Chronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease
Cydney Fong
California State University, Chico
Nursing 307P: Nursing Portfolio I
Jennifer Lillibridge, RN, PhD
June 20, 2011
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Chronic Obstructive Pulmonary Disease
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Pathophysiology & Related Nursing Care
Have 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
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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
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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 selfmanagement, 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).
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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 Care
Zakrisson & 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,
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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
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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.
Chronic Obstructive Pulmonary Disease
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 Care
To 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).
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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.
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References
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