NCLEX Review on COPD The name “blue bloaters” is due

to cyanosis from “hypoxia” and bloating from

Definition: pulmonary disease that causes edema AND increase in lung volume. The
chronic obstruction of airflow from the lungs bloating is from the effects of the lung disease
Keys Point for COPD: on the heart which causes right-sided heart
failure.
 Limited Airflow (due to thick and
swollen bronchioles that have
become deformed with excessive
sputum production and this narrows
the airways)
 Inability to fully exhale (due to
loss of elasticity of the alveoli sacs
from damage and the sacs start to
develop air pockets)
 Irreversible once developed…cases
vary among people from mild to
severe…managed with lifestyle
changes and medications.
 Happens gradually….most people
start to notice signs and symptoms
middle-aged and will present with
dyspnea with activity they could
normally tolerate, recurrent lung
infections, chronic cough etc. In chronic bronchitis, the bronchioles become
 COPD is a term used as a “catch damaged that leads them to be thick and swollen
all” for diseases that limit airflow and deformed. This is accompanied by more
and cause dyspnea. sputum production. This limits the ability of the
Types of COPD include:
person being able to completely exhale the air
taken in. So, when they take another breath in, it
 Emphysema “pink puffers”
 Chronic bronchitis “blue bloaters” will increase the air volume even more (because
they have retained air from the previous breath),
Pathophysiology of COPD and this leads to hyperinflation.

Normal breathing:
Inhaled oxygen travels down through the
trachea which splits at the carina into bronchial
tubes starting with the primary bronchus then
into smaller airways called secondary and
tertiary bronchi which divide into bronchioles
and the oxygen goes into the alveolar sacs
where gas exchange happens. As the alveoli
inflate and deflate with ease, inhaled oxygen
attaches to the red blood cells and carbon
dioxide enters the respiratory system to be
exhaled.
Also, less oxygen is getting into the blood and more
carbon dioxide is staying in the blood. This leads to
low blood levels and high carbon dioxide levels.
Patients will have cyanosis due to a decreased
oxygen level. To compensate, the body increases
RBC production and cause blood to shift elsewhere
which increases pressure in the pulmonary artery
leading to pulmonary hypertension. Pulmonary
hypertension leads to right-sided heart failure
(which is why you will start to see bloating..edema
in the abdomen and legs)

In conditions such as emphysema “pink puffers”:

What happens in breathing with COPD?
In conditions such as chronic bronchitis The name comes from hyperventilation (puffing to
“blue bloaters”: breathe) and pink complexion (they maintain a
relatively normal oxygen level due to rapid
breathing) rather than cyanosis as in chronic
bronchitis.
In emphysema, the alveoli sacs lose their ability to
inflate and deflate due to an inflammatory
response in the body. So, the sac is unable to
properly deflate and inflate. Inhaled air starts to
get trapped in the sacs and this causes major
hyperinflation of the lungs because the patient is
retaining so much volume.
Hyperinflation causes the diaphragm to flatten.
The diaphragm plays a huge role in helping the
patient breathe effortlessly in and out. Therefore,
in order to fully exhale, the patient starts to
hyperventilate and use accessory muscles to get
the air out now. This leads to the barrel chest look
and during inspect it may be noted there is an
INCREASED ANTEROPOSTERIOR DIAMETER.
The damage in the sacs cause the body to keep
high carbon dioxide levels and low blood oxygen
levels. Inhaled oxygen will not be able to enter into
the sacs for gas exchange and carbon dioxide won’t
leave the cells to be exhaled.
The body tries to compensate by causing
hyperventilation (increasing the respiratory
rate…hence puffer) and the patient will have less
hypoxemia “pink complexion” than chronic
bronchitis who have the cyanosis because pink
puffers keep their oxygen level just where it needs
to be from hyperventilation.
Signs & Symptoms of COPD
Remember: Lung Damage
Lack of energy
Unable to tolerate activity (shortness of breath)
Nutrition poor (weight loss) due to energy used
breathing especially with emphysema
Gases abnormal (high PCO2 >45 and low PO2
<90)..respiratory acidosis
Dry or productive cough constant (productive with
chronic bronchitis)
Accessory muscle usage during breathing,
Abnormal lung sounds: diminished, coarse crackles
(chronic bronchitis) or wheezing
Modification of skin color from pink to cyanosis in
lips, mucous membranes, nail beds (“blue
bloaters”)
Anteroposterior diameter increased (barrel
chest)….emphysema “pink puffers”
Gets in the Tripod Position during dyspnea (stands
leaning forward while supporting body with hands
on knees or an object)
Extreme dyspnea
In turn over time, people with COPD will be
stimulated to breathe due to low oxygen levels
RATHER than high carbon dioxide levels.
Complications of COPD
 Heart Disease (remember heart and lungs
work together in replenishing the body with
oxygen)…heart failure
 Pneumothorax (spontaneous due to
forming of air sacs)
 Risk for Pneumonia
 Cancer (especially lung)
How is COPD Diagnosed?
Spirometry: A test where a patient breathes into a
tube that measure how much volume the lungs can
hold during inhalation and how much and fast air
volume is exhaled.
 Measuring the FVC (Forced Vital Capacity):
a low reading shows restrictive
breathing….it measures the largest amount
of air a person exhales after breathing in
deeply in one second.
 Forced Expiratory Volume: measures how
much air a person can exhale within one
second. A low reading shows the severity of
the disease.
Nursing Interventions for COPD
Monitor Respiratory System:
 Assess lung sounds (may need suction) and
sputum production…obtain a culture if
ordered…at risk for pneumonia
 Keep oxygen saturation (88%-93%) why
between this range?
 Patients with COPD are stimulated to
breathe due to LOW OXYGEN SATURATION
rather than high carbon dioxide
levels….which is the opposite for people for
healthy lungs. If they are given too much
oxygen it will reduce their need to
 breathe…causing hypoventilation and
carbon dioxide levels will increase to toxic
levels.
 Given oxygen as prescribed in low amounts
1-2 liters
 Monitor effort of breathing and teach about
pursed-lip and diaphragmatic breathing
 Pursed-lip breathing: used for when patient
starts to get dyspneic. This technique
increases the oxygen level and encourages
them to breath out longer (remember these
patient don’t fully exhale very well). It is
similar to like blowing out a birthday
candle.
 Diaphragmatic breathing: uses abdominal
muscles for breathing rather than accessory
muscles helps make diaphragm stronger
which is weak slows down breathing rate to
allow breathing to be easier decreases
energy used to breathe used along with
pursued breathing technique
 Administering breathing treatments as
needed: bronchodilators, nebulizer etc.
Respiratory therapy helps play a role in this
as well (medications are discussed in more
detail below)
Patient Education for COPD
 Nutrition needs: eating high calorie, protein
rich meals that are small but frequent and
staying hydrated if not
contraindicated….avoid large heavy meals
due to compression on the lungs from the
stomach
 Avoiding sick people, irritants, hot humid
(smothering) or very cold weather
 Stop smoking or being around people who
smoke
 Vaccination up-to-date: annual flu shot and
Pneumovax every 5 years because it is very
hard for people with COPD to recover from
illnesses
 Pursed lip and diaphragmatic breathing
techniques
 Administering medications: be familiar with
groups, side effects, and patient teaching
Medication Regime for COPD
Remember the mnemonic: Chronic Pulmonary
Medications Save Lungs
Corticosteroids: decreases inflammation and
mucous production in airway… given: oral, IV,
inhaled and used in combination with
bronchodilator like:
Symbicort: combination of steroid and long acting
bronchodilator
Other corticosteroids: Prednisone, Solu-medrol,
Pulmicort
Side effects: easy bruising, hyperglycemia, risk of
infection, bone problems (long term use)
Patient education: rinse mouth after using inhaled
corticosteroids…can develop thrush, use
corticosteroid inhaler AFTER using bronchodilator
inhaler
Methylxanthines: Theophylline (most commonly
given orally) type of bronchodilator used long term
in patients who have severe COPD
 Remember: Narrow therapeutic range of
10 to 20 mcg/mL
 Increases risk for digoxin toxicity and
decreases the effects of lithium and Dilantin
Phosphodiestrace-4 inhibitors: “Roflumilast” used
for people who have chronic bronchitis and it
works by decreasing COPD exacerbation…not a
bronchodilator
 Side effects: can cause suicidal thoughts
(remember the word “last” in the drug’s
name…it could be the patient’s last days if
they are not assessed for this side effect)
and can cause weight loss.
Short-acting bronchodilators: relaxes the smooth
muscle of the bronchial tubes and are used in
emergency situations where quick relief is needed
 Albuterol (beta 2 agonist) and Atrovent
(anticholinergic)
Long-acting Bronchodilators: relaxes the smooth
muscle of the bronchial tubes (same as short-acting
bronchodilators BUT their effects last longer) used
over a longer period of time….taken once or twice
a day
 Beta 2 agonist: salmeterol, anticholinergics:
Spiriva
 Patient education: let them know which
drug is short and long-acting, how to use
inhaler and to use bronchodilator inhaler
 BEFORE steroid inhaler (wait 5 minutes in
between)
 WHY? TO OPEN UP THE AIRWAYS SO THE
STEROID CAN GET IN THERE AND DO ITS
JOB
 Side effects of beta 2 agonist: increased
heart rate, urinary retention
 Side effects of anticholinergic: dry mouth,
blurred vision