Nursing Care Plan for COPD

COPD Pathophysiology

Chronic obstructive pulmonary disease (COPD), refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis. It’s associated with structural lung changes due to chronic inflammation from prolonged exposure to noxious particles or gases, most commonly cigarette smoke. 

Chronic inflammation causes airway narrowing and decreased lung recoil. The inflammatory response and obstruction of the airways cause a decrease in the forced expiratory volume, and tissue destruction leads to airflow limitation and impaired gas exchange. 

Hyperinflation of the lungs is often seen in imaging studies and occurs due to air trapping from airway collapse during exhalation. The inability to exhale fully also causes elevations in carbon dioxide (CO2) levels. COPD often gets worse over time if it’s untreated. 

Emphysema is a condition involving damage to the walls of the air sacs (alveoli) of the lung. When emphysema develops, the alveoli cannot support the bronchial tubes. As a result, the tubes collapse and cause an obstruction, which traps air inside the lungs. 

Too much air trapped in the lungs can give some clients a barrel-chested appearance. Also, because there are fewer alveoli, less oxygen can move into the bloodstream. Lung elasticity and the loss of surfactant decrease the ability of the lung tissue to recoil and results in air trapping.

Chronic bronchitis is thought to be caused by overproduction and hypersecretion of mucus by goblet cells. Epithelial cells lining the airway respond to toxic, infectious stimuli by releasing inflammatory mediators. As a result, this leads to airflow impediment because of obstruction to small airways. 

The airways become clogged by debris, and this further increases the irritation. The characteristic cough of bronchitis is caused by the abundant secretion of mucus in chronic bronchitis.

COPD Memory tricks:

• Think “Chronic Obstruction from Chronic Destruction,” resulting in decreased gas exchange and leading to the double Cs:
  • C – Chronic air trapping results in reduced gas exchange, from inflammatory
  •  damage to the lungs!
  • C – CO2 High. Clients can’t blow off enough CO2 due to the inability to fully exhale.

Causes & Risk Factors

• Air pollution
• Smoking
• Exposure to chemicals, dusts, or fumes (such as asbestos and lead)
• Secondhand tobacco smoke
• Family history 

Subjective (Client May Report)

• Shortness of breath
• Coughing up phlegm (mucus)
• Chest tightness (that worsens with activity and improves with rest)
• Wheezing
• Sore throat (that does not go away)

Lab Values

• Below 80 (Normal 80 – 100)
• Low PaO2 32 = Hypoxemia
• High PaCO2 = HyperCapnic
• pH less than 7.35 = Acidosis
• PaCO2 – Over 45 = Acidosis

COPD Symptoms

• Coughing 
• Chest tightness
• Wheezing or whistling sound when clients breathe out
• Coughing up phlegm 
• Shortness of breath
• Frequent chest and lung infections
• Night sweats and/or fever
• Inflammation of the bronchi & excessive mucus production
• Clubbing fingers (round fingernail beds from long-term chronic hypoxia)

Key sign: Low O2 saturation for COPD clients is expected. NORMAL = 88-93%

COPD Nursing Diagnosis

To diagnose COPD, a thorough history and physical will need to be completed. The history will include questions about current and past symptoms and environmental factors that could cause the disease. You’ll also ask about any family history of respiratory diseases, smoking history, and other risk factors that may contribute to the onset of COPD.

Assessment is key in trying to confirm the diagnosis of COPD. First, a physical exam will need to be performed, including auscultating the lungs, observing breathing patterns, and obtaining vital signs, including pulse oximetry. Then, the health care provider (HCP) may order multiple diagnostic tests such as x-rays, sputum samples, CT, arterial blood gas (ABGs), or use a scope to visualize the lungs.

Assessment 

• Vital signs to include pulse oximetry
• Respiratory rate, rhythm, and pattern
• Lung sounds
• Capillary refill
• Skin and mucous membrane inspection
• Rib cage expansion

Nursing Interventions for COPD

There are many ways nursing interventions can help COPD clients deal with their condition and live as full a life as possible. The first step is to differentiate which type of COPD the client is experiencing.

Chronic bronchitis: This is characterized by inflammation in the mucous membrane of the airways and chronic cough that produces mucus. It may also involve sputum production and wheezing. Acute bronchitis consists of an infection in the airway lining, which may last up to three weeks before resolving on its own.

Emphysema: Emphysema occurs when there is permanent damage to alveoli (air sacs), causing them to lose elasticity and shrink over time from lack of oxygen exchange between alveoli and blood.

Cardiac Function

• Cardiac output 
• Myocardial contractility 
• Heart rate 

Respiratory function

• Decreased oxygenation and cardiac output
• Oxidative stress
• Lung inflammation

Neurologic and Sensory Functions

• Impaired cognition, smell, hearing, and taste

Visual Appearance & Labs

• Cyanosis (blue lips or skin)
• Excessive wheezing
• Paradoxical breathing
• Lung function
• Pulmonary function tests (PFTs)
• Spirometry

Nursing Actions for COPD

While there’s no cure for COPD, there are many things you can do to help manage your client’s symptoms. Here are some of the most effective nursing actions for COPD:

Perform

• A history and physical exam to assess the client’s respiratory status
• Respiratory management

Provide

• Instructions on how to use supplemental oxygen at home
• Oxygen therapy

Avoid

• Using oxygen masks on clients with COPD if they are not having difficulty breathing
• Administering aspirin, ibuprofen, or other non-steroidal anti-inflammatory drugs (NSAIDs).

Administer

• Oxygen, if needed
• Fluid management

Monitor

• Oxygen saturation levels
• Breathing patterns
• Pulse rate
• Chest sounds
• Respiratory rate (and depth)
• Lung function

Encourage

• The use of supplemental oxygen 
• Avoiding alcohol and tobacco use
• Proper use of supplemental oxygen equipment

Goals and Outcomes

• Maintain a normal respiratory rate and depth
• Take medications as prescribed
• Maintain a normal oxygen saturation level
• Get enough sleep
• Ability to maintain activities of daily living (ADLs)
• Maintain normal pulmonary function as measured by spirometry

Questions About COPD

Here are some COPD questions that might show up on the NCLEX:

1. The nurse has identified four nursing diagnoses for the client diagnosed with chronic obstructive pulmonary disease (COPD) and will prioritize interventions for which diagnosis first when planning the daily care?

Choose one of the four:

A. Provide ambulating assistance as an intervention for activity intolerance related to fatigue and dyspnea.

B. Allow the client to verbalize feelings as an intervention for anxiety related to dyspnea and life changes.

C. Monitor oxygen saturation as an intervention for ineffective breathing patterns related to airway obstruction.

D. Assist the client into a tripod position as an intervention for impaired gas exchange related to ventilatory muscle fatigue.

Answer: D. Assisting the client into a tripod position as an intervention for impaired gas exchange related to ventilatory muscle fatigue is the priority intervention the nurse will implement. Moving the client into the tripod position will immediately improve the breathing problems that the client is experiencing because of impaired gas exchange. This is the priority intervention based on ABCs for this client.

2. A client who is diagnosed with chronic obstructive pulmonary disease (COPD) is newly prescribed the use of a beclomethasone inhaler. The client has a history of oral candidiasis that negatively impacts oral intake. Which intervention should the nurse implement to decrease the risk for recurrence based on the newly prescribed medication?

Choose one of the four:

A. Request a prescription for oral lidocaine from the client’s practitioner.

B. Instruct the client to rinse the mouth and spit after each dose.

C. Encourage the client to brush their teeth twice daily.

D. Perform a nutritional assessment for the client.

Answer: B. Beclomethasone is a glucocorticoid inhaler used to treat and prevent COPD exacerbations. The client should be taught to rinse and spit after using this inhaler to help prevent oropharyngeal candidiasis.

Sources

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463976/

https://www.lung.org/lung-health-diseases/lung-disease-lookup/COPD/what-causes-COPD

https://www.cdc.gov/copd/about/index.html