Chronic obstructive pulmonary disease (COPD) is an umbrella term that also includes chronic bronchitis and emphysema. COPD causes the airways of the lungs to narrow due to inflammation, mucus, or other damage. This affects the ability to breathe normally and often results in shortness of breath, especially on exertion.
COPD is a progressive disease that is treatable and controllable but cannot be cured. Exacerbations or flare-ups cause the most harm, as this is when there is an increase in symptoms that require prompt treatment and often inpatient care.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Knowledge
- Impaired Gas Exchange
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
Nursing Process
COPD is a common condition nurses will frequently encounter. It is often complicated by other comorbidities such as asthma, pneumonia, and heart failure. Nurses will most likely care for patients when they are experiencing an exacerbation and must be vigilant in monitoring their respiratory status and administering oxygen and medications.
Nurses can use these opportunities to educate patients on the importance of quitting smoking, increasing their exercise tolerance, and instructing them on medication adherence to prevent future exacerbations.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to COPD.
Review of Health History
1. Assess the patient’s general symptoms.
Clinical manifestations of COPD include the following:
- Persistent coughing
- Wheezing
- Overproduction of secretions or sputum
- Dyspnea
- Chest tightness
- Frequent respiratory infections
- Unintentional weight loss
2. Review the patient’s present medical history.
Determine the presence of other lung diseases such as chronic bronchitis, emphysema, or asthma.
3. Determine the patient’s smoking history or exposure to pollution.
COPD often occurs from cigarette smoking, though COPD can occur in people who have never smoked. Secondhand smoking increases the risk of respiratory infections. Air pollution exposure may play a factor in COPD if complicated by other comorbidities.
4. Identify the patient’s family history.
Genetics may play a role in COPD. The rare genetic condition alpha-1-antitrypsin (AAT) deficiency accounts for less than 1% of COPD cases.
5. Review the past medical history.
The following conditions may contribute to the development of COPD:
- HIV
- Vasculitis syndrome
- Connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome)
Physical Assessment
1. Perform a physical examination.
- Respiratory: use of accessory respiratory muscles, prolonged expiration, pursed-lip breathing, barrel chest, wheezing, dyspnea on exertion, productive cough
- Integumentary: cyanosis, hypoxia, digital clubbing
- Musculoskeletal: muscle wasting, lower extremity edema for patients with right heart failure
2. Monitor the patient’s oxygen saturation.
Oxygen saturation is crucial in assessing COPD severity. A target oxygen saturation range of 88% to 92% will generally protect COPD patients from the dangers of hypoxia and hypercapnia.
3. Auscultate lung sounds.
COPD can result in the following lung sound findings:
- Wheezes
- Coarse crackles
- Rhonchi
- Pleural friction rub
- Decreased lung sounds
4. Perform a thoracic examination.
Patients with COPD commonly present with a “barrel chest” appearance due to lung hyperinflation. On percussion, hyperresonance is noted.
5. Use a COPD assessment tool.
- mMRC questionnaire: assesses the degree of breathlessness utilizing a scale of 0-4 (with 4 being the most severe).
- COPD Assessment Test (CAT): measures the impact of the disease on the patient’s functional status using eight parameters.
6. Assess the cardiovascular status.
Due to prolonged hypoxemia and vascular remodeling, secondary pulmonary hypertension affects many patients with chronic COPD. Cor pulmonale (right-sided heart failure) may arise from this.
Diagnostic Procedures
1. Perform spirometry testing.
Diagnosing, staging, and monitoring COPD using pulmonary function testing (PFT) is crucial.
2. Monitor ABGs.
Arterial blood gas (ABG) monitoring assesses the severity of acute exacerbations. Patients may display hypoxemia with or without hypercapnia.
3. Obtain a sputum culture.
Patients who present with acute exacerbations with a productive cough should have their sputum cultured for the presence of pathogens.
4. Assist the patient in a 6-minute walk test.
On a flat, straight surface indoors, the test evaluates the patient’s walking distance over six minutes in a 100-foot-long hallway. Patients with COPD who desaturate during the test have a higher mortality rate.
5. Obtain a sample for blood testing.
A complete blood count is needed for laboratory testing to check for infections, anemia, and polycythemia. Electrolytes are also monitored as medications used to treat COPD can cause hypokalemia, hypocalcemia, and hypomagnesemia. Alpha-1-antitrypsin levels can be tested as a possible diagnosis of COPD.
6. Prepare the patient for imaging scans.
Chest radiography (X-ray) and computed tomography (CT) scans are the imaging tests performed to diagnose COPD, evaluate disease progression, and assess for underlying complications like pulmonary hypertension.
7. Prepare the patient for cardiovascular tests.
COPD commonly coexists with cardiac diseases. Patients may undergo the following tests:
- Two-dimensional echocardiography: screens by measuring systolic pressure in the lungs and heart.
- Electrocardiography: determines that the underlying cause of dyspnea is not cardiac and that hypoxia is not caused by cardiac ischemia.
- Right-sided heart catheterization: used to assess pulmonary artery pressures directly to confirm pulmonary hypertension and gauge the response to vasodilators.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with COPD.
Improve Patient’s Quality of Life
1. Enroll the patient in a disease management program.
Research shows that a disease management program that includes education, self-treatment for exacerbations, and follow-up with a case manager is associated with fewer ER visits and hospitalizations.
2. Refer to a dietician.
Poor nutrition and weight loss complicate COPD and impair the patient’s respiratory status, lower their exercise capacity, and increase the rate of mortality.
3. Encourage smoking cessation.
Quitting smoking is crucial for optimal lung function and in reducing the risk of mortality. Assist the patient in setting a quit date, locating support programs, and utilizing nicotine-replacement therapy.
4. Manage infections.
In patients with an acute exacerbation, empiric antibiotic therapy is advised when there is evidence of an infectious process.
5. Administer oxygen as prescribed.
Oxygen supplementation lowers mortality rates in patients with advanced COPD. Most stable patients receive continuous low-flow oxygen via nasal cannula. NIPPV (noninvasive positive pressure ventilation) is advised for patients experiencing hypercapnic respiratory failure.
6. Prepare the patient for a lung transplant.
The mean survival after lung transplantation is five years. The main purpose is to improve symptoms and quality of life.
7. Refer the patient to pulmonary rehabilitation.
Pulmonary rehabilitation improves the quality of life by lessening airflow limitation, preventing and treating complications, and alleviating symptoms.
Pulmonary rehabilitation requires a team approach including physicians, nurses, dieticians, respiratory therapists, pharmacists, and occupational and physical therapists. It includes:
- Patient and family education
- Smoking cessation
- Medical management
- Respiratory and chest physiotherapy
- Physical therapy
- Bronchopulmonary hygiene, exercise, and vocational rehabilitation
- Psychosocial support
8. Prepare for end-of-life care.
COPD is a chronic and progressive disease. Hospice and palliative care are vital services to improve the quality of life through symptom management.
Prevent Infections and Exacerbations
1. Advise the patient to get vaccinated.
All patients with COPD should receive a pneumococcal vaccine and annual influenza shot. Recommend the following to patients 65 years and older (with at least one year apart):
- 13-valent pneumococcal conjugate vaccination (PCV13)
- 23-valent pneumococcal polysaccharide vaccine (PPSV23)
PPSV23 is recommended for patients 64 years of age or younger with significant comorbidities such as the following:
- Diabetes mellitus
- Chronic heart disease
- Chronic lung disease
2. Administer medications as ordered.
Common medications for COPD include the following:
- Bronchodilators: relax the airway’s smooth muscle to provide immediate relief.
- Anticholinergics: aid in bronchodilation.
- Xanthine derivatives: relax the smooth muscles of the bronchi and pulmonary blood vessels.
- Inhaled corticosteroids (ICS): decrease inflammation.
- Phosphodiesterase-4 (PDE4) inhibitors: reduce exacerbations.
- Antibiotics: treat lower airway infections.
3. Instruct on breathing techniques.
The nurse or respiratory therapist can instruct the patient on diaphragmatic or pursed lip breathing to improve ventilation and prevent airway compression.
4. Clear the airways.
Mucolytic medications reduce the viscosity of sputum and enhance secretion clearance. Clear the airway by teaching the patient huff coughing or suction through a machine.
5. Educate the patient about when to seek medical attention.
Educate the patient on symptoms of an acute exacerbation that may require inpatient treatment, such as:
- Severe dyspnea
- Worsening cough
- Increase or change in sputum production
- Changes in mentation
Nursing Care Plans
Once the nurse identifies nursing diagnoses for COPD, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for COPD.
Activity Intolerance
As COPD worsens, participating in physical activities may become more challenging. Patients often experience exercise intolerance due to dyspnea which negatively affects their strength and quality of life.
Nursing Diagnosis: Activity Intolerance
Related to:
- Imbalance between oxygen supply and demand
- Deconditioning
- Sedentary lifestyle
- Weakened diaphragm
As evidenced by:
- Dyspnea
- Fatigue
- Weakness
- Shortness of breath with minimal exertion
- Abnormal rise in BP or HR in response to activity
Expected outcomes:
- Patient will participate in exercise while maintaining respiratory pattern and vital signs within normal limits.
- Patient will report an increase in tolerance in performing tasks, ADLs, and exercise.
- Patient will verbalize techniques that aid in improved activity tolerance.
Assessment:
1. Evaluate current activity level.
Assess activities the patient currently partakes in. Observe the patient’s ability to perform ADLs, ambulation ability, and the degree of debility.
2. Assess emotional factors affecting activity.
Depression due to a loss of independence or anxiety from a fear of dyspnea can prevent the patient from attempting physical activity. Assess for these deeper concerns if a patient seems unmotivated or unwilling to participate.
3. Monitor cardiopulmonary response.
To ensure the patient is safe to partake in exercise, monitor vital signs and changes in the respiratory pattern as well as fatigue and an increased need for supplemental oxygen.
Interventions:
1. Teach conservation techniques.
Increase activity gradually. Perform tasks that require the most effort when feeling the most energized. Take frequent rest breaks. Go at a slower pace. Perform tasks sitting such as brushing teeth or folding laundry.
2. Keep track of physical activity.
Many devices exist now that can track physical activity, known as accelerometers. They can be worn around the arm or waist and track posture, energy expenditure, and the quantity and intensity of body movements. Even simple pedometers can be useful in measuring physical activity over time.
3. Instruct on diaphragmatic breathing.
Diaphragmatic breathing can be useful to implement during daily activities such as climbing stairs, showering, and going on long walks. It takes time to learn but will strengthen the diaphragm. As you inhale, your abdomen should rise, and lower as you exhale. Placing your hands on your chest and abdomen will show if this is occurring.
4. Educate on medications to improve tolerance.
Long-acting bronchodilators such as Spiriva have been shown to increase exercise endurance as patients reported an increase in participation in physical activities, which consequently improved quality of life.
Deficient Knowledge
A lack of knowledge related to the contributing factors, pathophysiology, symptoms, and treatments of COPD can lead to poor choices and worsening health outcomes.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Lack of information provided
- Lack of understanding
- Misinterpretation of education
- Lack of interest
As evidenced by:
- Request for additional information or clarification
- Verbalizes inaccurate information
- Demonstrates incorrect techniques
- Poor follow-through with tests or treatment
- Development of worsening conditions
Expected outcomes:
- Patient will verbalize factors that contribute to worsening COPD.
- Patient will demonstrate appropriate use of inhaler and oxygen.
- Patient will verbalize symptoms that warrant assessment and intervention.
Assessment:
1. Assess how the patient learns best.
Medical information can be complicated. Provide information without jargon that is easy to understand. Use repetition. Provide verbal and written education as well as pictures or videos that reinforce breathing techniques or how to properly use inhalers or oxygen.
2. Assess readiness and motivation.
Assess the patient’s interest in learning about their disease. If the patient is not mentally or emotionally ready to accept teaching it will be futile. Dig deeper into their motivation to learn or lack thereof.
3. Assess for a support system.
Chronic conditions can be difficult to manage alone. Assess for family members or friends that can support the patient in reinforcing teaching instructions.
Interventions:
1. Instruct on how to prevent and recognize exacerbations.
COPD exacerbations refer to a worsening in symptoms for days or weeks and often require hospitalization. Respiratory infections, pollution, and allergies can cause a flare-up. If the patient notices an increase in coughing, dyspnea, changes in sputum, and difficulty sleeping they should contact their provider.
2. Educate on hygiene practices.
Staying healthy will keep the immune system strong to prevent infections and viruses. Frequent hand washing, staying away from sick people, regular exercise, keeping the airways clear, and eating healthy should be encouraged.
3. Recommend pulmonary rehab.
Pulmonary rehabilitation educates on exercise training, nutrition advice, and counseling specific to controlling COPD. Pulmonary rehab can help reduce exacerbations and hospital readmissions.
4. Quit smoking.
If the patient smokes, this is one of the most important instructions that can be given. Quitting smoking is difficult but is essential in preserving lung function and preventing exacerbations.
Impaired Gas Exchange
Obstruction of the airway and impaired pulmonary ventilation cause hypoxemia and hypercapnia in patients with COPD.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Alveolar-capillary membrane changes
- COPD exacerbation
- Respiratory failure
As evidenced by:
- Dyspnea
- Changes in mental status
- Altered ABGs
- Agitation
- Restlessness
Expected outcomes:
- Patient will demonstrate an improvement in ventilation and oxygenation as evidenced by ABGs within normal limits.
- Patient will verbalize signs of acute COPD exacerbation.
Assessment:
1. Assess respiratory rate and depth.
Note the respiratory rate, rhythm, and depth, the use of accessory muscles, pursed-lip breathing, positioning, activity intolerance, and their ability to converse to evaluate the degree of respiratory distress.
2. Monitor ABGs.
ABGs should be assessed with an acute exacerbation to monitor the level of hypoxemia. As the patient’s condition worsens, hypercapnia may occur.
3. Monitor changes in the patient’s level of consciousness and mental status.
Concerning manifestations of poor gas exchange are somnolence, restlessness, agitation, and anxiety.
Interventions:
1. Administer supplemental oxygen.
Oxygen should be administered at the lowest concentration indicated, usually 2-4L continuously via nasal cannula.
2. Encourage pursed-lip breathing.
Pursed lip breathing helps bring more oxygen into the lungs while removing carbon dioxide.
3. Administer medications.
Beta2-agonists are administered first to relax the smooth muscles of the airways. Inhaled corticosteroids are given after to improve inflammation and lung function.
4. Prepare for assisted ventilation.
If oxygenation or ventilation worsens and the patient experiences worsening hypoxemia or respiratory acidosis, consider noninvasive positive-pressure ventilation (NIPPV) or intubation with mechanical ventilation.
Ineffective Airway Clearance
Chronic obstructive pulmonary disease causes increased sputum production, resulting in ineffective airway clearance.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Bronchoconstriction
- Increased sputum production
- Ineffective cough
- Smoking
- Infection
As evidenced by:
- Dyspnea
- Abnormal breath sounds
- Excessive sputum
- Restlessness
- Orthopnea
- Changes in respiration
- Use of accessory muscles
- Cyanosis
Expected outcomes:
- Patient will practice breathing and airway clearance exercises.
- Patient will display clear breath sounds.
- Patient will report an improvement in dyspnea.
Assessment:
1. Monitor respiratory rate and depth and the use of accessory muscles.
Changes in breathing rate and pattern may occur with accessory muscle use due to an increased work of breathing.
2. Auscultate the lung fields.
Secretion accumulation may cause coarse crackles or rhonchi.
3. Obtain a sputum sample.
An increase or change in sputum production requires culturing to assess for the presence of bacteria that may cause pneumonia or other infections.
Interventions:
1. Elevate the head of the bed and change positions frequently.
This lowers the diaphragm and encourages chest expansion, aeration of lung segments, and drainage of secretions to keep airways clear.
2. Suction excess sputum as indicated.
If the patient is unable to cough effectively, suctioning may be required to clear the airway.
3. Administer mucolytics.
Mucolytics can reduce sputum viscosity and improve secretion clearance. Administer along with a bronchodilator to prevent bronchospasm.
4. Educate the patient on huff coughing.
Huff coughing is a method used in patients with COPD to loosen and force mucus through the airways without collapsing the airways.
Ineffective Breathing Pattern
The cardinal symptom of COPD is shortness of breath from airflow obstruction. It can be frightening for patients and requires prompt assessment and intervention.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Alteration in oxygen-carbon dioxide ratio (hyperventilation or hypoventilation)
- Inappropriate lung expansion/respiratory muscle fatigue
- Secretions
- Fatigue
- Anxiety
As evidenced by:
- Dyspnea
- Accessory muscle use
- Orthopnea
- Uneven respiratory rhythm
- Increased respiratory rate
- Pursed-lip breathing
- Sputum production
Expected outcomes:
- Patient will maintain an effective respiratory pattern as evidenced by an even, unlabored respiratory rate and rhythm.
- Patient will demonstrate techniques to improve breathing pattern.
- Patient will verbalize factors contributing to an ineffective breathing pattern.
Assessment:
1. Auscultate breath sounds and vital signs.
Monitor blood pressure, heart rate, and sp02 closely. Auscultate lungs to assess for adventitious sounds such as rhonchi which could signal retained secretions.
2. Note the type of breathing pattern.
Observe the rate, depth, and irregularity of the breathing pattern. Note accessory muscle use, audible wheezing, and nasal flaring.
3. Assess ABGs.
Arterial blood gases determine the degree of oxygenation and CO2 retention.
Interventions:
1. Decrease anxiety.
An ineffective breathing pattern may be caused by or due to anxiety. First, maintain a calming presence and stay with the patient to decrease their fear; breathlessness is scary. Create a relaxing environment with decreased stimuli.
2. Administer medications.
Bronchodilators relax the airways and inhaled steroids reduce inflammation to prevent exacerbations. IV or oral steroids may also be ordered to reduce inflammation.
3. Apply oxygen.
Apply supplemental oxygen at the lowest concentration necessary. COPD patients can be easily over oxygenated if their respiratory effort is inefficient leading to dangerous levels of O2 and CO2 (hypercapnia).
4. Instruct on pursed-lip breathing.
Instruct the patient to first relax and drop their shoulders so they aren’t tense. Pursed-lip breathing helps slow the respiratory rate and stay calm. Have the patient breathe in through their nose, pucker their lips like they are blowing out a candle, and exhale. The exhalation should be twice as long as the inhalation.
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