Nursing Diagnoses

Five Key Nursing Diagnoses:

1) Ineffective Airway Clearance: Possibly evidenced by statement of difficulty breathing, changes in depth/rate of respirations, use of accessory muscles, abnormal breath sounds, persistent cough and sputum. More info in table below!

2) Impaired Gas Exchange: May be related to altered O2 supply, Alveoli destruction, and alveolar-capillary membrane changes. Evidenced by dyspnea, abnormal breathing, confusion, restlessness, inability to move secretions, hypoxia, hypercapnia, changes in vital signs, and activity intolerance.

3) Imbalanced Nutrition: May be related to dyspnea, sputum production, medication side effects, fatigue. Possibly evidenced by weight loss, loss of muscle mass, poor muscle tone, reported altered taste sensation, aversion to eating, and lack of interest in food.

4) Risk for Infection: Risk factors include inadequate primary defenses, inadequate acquired immunity, chronic disease process, and malnutrition.

5) Knowledge Deficit: May be related to lack of information/unfamilarity with resources, misinterpretation and lack of recall cognition. Evidenced by patient requesting information, statement of concerns/misconceptions, inaccurate follow-through of instructions, and development of preventable complications. 

Nursing Diagnosis	Ineffective Airway Clearance
Actual or Potential	-Potential
Related to	-Broncospasm -Increased production of secretions; retained secretions; thick, viscous secretions -Allergic airways -Hyperplasia of bronchial walls -Decreased energy/fatigue
Plan and Outcome	-Maintain airway patency with breath sound clear/clearing -Demonstrate behaviors to improve airway clearance (cough effectively, expectorate secretions)
Nursing Intervention	-Auscultate, assess, and monitor breath sounds; note rate, i/e ratio, and adventitious sounds -Evaluate degree of dyspnea -Comfort; elevate HOB, lean over on table, sit on edge of bed -Minimize exposure to dust, smoke, feathers -Observe cough -Increase fluid intake within cardiac tolerance (3000mL). Warm or tepid liquid.

This website is my favorite and is the most clear about the different nursing care diagnosess and interventions. It is longer and in-depth, however very organized and extremely easy to read!
NurseLabs.com

HEY NURSES! Ways to care for patients COPD.

Nursing Diagnosis	Rationale
Ineffective Airway Clearance	-Auscultate, assess, and monitor breath sounds; note rate, i/e ratio, and adventitious sounds -Evaluate degree of dyspnea -Comfort; elevate HOB, lean over on table, sit on edge of bed -Minimize exposure to dust, smoke, feathers -Observe cough -Increase fluid intake within cardiac tolerance (3000mL). Warm or tepid liquid.
Impaired Gas Exchange	-Asses RR; note accessory muscle use, purse-lip breathing, inability to speak -Elevate HOB; encourage deep, slow, purse-lip breathing -Monitor skin/mucus membrane color -Encourage sputum; suction as needed -Auscultate breath sounds -Palpate for fremitus -Evaluate level of activity intolerance and sleep patterns -Vitals and cardia rhythm
Imbalanced Nutrition	-Assess dietary habits -Auscultate bowel sounds -Frequent Oral care -Avoid gas-producing, carbonated, very-hot, and very-cold beverages/foods -Weigh -Administer O2 with meals as indicated
Risk of Infection	-Monitor temp -Observe sputum odor, color, character; obtain specimen by deep cough/suction -Stress hygiene and proper tissue disposal -Monitor visitors -Encourage balance b/t activity and rest -Discuss adequate nutrition intake -Administer antimicrobials as indicated
Knowledge Deficit	-Explain disease process -Stress oral and dental hygiene! -Discuss avoiding people with Resp. Infections. Discuss individual aggravating factors. Avoidance of smoking/harmful pollutants. Activity limitations. Need for follow-up appointments. -Discuss medications, O2 needs, inhaler usage and technique

Below are some helpful links that go more in depth in nursing care for individuals with COPD:

1) This website is my favorite and is the most clear about the different nursing care interventions to give. It is longer and in-depth, however very organized and extremely easy to read! Because of it's informative and simple format, this is important for nurses to read through because it touches on all key interventions, while not presenting it like a paper or essay!
NurseLabs.com for COPD

2) This website gives interventions/care and rationales for that care in two VERY BRIEF lists: one for chronic bronchitis, and one for emphysema. I recommend this website to the nurse who simply needs a brief list for COPD patients on a case-by-case basis.
NursingFile.com for COPD

3) Also here is a great resource from The Asthma Foundation to send your patients home with for management guidance!!

Treating for COPD

Because COPD is a progressive disease, the key is managing and preventing (as best we can) any further complications for whatever stage we are in. The most important complications for COPD are coughing, changes in sputum (color/amount), and fever (and need to be reported to your provider). The most important side effects are those for Streroid therapy; these may include weight gain, diabetes, osteoporosis, cataracts and an increased risk of infection.

1) Lifestyle Changes

-Quit Smoking and Avoid Lung Irritants

Quitting smoking is the most important step you can take to treat COPD. Talk with your doctor about programs and products that can help you quit. If you have trouble quitting smoking on your own, consider joining a support group. Many hospitals, workplaces, and community groups offer classes to help people quit smoking. Ask your family members and friends to support you in your efforts to quit. Try to avoid secondhand smoke and places with dust, fumes, or other toxic substances that you may inhale.

-Other Lifestyle Changes

If you have COPD, you may have trouble eating enough because of your symptoms, such as shortness of breath and fatigue. (This issue is more common with severe disease.) As a result, you may not get all of the calories and nutrients you need, which can worsen your symptoms and raise your risk for infections. Talk with your doctor about following an eating plan that will meet your nutritional needs. 

2) Medicines

-Bronchodilators

Bronchodilators relax the muscles around your airways. This helps open your airways and makes breathing easier. Depending on the severity of your COPD, your doctor may prescribe short-acting or long-acting bronchodilators. Short-acting bronchodilators last about 4–6 hours and should be used only when needed. Long-acting bronchodilators last about 12 hours or more and are used every day. Most bronchodilators are taken using a device called an inhaler. This device allows the medicine to go straight to your lungs. Not all inhalers are used the same way. 

-Combination Bronchodilators Plus Inhaled Glucocorticosteroids (Steroids)

If your COPD is more severe, or if your symptoms flare up often, your doctor may prescribe a combination of medicines that includes a bronchodilator and an inhaled steroid. Steroids help reduce airway inflammation.  In general, using inhaled steroids alone is not a preferred treatment. 

3) Vaccines

-Flu Shots

The flu (influenza) can cause serious problems for people who have COPD. Flu shots can reduce your risk of getting the flu.

-Pneumococcal Vaccine

This vaccine lowers your risk for pneumococcal pneumonia and its complications. People who have COPD are at higher risk for pneumonia than people who don't have COPD. 

4) Pulmonary Rehabilitation

Pulmonary rehabilitation is a broad program that helps improve the well-being of people who have ongoing breathing problems. Rehab may include an exercise program, disease management training, and nutritional and psychological counseling. The program's goal is to help you stay active and carry out your daily activities.

5) Oxygen Therapy

If you have severe COPD and low levels of oxygen in your blood, oxygen therapy can help you breathe better. For this treatment, you're given oxygen through nasal prongs or a mask. You may need extra oxygen all the time or only at certain times. For some people who have severe COPD, using extra oxygen for most of the day can help them:

• Do tasks or activities, while having fewer symptoms
• Protect their hearts and other organs from damage
• Sleep more during the night and improve alertness during the day
• Live longer

6) Surgery

Surgery may benefit some people who have COPD. Surgery usually is a last resort for people who have severe symptoms that have not improved from taking medicines.

Surgeries for people who have COPD that's mainly related to emphysema include bullectomy (bul-EK-toe-me) and lung volume reduction surgery (LVRS). A lung transplant might be an option for people who have very severe COPD.

-Bullectomy

When the walls of the air sacs are destroyed, larger air spaces called bullae (BUL-e) form. These air spaces can become so large that they interfere with breathing. In a bullectomy, doctors remove one or more very large bullae from the lungs.

-Lung Volume Reduction Surgery

In LVRS, surgeons remove damaged tissue from the lungs. This helps the lungs work better. In carefully selected patients, LVRS can improve breathing and quality of life.

-Lung Transplant

During a lung transplant, your damaged lung is removed and replaced with a healthy lung from a deceased donor. A lung transplant can improve your lung function and quality of life. However, lung transplants have many risks, such as infections. The surgery can cause death if the body rejects the transplanted lung.

Learning Objective:  Analyze the treatment guidelines of your disease from current resources. Identify key article that will be part of your blog in this area. What are the current treatment recommendations during various stages of your disease? Describe the treatment progression. Which side effects are most important? Which side effects are most common? When does the treatment need to be stopped because of side effects?

Learning Activity 1. Find treatment information on websites, textbooks and journals. If possible create a chart with the two most frequently used treatment guidelines and compare them for their information. 2. Find information related to side effects on websites, textbooks and journals. If possible create a chart with the five most frequent side effects and what to do about them. 3. Post references that explain most comprehensively the treatments of the disease on your blog.

Key Articles: 
National Heart Lung and Blood Institute 

American Lung Association.

Anderson B, Conner Anderson B, Conner K, Dunn C, et al. Institute for Clinical Systems Improvement. Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD). https://www.icsi.org/_asset/yw83gh/COPD.pdf. Accessed May 5, 2014.

Balkissoon R, Lommatzsch S, Carolan B, Make B. Chronic obstructive pulmonary disease: a concise review. Med Clin N Am. 2011;95:1125-1141

WHAT SHOULD I EXPECT TO LOOK AND FEEL LIKE WHEN I HAVE COPD?

Chronic obstructive pulmonary disease (COPD) can cause shortness of breath, tiredness, production of mucus, and cough. 

COPD patients and their disease progression are staged based on lung function, that sadly typically decreases over time. Below is table giving what you might experience as lung function declines.

 Decreasing lung function and the discomfort and declining quality of life calls for great healthcare. Below are FAQs and general recommendations about how to cope, treat, and when to seek care for your symptoms. 

Many people with COPD develop most, if not all, of these signs and symptoms.

Why is shortness of breath a symptom of COPD?
Shortness of breath (or breathlessness) is a common symptom of COPD because the obstruction in the breathing tubes makes it difficult to move air in and out of your lungs. This produces a feeling of difficulty breathing. Unfortunately, people try to avoid this feeling by becoming less and less active. This plan may work at first, but in time it leads to a vicious cycle: avoiding activities leads to getting out of shape or becoming deconditioned, and this can result in even more shortness of breath with activity.

What can I do to treat shortness of breath?
If your shortness of breath is a result of COPD, you can do several things:

• Take all of your medications regularly as prescribed.
  If you do not think that your medications are helping your shortness of breath, talk to your healthcare provider, but don’t stop the medication.
  
• Begin a regular exercise program to build-up your strength.
  
• Learn about paced breathing and ways of breathing more efficiently with activities.
  Pulmonary rehabilitation programs offer an exercise program and teach you how to control your shortness of breath. Breathing support groups offer more general information. To locate a rehabilitation program or support group, contact your local American Lung Association. 
  When should I call my healthcare provider about my shortness of breath?
  If your shortness of breath is new, or it worsens for no known reason, call your healthcare provider. Describe to your provider when the shortness of breath started, how long it has lasted, and what makes it better or worse.
  

Is tiredness a symptom of COPD?
Tiredness (or fatigue) is a common symptom in COPD. Tiredness discourages a person from keeping active, which leads to greater loss of energy, which then leads to more tiredness. When this cycle begins it is sometimes hard to break.
What can I do to increase my energy level?
If you and your healthcare provider find that your tiredness is from your COPD, begin a regular program of exercise to build your strength. Learn about paced breathing and ways of breathing with less effort during activities. Consider going to a breathing support groups offered by your Lung Association or enrolling in a pulmonary rehabilitation program.
When should I call my healthcare provider about my tiredness?
Call your healthcare provider when unexpected tiredness does not go away. Describe when the tiredness started, how long it has lasted, and what makes the tiredness better or worse.
Is mucus production a symptom of COPD?
Excess mucus (phlegm or sputum) can be a symptom of COPD. It is normal for the breathing tubes to produce several ounces of mucus a day. Mucus is needed to keep the breathing passages moist. This mucus is normally swallowed without even knowing that you are doing so. However, when the lungs are infected or bothered by irritants, they try to protect themselves by producing more mucus than normal, which often makes you cough.

Should I look at the mucus I cough up?
Mucus needs to be coughed up and you need to look at it. Swallowing small amounts of mucus is not known to cause health problems, but looking at your mucus can give you an idea of what is happening in your lungs. It is best to cough your mucus into a disposable tissue so that you can see the color, thickness, and amount of mucus. Describing your mucus to your healthcare provider is helpful.
How can I lessen the amount of mucus produced in my lungs?
If you smoke, stop smoking. Everyone should avoid smoke and limit exposure to other items that can cause irritation to the lungs, such as pollution and fumes (paints, cleaning products and perfumes). Besides avoiding irritants, medicines like bronchodilators (to open up the breathing tubes), expectorants (to make the mucus easier to cough out), mucolytics (to thin thick mucus) and antibiotics (to treat infection in the lung) can be used.

When should I call my healthcare provider about changes in mucus?

For people with COPD, it is important to contact your healthcare provider soon after noticing a change in your mucus. Generally, a change in the color, thickness, and/or the amount of mucus is a sign that there is something abnormal going on in your lungs. Call your healthcare provider if you cough up blood or mucus that is deep yellow or green.
Is coughing a symptom of COPD?
A cough is common with COPD. Coughing can be a result of the lungs trying to remove extra mucus (phlegm or sputum) or it can be a way for the breathing tubes to protect themselves from inhaled irritants. Coughing is a good thing when it moves mucus out of the lungs because if large amounts of mucus stay in the breathing tubes, it can prevent oxygen from entering into the blood or can result in pneumonia. For this reason, your healthcare provider may not recommend medication to prevent your cough.

When should I call my healthcare provider about my cough?
Most coughing is not dangerous. You should call your healthcare provider if you notice any of the following: unexplained cough; severe cough; or coughing that causes you to black out. 

Key Articles: 
-ATS/ERS Standards for the Diagnosis and Management of Patients with COPD, http://www.thoracic.org/COPD/18/signs.asp 
-O'Donnell DE, Aaron S, Bourbeau J, Hernandez P, Marciniuk DD, Balter M, Ford G, Gervais A, Goldstein R, Hodder R, Kaplan A, Keenan S, Lacasse Y, Maltais F, Road J, Rocker G, Sin D, Sinuff T, Voduc N, Can Respir J. 2007 Sep; 14 Suppl B():5B-32B