Universidad de Sta.

Isabel COLLEGE OF HEALTH EDUCATION Bachelor of Science in Nursing Academic Year 2012-2013

CASE PRESENTATION
Chronic Obstructive Pulmonary Disease (COPD)

Prepared by: CLIMACO,Karen ELOPRE, Ma. Rogine C. ESPEDIDO, Janine F. FAJARDO, Cristina Joy K. FAVORITO, Carl Earvin L. FELIPE, Eloisa Julia B.

Chronic Chronic obstructive obstructive pulmonary disease pulmonary disease (COPD)

Objectives:
To be able to know what causes the disease. To identify preventive measures against the disease. To be able to know the nursing interventions and medical managements/treatments for the disease. To identify what the disease is and how it exist in a person.

INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible, also known as chronic obstructive lung disease (COLD), chronic obstructive airway disease (COAD), chronic airflow limitation (CAL) and chronic obstructive respiratory disease (CORD), it is the occurrence of chronic bronchitis or emphysema, a pair of commonly coexisting diseases of the lungs in which the airways narrow over time. This limits airflow to and from the lungs, causing shortness of breath (dyspnea).

INCIDENCE
Chronic obstructive pulmonary disease (COPD) ranks among the leading causes of adult morbidity and mortality worldwide, especially among smokers. An estimated 16 million Americans have the disorder. According to World Health Organization COPD as a single cause of death shares 4th and 5th places with HIV/AIDS (after coronary heart disease, cerebrovascular disease and acute respiratory infection). In 1990, a study by the World Bank and WHO ranked COPD 12th as a burden of disease; by 2020, it is estimated that COPD will be ranked 5th. According to the WHO, passive smoking carries serious risks, especially for children and those chronically exposed. The WHO estimates that passive smoking is associated with a 10 to 43 percent increase in risk of COPD in adults.

INCIDENCE
Based on the 2004 Global Burden of Diseases, COPD is among the leading causes of death worldwide, along with lower respiratory tract infections, tuberculosis and lung cancer. Due to tobacco use and population ageing, the burden of chronic respiratory diseases such as COPD, lung cancer and asthma are also likely to worsen. In 2004, WHO estimated that there are 64 million people with COPD, and in 2005, more than 3 million people died of the disease. Almost 90% of deaths due to COPD occur in low and middle income countries. WHO also predicted that by 2030, COPD will become the third leading cause of death worldwide.

INCIDENCE
In the Philippines, the Department of Health (DOH)considers COPD as one of the country's major health problems. It is seventh among the top ten causes of mortality in the country. Although, there is no large scale study to determine the prevalence of COPD in the Philippines, estimates have been based primarily on morality statistics. However, proceedings of the Asia-Pacific regional workshop in 2000 cited that there is 6.3% prevalence of COPD in the country. In 1997, on a spirometry based study in a rural community, it found out that 3.7% of its population has irreversible airway obstruction.

What is COPD?

 COPD, or chronic obstructive pulmonary disorder, is a lung disease that makes it hard to breathe. The first symptoms can be so mild that people mistakenly chalk them up to "getting old." People with COPD may develop chronic bronchitis, emphysema, or both. COPD tends to get worse over time, but catching it early, along with good care, can help many people stay active and may slow the disease.

Symptoms of COPD ;
Inside the lungs, COPD can clog the airways and damage the tiny, balloon-like sacs (alveoli) that absorb oxygen. These changes can cause the following symptoms: Shortness of breath in everyday activities Wheezing Chest tightness Constant coughing Producing a lot of mucus (sputum) Feeling tired Frequent colds or flu

Advanced Symptoms of COPD;

Severe COPD can make it difficult to walk, cook, clean house, or even bathe. Coughing up excess mucus and feeling short of breath may worsen. Advanced illness can also cause: Swollen legs or feet from fluid buildup Weight loss Less muscle strength and endurance A headache in the morning Blue or grey lips or fingernails (due to low oxygen levels)

COPD: Chronic Bronchitis

This condition is the main problem for some people with COPD. Its calling card is a nagging cough with plenty of mucus (phlegm). Inside the lungs, the small airways have swollen walls, constant oozing of mucus, and scarring. Trapped mucus can block airflow and become a breeding ground for germs. A "smoker's cough" is typically a sign of chronic bronchitis. The cough is often worse in the morning and in damp, cold weather.

Signs & Symptoms of Chronic Bronchitis:

Long-Term Cough Increased Mucus Production Shortness of Breath Frequent Respiratory Infections Wheezing Swelling and Weight Gain

COPD: Emphysema
Emphysema damages the tiny air sacs in the lungs, which inflate when we take in a breath and move oxygen into the blood. They also push out carbon dioxide, a waste gas, when we breathe out. When you have emphysema, these delicate air sacs can't expand and contract properly. In time, the damage destroys the air sacs, leaving large holes in the lungs, which trap stale air. People with emphysema can have great trouble exhaling.

Symptoms of Emphysema
Shortness of Breath Rapid Breathing Chronic Cough (With or Without Sputum) Wheezing Reduced Exercise Tolerance Loss of Appetite Leading to Weight Loss Barrel Chest

Presentation Title

Diagnosis: Spirometry Breath Test

Spirometry is the main test for COPD. It measures how much air you can move in and out of your lungs, and how quickly you do it. You take a deep breath and blow as hard as you can into a tube. You might repeat the test after inhaling a puff of a bronchodilator medicine, which opens your airways. Spirometry can find problems even before you have symptoms of COPD. It also helps determine the stage of COPD.

PATIENT PROFILE

Name: Mr. A Age: 59 years old Gender: Male Occupation: Construction worker and Painter Religion: Roman Catholic Citizenship: Filipino Attending Physicians: Dr. Dee, Dr. Divinagracia, Dr. De Leon CC: Difficulty of Breathing, easy fatigability upon exertion Dx: Chronic Bronchitis

PERSONAL BACKGROUND:
Mr. A is a 59 years old construction worker/ painter and currently living with his three children and wife who is a vendor. He was a construction worker for almost 20 years. Mr. A admits to be a smoker since he was 18 years old, during his early 20s, he consumed ten sticks of cigarette per day and drinks alcoholic beverages occasionally with his friends. According to him, they have a history of lung cancer because his father was diagnosed with this kind of disease.

Medical History:
Prior to admission the client had experienced productive cough for 8 days, accompanied by easy fatigability. He has poor appetite and constantly feels exhausted. To manage the symptoms, her daughter brought him mucolytic for his cough, but the condition get worse for several days due to DOB, her daughter decided to admit him to the hospital. Upon admission, he was hooked to O2 inhalation 2-3 LPM via nasal cannula and inserted with dextrose aseptically at left cephalic vein. His attending physician ordered some lab exam such as CBC and ABG. After undergoing a thorough examination, he was diagnosed to have a chronic obstructive pulmonary disease.

CLIENTS PRESENT STATUS: Presently the client is stable, but still hooked to O2 inhalation, and currently manage with antibiotics agents, bronchodilators and mucolytic agents.

PHYSICAL EXAM:
General Appearance: obviously underweight with very reduced muscle mass & strength, using accessory muscles of respiration when breathing Vital signs: T= 37.7 P=92bpm R= 26cpm BP= 130/80 Heart: regular rate and rhythm, with slightly enlargement noted.

 Extremities: slightly cyanotic but no clubbing noted Neurologic: Coherent and oriented Skin: Warm and dry, 2-3 second capillary refill of finger nail beds Chest/ Lungs: decreased breath sounds, prolonged expiration w/ wheezing and rhonchi using accessory muscle @ rest, with productive cough( clear & thick mucus).

Gordons Functional Health Pattern

Health Perception Health Management Mr. As daughter brought him mucolytics for his cough but the condition get worse for several days due to difficulty of breathing, her daughter decided to bring him to the hospital.

Nutritional-Metabolic
He eats three times a day almost consist of vegetables, rice. He seldom eats meat and fruits. Sometimes she eats a very small amount of foods if his appetite is low.

Elimination
He eliminates every other day and he urinates 4-5 times a day with a little amount, it depends to the amount of water he takes.

Activity-Exercise
Before he has no time for exercise because of his work, he said that dikit lang na lakaw lakaw ang exercise ko. Now, he cannot exercise because of easy fatigability and difficulty of breathing.

Role-Relationship
He has a strong relationship with his wife and children. He tries to be strong to make himself feel better and his family not to worry about him.

Sleep- Rest Pattern

He sleeps less than 6 hours per day because of his cough and DOB.

Coping-Stress Tolerance Mr. A would just have a rest (sleep) every time he is on stress. Watching TV is also a form of relaxing for him.

Value-Belief Mr. A is a roman catholic. He always prays to God for her good health and long life, but he seldom goes to church every Sunday.

Anatomy & Physiology of the Respiratory System

Function of the Respiratory Oversees gas exchanges (oxygen and System

carbon dioxide) between the blood and external environment

Exchange of gasses takes place within the lungs in the alveoli(only site of gas exchange, other structures passageways Passageways to the lungs purify, warm, and humidify the incoming air Shares responsibility with cardiovascular system

Organs of the Respiratory system Nose

Pharynx

Larynx
Trachea

Bronchi
Lungs alveoli

Upper Respiratory Tract

NOSE
The nose function primarily as the organ of smell and as a passage through which are travels on its way in and out of e lungs. The upper part of the nose is supported by bone and the lower part is supported by cartilage. The external opening of the nose are the nostril or nares.

PARANASAL SINUSES
It include the frontal sinuses, located in the lower forehead between and above the eyes; the ethmoidal group of sinuses, both anterior and posterior, extended along the roof of the nostrils; the sphenoidal sinuses, opening at the rear; and the maxillary sinuses are located on either side of the nose. The same type of ciliated epithelium that lines the nasal passages also lines these

TURBINATE BONES (CONCHAE)

(The name is suggested by their shelllike appearance ) are adapted by shape and position to increase the mucous membrane surface of the nasal passages and to slightly obstruct the current of air flowing through them. The sense organ of smell is located in the olfactory membrane, which covers the roof of the nose and the superior turbinate bone.

PHARYNX
The pharynx or throat, is limited below by the larynx and the upper portion of the esophagus . Its upper extension is the nasopharynx, into which open the posterior nostril ad the auditory (euthachian)tube from the middle ears.

Larynx(voice box)
Is a cartilaginous epithelium-lined structure that is the transition between the upper airway and the lower airway. The major function of the larynx is to permit vocalization It also protect the lower airway from foreign substances and facilitates coughing. Routes air and food into proper channels Plays a role in speech

Structures of the Larynx

Epiglottis- a valve flat of cartilage that covers the opening to the larynx during swallowing Glottis- the opening between the vocal cord and the larynx Thyroid cartilage- part of it forms the adams apple, the largest cartilage in the trachea Arytenoids cartilages- use in vocal cord movement with the thyroid cartilage Vocal cords- ligaments controlled by muscular movement that produce vocal

Trachea (Windpipe)
Connects larynx with bronchi Lined with ciliated mucosa
Beat continuously in the opposite direction of incoming air Expel mucus loaded with dust and other debris away from lungs

Walls are reinforced with C-shaped hyaline cartilage

Primary Bronchi
Formed by division of the trachea

Enters the lung at the hilus (medial depression) Right bronchus is wider, shorter, and straighter than left Bronchi subdivide into smaller and smaller branches

LUNGS

Coverings of the Lungs

Pulmonary (visceral) pleura covers the lung surface Parietal pleura lines the walls of the thoracic cavity Pleural fluid fills the area between layers of pleura to allow gliding

 Each lung is divided into lobes. The right lung, which has three lobes, is slightly larger than the left, which has two. The lungs are housed in the chest cavity, or thoracic cavity, and covered by a protective membrane called the pleura. The diaphragm, the primary muscle involved in respiration, separates the lungs from the abdominal cavity.

 The pulmonary arteries carry deoxygenated blood from the right ventricle of the heart to the lungs. The pulmonary veins, on the other hand, carry oxygenated blood from the lungs to the heart, so it can be pumped to the rest of the body.

 From the outside, lungs are pink and a bit soggy, like a sponge. At the bottom of the trachea or windpipe, there are two large tubes. These tubes are called the main stem bronchi, and one heads left into the left lung, while the other heads right into the right lung. Each main stem bronchus then branches off into tubes that get smaller. The tiniest tubes are called bronchioles and there are about 30,000 of them in each lung.

At the end of each bronchiole is a special area that leads into clumps of tiny air sacs called alveoli. There are about 600 million alveoli in the lungs. Each alveolus has a mesh-like covering of very small blood vessels called capillaries. These capillaries are so tiny that the cells in the blood need to line up single file just to pass through them.

BRONCHIOLES

Smallest branches of the bronchi

Figure 13.5a

BRONCHIOLES

All but the smallest branches have reinforcing cartilage

Figure 13.5a

BRONCHIOLES

Terminal bronchioles end in alveoli

Figure 13.5a

Mechanics of Breathing
To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways.

Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax).

PHYSIOLOGY OF GAS EXCHANGE Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveoli in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over.

 Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients.

 CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.

Control of Respiratory System

Respiratory control centers found in the pons and the medulla oblongata Control breathing Adjusts the rate and depth of breathing according to oxygen and carbon dioxide levels Afferent connections to the brainstem Hypothalamus and limbic system send signals to respiratory control centers

Chronic Obstructive Pulmonary Disease (COPD)

LABORATORY RESULTS

HEMATOLOGY REPORT
Test WBC Result 15 Interpretation High Normal Value 4.3-10 Implication An elevated WBC count (leukocytosis) commonly signals infection. A low Hgb. count is a belowaverage concentration of oxygen carrying Hgb. proteins in the blood. This is supported by dyspnea experiencing by the patient. Decrease hct. Suggests fluid overload and increase plasma volume. Both decrease in hgb. And hct. Indicates anemia.

Hemoglobin

11.5

Low

12-16 g/dl

Hematocrit

34

Low

37-47%

Lymphocyte s

10

Low

25-40%

Decrease lymphocyte indicates severe debilitating illness like heart failure and renal failure.

Test

Resul Interpretati t on
3.2 Low

Normal Value
3.5-5.0 g/dl

Implication

Albumin

Low albumin levels indicates inflammation, shock, and malnutrition. It may be seen with conditions in which the body does not properly absorb and digest protein.

Total protein

5.8

Low

6.0-8.0 g/dl

Low total protein commonly indicates liver disease, malabsorption and malnutrition.

BUN

High

8.26 mg/dl

High BUN levels occur in reduce renal blood flow (from dehydration).

ABG REPORT
Test Result Interpretatio n High Normal Value Implication

PCO2

50.9

35-45 mmHg If the PCO2 is elevated, it indicates pulmonary edema; there is an extra layer of fluid in the alveoli that interferes with the lungs' ability to get rid of CO2. This leads to a rise in pCO2.

P02

76.8

Low

>80 mmHg

Low PO2 level indicates an interference with ventilation process. Decreased oxygen levels in the inhaled air & Heart decompensation. Elevated C02 level indicates impaired renal function and unusual losses (diarrhea) which are seen in severe vomiting and in COPD patients.

C02 Content

31

High

25-30 mmol/L

CHEST X-RAY :

Chest X-ray shows softening of the diaphragm, slight cardiac enlargement, prominent vascular and bronchial markings, and patchy infiltrates.

MEDICATIONS

MEDICATION

CLASSIFICATIO N Bronchodilators

INDICATION

ACTION

Combivent/ Asmavent

Bronchodilators are often used to treat conditions that cause airways to narrow or become inflamed, such as: breathlessness asthma bronchiectasis a lung condition where the airways are abnormally widened chronic obstructive pulmonary disease (COPD) permanent lung damage usually caused by smoking Corticosteroids may be used to treat chronic obstructive pulmonary disease (COPD) when symptoms rapidly get worse (COPD exacerbation), especially when there is increased mucus production.

Medicines that relax (dilate) the airways of the lungs (bronchial tubes). This makes it easier for a person to breathe in more air.

Hydrocortison e

Corticosteroids

Corticosteroids decrease inflammation in the airways (reducing swelling and mucusproduction), making breathing easier.

MEDICATION

CLASSIFICATIO N

INDICATION

ACTION

Cefuroxime

Antibiotic

Treatment of infections of lower Inhibits mucopeptide synthesis in respiratory tract, urinary tract, skin bacterial cell wall. and skin structures, bone and joint; preoperative prophylaxis; treatment of septicemia, gonorrhea, and meningitis caused by susceptible strains of specific microorganisms.

Fluimucil

Mucolytic

Treatment of respiratory affections ch aracterized by thick and viscoushypers ecretions: acute bronchitis, chronic br onchitis and its exacerbations; pulmon aryemphysema, mucoviscidosis and bronchiectasis.

Exerts mucolytic action through its free sulfhydryl group which opensup the disulfide bonds in the m ucoproteins thus lowering mucous vis cosity. The exactmechanism of action in acetaminophen toxicity is unknown. It is thought to act by providingsubstrate for conjugation with the toxic metabolite. The exact mechanism of action of is not known.

Paracetamol

Antipyretic

pain reliever and a fever reducer.

DISCHARGE PLAN

MEDICINES
The patient was prescribed to take: Combivent/ Asmavent neb TID - management of asthma. Hydrocortisone q 6 hr. Cefuroxime 750 mg - is an antibiotic. It is used to treat certain bacterial infection Fluimucil 200mg- Acute & chronic resp tract infections w/ abundant mucus secretions due to acute bronchitis Paracetamol 500mg- nd for symptomatic relief of fever and pain, Upper respiratory tract infections

EXERCISE
Aerobic exercise is very beneficial for COPD. This type of exercise, which uses large muscle groups, strengthens the lungs and heart. It also helps the body to use oxygen better and lowers your heart rate. It will improve breathing, because the heart won't have to work as hard during exercise, Practice a coughing exercise to help keep your lungs clear. Start by sitting in a chair. Relax. Lean your head forward slightly. Both feet should be placed firmly on the floor. Breathe in deeply and slowly. Hold your breath for three seconds, if possible. Open your mouth a little and cough twice. Take a breath, then repeat the exercise two to four times. A pursed lip breathing exercise can help release air trapped in your lungs. It also helps to eliminate shortness of breath and improves ventilation.

TREATMENT
Nicotine Replacement Therapy - Including gum, inhalers, tablets, patches and nasal spray. These aids help reduce cravings, making it easier to quit. Aerosol therapy is the process of dispensing particles of medication in a fine spray or mist by way of a nebulizer. The medications frequently used during this process are bronchodilators. Nebulizer aerosols work by relieving spasms in the lungs, decreasing swelling, and making your secretions easier to cough up. Oxygen therapy not only increases survival rates in patients with COPD, but it may help alleviate symptoms and improve your quality of life. Remember, oxygen is a drug and must be prescribed by a physician

HEALTH TEACHING
Teach the patient and his family how to recognize early signs of infection; warn the patient to avoid contact with people with respiratory infections. Encourage good oral hygiene to help prevent infection. Help the patient and his family adjust their lifestyles to accommodate the limitations imposed by this debilitating chronic disease. Instruct the patient to allow for daily rest periods and to exercise daily as directed. Teach good habits of well-balanced, nutritious intake. Encourage high-protein diet with adequate mineral, vitamin, and fluid intake. Advise against excessive hot or cold fluids and foods, which may provoke an irritating cough.

 Advise to avoid hard-to-chew foods (causes tiring) and gas-forming foods, which cause distention and restrict diaphragmatic movement. Advise patient to stop smoking and avoid exposure to second-hand smoke. Advise patient to avoid sweeping, dusting, and exposure to paint, aerosols, bleaches,ammonia, and other respiratory irritants. Advise patient to keep entire house well-ventilated. Warn patient to stay out of extremely hot/cold weather to avoid bronchospasm and dyspnea Breathing exercises to strengthen and coordinate muscles of breathing to lessen work of breathing and help lung empty more completely. If the patient use oxygen therapy at home, teach him how to use the equipment correctly.

OPD
Follow up your doctor for further advises and if any unusual symptoms arise. Follow the treatment regimen

DIET
Warn against potassium depletion. Patients with COPD tend to have low potassium levels; also, patient may be taking diuretics; Watch for weakness, numbness, tingling of fingers, leg cramps, Encourage foods high in potassium include bananas, dried fruits, dates, figs, orange juice, grape juice, milk, peaches, potatoes, tomatoes. Advise patient on restricting sodium as directed. Limit carbohydrates if CO2 is retained by patient, because they increase CO2

SPIRITUAL
You may also find yourself facing some tough questions, suchas how long you have to live and what you will do if you no longer can take care of yourself.Share your fears and feelings with your family, friends and doctor. And always have a strong faith in God.

THANKYOU FOR LISTENING!