CHRONIC OBSTRUCTIVE PULMONARY DISORDER

 COPD is the third leading cause of mortality in the United States (Hinkle & Cheever, 2019), and can be properly managed through appropriate care principles that start with an accurate assessment and diagnosis. Applying appropriate and conducive interventions in company with other healthcare professionals will pinpoint and treat disease complications. Lastly, evaluating and offering alternatives to a patient’s lifestyle can positively impact their care and will illustrate a holistic, exclusive care experience.

Pathophysiology and Diagnosis

COPD can be described as an umbrella term that covers several specific disease processes that can restrict any or all of the airway passages, with the main diseases being chronic bronchitis and emphysema. Although the diseases are different in nature, they all restrict respiratory function and are usually provoked from environmental factors, such as mining, smoking, or even air pollution. Eventually, these factors can aggravate and inflame the airway passages, leading to irreversible deformity and increased mucous production. A patient can go undiagnosed for many years until the disease causes irreversible damage. COPD patients are typically diagnosed in their middle adult years, and there is an increased incidence between older age and diagnosis.

Goblet cells line the respiratory airways that produce mucus to help expel foreign particles. In chronic bronchitis, these cells are continuously inflamed and aggravated, which causes the cells to swell, overproduce mucously and cause congestion of the airways. In addition, the inner wall of the bronchiole will thicken, causing the lumen to compress and become narrow. The incessant production of mucous along with the restricted bronchiole can also damage nearby alveolar macrophages, which can later put the patient at risk for respiratory infections like pneumonia.

There are several types of emphysema that can affect the lungs and cause permanent damage. In general, emphysema causes the elastic fibers of the alveoli in the lungs to become weak and distended due to defective air exchange. Therefore, the alveoli will have a floppy, overinflated, shape, experience a decrease in its surface area, and eventually the walls of the alveoli will breakdown, and become dead tissue. Emphysema can further affect the body to cause a cascade of heart problems like pulmonary hypertension and right-sided heart failure. With the effects of chronic bronchitis and emphysema combined, the inspired air will become trapped within the alveoli, and will be unable to escape upon expiration. This will cause hypoxia to all body parts, leading to a decrease in tissue perfusion, and could permit the need of repeated pulmonary rehabilitation or oxygen therapy.

Assessment Findings

Classic COPD assessment findings include adventitious lung sounds, and a “barrel” chest. Dyspnea is the most familiar subjective symptom seen in COPD suffers. Up to 94% of patients can describe the sense of dyspnea as “air hunger” (Mitchell, 2015). Therefore, dyspnea can adversely affect patients’ activities of daily living and other routine tasks. In addition, chronic cough and sputum production can further exacerbate the illness.

One objective sign noted among COPD patients with chronic stages of emphysema is the presence of a “barrel chest”. Inside an ordinary person’s chest wall, they will have a one-to-two thorax ratio, which means their chest wall from front to back is half as long as their chest wall left to right (Hinkle & Cheever, 2019). A person with COPD will demonstrate a one-to-one thorax ratio, meaning their chest wall is approximately in equal dimensions around their whole thorax, hence the “barrel” shape. This “barrel” appearance is caused from the inability to completely expire air within the lungs, leading to hyperinflation and alveolar damage.

Psychosocial Variables

COPD management can be affected by several psychosocial aspects such as: encountering diverse cultural or demographic norms, living in rural populations, or experiencing negative emotions due to a diagnosis of COPD. In certain demographics, smoking in social settings or using smoking as a coping mechanism can be portrayed as a normal way of life. Socioeconomic communities like rural towns can have almost double the rate of diagnosis than do metropolitan districts due to heightened environmental toxins, inability to access quality healthcare, and fewer options to discontinue smoking. Newly diagnosed COPD suffers can have overwhelming feelings of guilt, shame, and anxiety about burdening themselves and close family members with this disease.

Chronic Complications

COPD patients’ can also present two chronic diseases, or comorbidities, such as right-sided heart failure or depression. Mitchell (2015) describes right-side heart failure as “long-term low oxygen levels resulting in narrowing of the pulmonary blood vessels, and resulting in a backflow of blood to the right ventricle of the heart” (p. 448). Depression can be a major emotional complication when treating patients with COPD. Memon (2017) states that “Depression has been found to occur in … persons with COPD up to four times more frequently than it occurs in persons without COPD” (p. 130). Depression can affect multiple aspects of life such as relationships, daily routines, self-esteem, motivation, and should be should not be overlooked. Prevention of right-sided heart failure and depression can include: getting regular exercise, eating healthier foods, taking medication as prescribed, and avoiding alcohol and smoking.

Independent Nursing Interventions

Three important nursing diagnosis for COPD are ineffective airway clearance, impaired gas exchange, and risk of infection. Ineffective airway clearance is the primary concern because the airway is the first priority of patient care. Impaired gas exchange is another considerable nursing diagnosis of COPD patients; it can precipitate abnormal breathing patterns, restlessness, and hypoxia. Risk of infection, particularly respiratory infection, is valuable because of the damaged alveolar macrophages and stagnant sputum collecting in the airway.

Patients can be encouraged to cough whenever possible or request oropharyngeal suctioning to help eliminate the sputum and clear the airway. Helping the patients in this way would be a great time to introduce the effects smoking has on mucus production and lung damage, and offer resources to help the patient practice smoking cessation. Unless contraindicated, increasing fluid intake can help reduce sputum viscosity and make up for insensible fluid losses. Handwashing is another practical and simple method of educating the patient about preventing foreign or harmful bacteria to themselves, especially with COPD exacerbations.

Interprofessional Collaboration

Respiratory therapists, nutritionists, and occupational therapists all play a crucial role in providing lung support by reducing disease symptoms, improving quality of life, and encouraging physical and emotional participation of self-care. Respiratory therapists have a wealth of knowledge pertaining to the anatomy and physiology of the lungs, treatment options, and complication prevention strategies. Learning about helpful advice such as breathing techniques or recognizing the symptoms of an exacerbation can help COPD patients control their respirations and maximize oxygen.

Nutritionists can help reverse malnutrition and weight loss due to increased energy needs by stimulating clients’ appetite and suggesting frequent, high-calorie meals. According to Hodson (2016), nutritional assessment of the patient is important to “understand the physiological, social, psychological, and environmental factors that may affect the patients ability to eat” and can help to “meet their nutritional needs and own personal goals” (p. 550). Occupational therapists can benefit COPD patients by demonstrating changes into their daily lifestyle to manage disease complications such as dyspnea and fatigue. Patients can learn different techniques to help with daily tasks such as bathing or ambulating, while using their energy wisely and achieving rest periods.

Conclusion

COPD is a chronic and progressive, yet preventable respiratory disease that can be carefully assessed and diagnosed by observing both objective and subjective data such as dyspnea, and a “barrel” chest. Nurses can apply simple and independent interventions like increasing fluid intake, coughing, and educating about smoking cessation to help ease adverse effects of the disease of COPD. Lastly, occupational therapists, respiratory therapists, and nutritionists can help nurses work with patients’ to conserve energy and achieve some sense of normalcy when participating in daily activities.

References

1. Centers for Disease Control. (2018, March 8). Urban-Rural Differences in COPD. https://www.cdc.gov/features/copd-rural-areas/index.html
2. Hinkle, J. L., Cheever, K. H. (2019). Lippincott CoursePoint Enhanced for Brunner & Suddarth's Textbook of Medical-Surgical Nursing, [VitalSource Bookshelf 14th edition]. Wolters Kluwer. vbk://9781975123383
3. Hodson, M. (2016). Integrating nutrition into pathways for patients with COPD. British Journal of Community Nursing, 21(11), 548–552. https://doi.org/10.12968/bjcn.2016.21.11.548
4. Memon, N. S. (2017). Prevalence of Depression in Patients with COPD. Indian Journal of Physiotherapy & Occupational Therapy, 11(4), 129–132. https://doi.org/10.5958/0973-5674.2017.00133.2
5. Mitchell, J. (2015). Pathophysiology of COPD: Part 1. Practice Nursing, 26(4), 172–178. http://lrcserver.tcl.edu:2231/login.aspx?direct=true&db=rzh&AN=103785332&site=ehost-live
6. Mitchell, J. (2015). Pathophysiology of COPD: Part 2. Practice Nursing, 26(9), 444–449. http://lrcserver.tcl.edu:2231/login.aspx?direct=true&db=rzh&AN=109839119&site=ehost-live

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