2008).Nurses must also provide a thorough assessment to determine the patient’s needs. “Smoking cessation is the only intervention proven to slow the accelerated decline in lung function and the progression of COPD” (Smeltzer et al., 2008). A few examples of patient needs are improvement of gas exchange, achieving good airway clearance, improving breathing patterns, improving activity tolerance, and enhancing self-care strategies. Other important aspects of nursing include helping to enhance individual coping strategies, monitoring and managing potential complications, and promoting home and community-based care (Smeltzer et al., 2008).Scientific Principles of Nursing Interventions: Health Maintenance & Preventative CareZakrisson & Hagglund, (2009) make a good point that “in order for nurses to provide good education they need the support of management and colleagues as well as increased knowledge on promoting the learning of others in lifestyle changes, to be more secure in their patient education”. The first step in determining a particular patient’s interventions is to obtain an assessment to provide a clear history of the disease process (Smeltzer et al., 2008).Once the nurse has completed the assessment a nursing diagnosis can be established, which will help him/her to know what they need to focus on for a patient’s intervention. The most important teaching materials a nurse can provide is smoking cessation strategies and counseling. As stated earlier, that it is the only intervention proven to slow the decline in lung function (Smeltzer et al., 2008). Gas exchange is monitored by the nurse and pharmacological therapy is administered if the patient’s symptoms are not relieved with rest. Bronchodilators relieve bronchospasms and increase oxygenation throughout the lungs and improve alveolar ventilation. Corticosteroids are used more for patients in stage III and IV and those who experience repeated exacerbations. These have been shown to improve symptoms, but not necessarily slow the decline in lung function. Long term oxygen therapy (15+ hours per day) is used for patients with a PaO2 of 55 mm Hg. The use of oxygen greatly improves quality of life and decreases episodes of dyspnea. It is important that these patients receive their annual influenza vaccination and pneumococcal vaccination every five years because of their increased susceptibility of respiratory infections due not only to their chronic illness but also their age (Smeltzer et al., 2008).To achieve airway clearance, sputum must be cleared from the airways and irritants must be eliminated or minimized from the patient’s environment. Controlled coughing is instructed as it is more effective in clearing the airway and reduces fatigue. Slow, maximal inspiration followed by breath-holding for several seconds and then two or three coughs is an adequate teaching approach. The most fundamental exercise nurses can teach their COPD patients is improving their breathing patterns to diaphragmatic breathing. This type of breathing will reduce the respiratory rate, increase alveolar ventilation, and help expel as much air as possible during expiration. Pursed lip breathing is another technique that can be taught, which helps slow expiration, prevents collapse of small airways, and controls the rate and depth of respirations. Through these breathing exercises patients are able to relax more as they gain control of their dyspnea (Smeltzer et al., 2008).Many patients with COPD have a difficult time in the morning because secretions have had a chance to accumulate throughout the night while lying down. Nurses teach their clients how to pace their activities, use supportive devices, and strategies to promote as much independence as possible for activities of daily living. It is also important for nurses to help the patients set realistic goals. The main goal for all patients, no matter what stage they are in, is to preserve current pulmonary function and relieve symptoms as much as possible (Smeltzer et al., 2008).These patients need to be taught to avoid temperature extremes, air pollutants, humidity, and high altitudes as these can promote bronchospasms or aggravate their hypoxemia further. Nurses must also teach patients that emotional disturbances and stress may trigger a coughing episode and exacerbate their symptoms. Avoiding these circumstances as much as possible is encouraged. Patients and their family members need to be make an effort to be aware of the necessary medications and to look for early signs and symptoms of infection or other complications. Along with physical symptoms, patients may also experience psychological symptoms. It is important for nurses to identify depression, altered mood or functional status, and social isolation and to promote interventions for the patients (Smeltzer et al., 2008).Physiological, Psychological, & Cultural/ Spiritual Factors That Influence Health Status Many people see COPD as “self-inflicted and irreversible” (Fraser et al., 2011). Fraser et al., (2011), a woman diagnosed with COPD at age fifty-four is promoting that “those with COPD need encouragement and help to be their own advocates”. She herself saw COPD as a disease where “patients were told to go home and rest… it progressively deprives you of oxygen” (Fraser et al., 2011). Fraser et al., (2011), has made it her purpose in life to not let COPD define her but to continue living life to its fullest. She developed an arts/activist project which promotes exercise for COPD self-management called ‘Drawing Breath’. Her first project was to cycle around the Kent coast from the town of Whistable to Hastings in Britain, which is about forty-one miles. This ride took her a month to complete where Fraser would ride between three to fifteen miles a day depending on the terrain. It was an exhausting and yet the most invigorating ride of her life. She says that ‘Can do’ works better than ‘Can’t’ and “it just takes adjustment, and the willingness of health practitioners to support and encourage the whole person in their care, enabling them to identify and build on their strengths” (Fraser et al., 2011).Teaching, Decision Making Theories, Using Critical Thinking Pertaining to CareTo best understand the needs of patients living with COPD what better way than to ask patients directly? Research shows that hypoxia, lack of energy, and anorexia are all typical objective signs that health care professionals can determine in patients living with COPD. More serious symptoms to the patient are subjective findings like anxiety, panic, and depression associated with breathlessness and oxygen dependence. These findings also coincide with their limited mobility and eventually becoming housebound. The signs and symptoms that worry health care professionals differ greatly from what actual patients with COPD consider to be important. As stated earlier, self- reliance and independence through adaptation, stable health with maintenance, and living with constraints are the most important things for patients with COPD (Wilson et al., 2008).These “participants were living their lives in as normal a manner as possible, through continuing hobbies declares” Wilson et al., (2008). All of the clients adapted their ways out of necessity from the reliance on oxygen and increased incidents of breathlessness. They were all active participants in maintaining their stable health. These clients did this through regular checkups, seeking prompt medical attention for impending respiratory crisis, and avoiding situations that would risk their breathing status such as crowds, dust, and contact with people who were experiencing colds or influenza. Some even participated in regular exercise and wellness programs (Wilson et al., 2008).The most adaptation these clients required was around their constraints of having an oxygen tank a majority if not all of the time. Any activity outside of the house had to be structured around how much oxygen they had available, the size of their tank, and appropriate transportation to desired facilities. Wilson et al., (2008) points out that “fears of running out of oxygen or of oxygen equipment malfunctioning were never far from their minds”. Many tried to keep active in their home where they felt most safe, either on treadmills or stationary bicycles. As health care professions, it is vital to provide patients the empowerment of education. Education can help increase a patient’s outcome because they can better understand why they are experiencing certain symptoms and learn how to manage them. This will allow them to gain more control of their life. It is even more crucial that nurses listen to what their patient’s needs. Through effective communication patients will also feel more at ease with their care providers and therefore a greater willingness to learn. ReferencesBarnett, M. (2007). Using a model in the assessment and management of COPD. Journal of Community Nursing, 21(11), 4-10. Retrieved June 15, 2010, from nursing resources database. Fairclough, P. & Burns, D. (2009). COPD exacerbations: assessment & management. Practice Nursing, 37(3). Retrieved June 20, 2011, from CINAHL Plus. Fraser J., Page S., Skingley A. (2011). Drawing breath: promoting meaning & self management in COPD. British Journal of Community Nursing, 16(2), 58-64. Retrieved June 20, 2011, from CINAHL Plus.Greener, M. (2011). Easing the burden of COPD: NICE guidelines and new agents. Nurse Prescribing, 9(2), 64-67. Retrieved on June 15, 2011, from nursing resources database.Higginson, R. (2010). COPD: pathophysiology and treatment. Nurse Prescribing, 8(3), 102-110. Retrieved June 20, 2011, from CINAHL Plus.Ng, B.H.P., Tsang H.W.H., Jones A.Y.M., So C.T., & Mok T.Y.W. (2011) Functional and psychosocial effects of health qigong in patients with COPD: a randomized controlled trial. The Journal of Alternative Medicine & Complementary Medicine, 17(3), 243-251. Retrieved June 20, 2011, from CINAHL Plus. Scullion, J. & Holmes, S. (2011). Strategies to reduce COPD exacerbations. Practice Nursing, 22(2), 83-86. Retrieved June 20, 2011, from CINAHL Plus.Smeltzer, S.C., Bare B.G., Hinkle, J.L, & Cheever, K.H. (2008). Brunner and Suddarth’s textbook of medical surgical nursing. (11th Ed.) Philadelphia: J.B. Lippincott.Wilson, D. M., Ross, C., Goodridge, D., Davis, P., Landerville, A., & Roebuck, K. (2008). The care needs of community-dwelling seniors suffering from advanced chronic obstructive pulmonary disease. Canadian Journal on Aging, 27(4), 347-357. Retrieved on June 20, 2011, from CINAHL Plus.Zakrisson, A., & Hagglund D. (2009). The asthma/COPD nurses’ experience of educating patients with chronic obstructive pulmonary disease in primary health care. Caring Sciences, 24, 147-155. Retrieved June 20, 2011, from CINAHL Plus. ................
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