• Man (D.Z.) in his 60’s
• Admitted with chronic emphysema with an acute exacerbation.
• HX of 6 yrs HTN and Dx of pneumonia yearly x3
• Productive cough, sleeping poorly, fatigue
• Thin, poorly nourished
• Irritable and anxious
• Vital Stats
COPD- Chronic Obstructive Pulmonary Disorder is
characterized by progressive airflow limitation “associated
with an abnormal inflammatory response of the lungs to
noxious particles or gases primarily caused by cigarette
smoking.” (Lewis, 2007)
• Emphysema and Chronic
Bronchitis are two types of COPD.
– Emphysema is the over-inflation leading to
destruction of the alveoli and/or collapse of
– Chronic Bronchitis is a chronic productive cough
for 3 or more months in each of two consecutive
years. (Lewis, 2007)
Pathophysiology of Emphysema
• 2 part destruction:
-The elasticity of the
lung is lost leading to
damage to the walls
of the alveoli. This
causes them to break
down creating the
bleb you see here.
• -The elasticity of the
larger airways are
also lost causing them
to collapse upon
• SLINKY DEMO!
CLUSTER OF GRAPES
Symptoms PAPER BAG
• Shortness of breath
• sleep problems
• heart problems
• weight loss
• Depression •www.broncus.com/images/emphyillus.jpg
• Chocolate cravings
• Chronic high levels of CO in blood and low O
(don’t give too much O )
• Pulmonary function test
• Peak flow meter
• ABG tests
• Chest x-ray
• Sputum analysis http://www.ricksmagic.com/smoking/badlungs.html
“16-30 million U.S. citizens are
- 10.7 million adults have emphysema
- Only disease where more whites die than African
afflicted with emphysema… and
Americans every year approximately 100,000
- More widespread in men, but more females have
died than males since 2000. why? sufferers die of the disease”
- Greater than 50% die within 10 years of Dx http://www.emphysemafoundation.org/
• Goal of treatment is to live more comfortably by
providing symptom relief and prevent further
progression of the disease
– Quit smoking
– Antibiotics http://www.s k.lung.ca/content.cfm?edit_realword=kemphy
– Oral medications
– Inhaled medications
– Teach breathing techniques
– Supplemental O 2 therapy
– LVRS or Transplantation
– Pulmonary rehabilitation
– Death- 4th leading cause of death in US (100,000)
• Ineffective Airway Clearance
– Unable to clear secretions from respiratory system
Related to Smoking 2 packs a day for 38 years
As evidenced by difficulty breathing, productive thick yellow
sputum, and tachycardia, and tachypnea (36 rpm)
– Maintain patient airway, auscultate clear breath sounds in all
lung fields bi-latterly, cough effectively
– Teach effective coughing techniques, provide proper airway
management, provide suctioning when needed, monitor resperations
and O2 levels, encourage activity and ambulation, teach how to use
new inhalers and medication treatments (Ackley, 2006)
• Activity Intolerance
– Lack of energy to conduct ADL’s
Related to imbalance of oxygen supply and demand, and poor
As evidenced by pt reporting poor sleep and feeling very tired
lately, need for assistance to ambulate
– Independently ambulate around unit, able to complete ADL’s on
own, and eat 100% of meals if tolerable
– Assist pt in resting techniques and in exercise activities, consult
with physical therapist, respiratory therapist, and dietician for
increased attention that pt may require (Ackley, 2006)
• Imbalanced Nutrition: Less than body requirements
– Intake of nutrients are insufficient to meet metabolic needs
Related to inability to intake adequate amounts of food due to
biological or economic factors
As evidenced by a thin and poorly nourished physical appearance
who is very tired most of the time.
– Gain weight until desired weight suggested by dietician and
patient is reached, patient understands reason why he is
underweight, identify nutrition requirements, regain healthy
– Daily weights, compile list with patient of healthy nutritional
foods that he enjoys eating, monitor his food intake, observe
ability to eat. (Ackley, 2006)
• “I don’t understand it. I can be so
hungry, but when I start to eat, I
have trouble breathing and I have to
• What is the phenomenon of carbohydrate
– “High-carbohydrate meals can increase CO2 output in COPD patients.
However, some patients may increase ventilation to get rid of the CO2,
and some have a tolerance for rather high blood CO2 levels (retainers).
Thus, metabolic demands can be met but at a physiologic cost. The
degree of exercise restriction needed to compensate for the increased
CO2 is under investigation.” (Chapman, 1996)
What can we do to improve D.Z.’s caloric
- Eat main meal early in order to have more energy for rest of day. (AARC)
- Eat small frequent meals to stay fed but not compress the stomach on the
- Provide high calorie finger foods and drinks that are easy (don’t take up much
energy) to eat.
- Continue O2 therapy while eating to improve oxygenation. (AARC)
- Rest an hour before eating and after eating.
What can you do to improve D.Z.’s
oxygenation in general?
– Teach huff coughing for effective coughs (cough and deep
• Pursed lip breathing
• Abdominal breathing
– Request chest physiotherapy: percussion, vibration, postural
– Provide a flutter mucus clearance device and/or encourage
inspiratory spirometer. (lewis,2007)
– Cluster interventions to decrease activity
– Put the head of bed to 30 degrees or higher
Pyschosocial Nursing Care
• What may make it • Read #14 from case
difficult for D.Z. to study. How would you
quit smoking? respond to D.Z.’s
- Social reasons? wife?
Helping your patients quit
• The 5 A’s • Role play with nurse
-Ask and Amy Winehouse!!
Ackley, B. J., Ladwig, G. B. (2006). Nursing Diagnosis Handbook, A Guide to Planning Care. St.
Louis, MI: Mosby Elsevier.
• American Association for Respiratory care. (2002) Eating Right: Tips for the COPD patient.
Retrieved September 9, 2008, from source.
• Black, K. (2007). Advance care planning throughout the end-of-life: focusing the lens for social
work practice. Journal Of Social Work In End-Of-Life & Palliative Care, 3(2), 39-58.
Retrieved September 17, 2008, from MEDLINE database.
• Chapman, K., & Winter, L. (1996, December). COPD: using nutrition to prevent respiratory
function decline. Geriatrics, 51(12), 37-42. Retrieved September 15, 2008, from MEDLINE
• Clancy, C. M. (2008) Quitting smoking, helping your patients kick the habit. Nursing for Women’s
Health, 12(4), 282-284. Retrieved September 13, 2008, from CINHAL database.
• EMedicineHealth: A Practical Guide to Health. (2005) Emphysema. Retrieved September 15, 2008,
• Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., O’Brien, P. G., & Bucher, L. (2007). Medical-
surgical nursing, assessment and management of clinical problems. St. Louis, MI: Mosby
• Musich, S., Mcdonald, T., Hirschland, D., & Edington, D. (2002, April). Excess healthcare
costs associated with excess health risks in diseased and non-diseased health risk
appraisal participants. Disease Management & Health Outcomes, 10(4), 251-258.
Retrieved September 17, 2008, from CINAHL with Full Text database.
• National Emphysema Foundation. (2007) COPD. Retrieved September 15, 2008, from source.
• Tinker, R., & While, A. (2006, July). Promoting quality of life for patients with moderate to severe
COPD. British Journal of Community Nursing, 11(7), 278. Retrieved September 16, 2008,
from CINAHL with Full Text database.
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