Dr.Sarma@works2 CHRONIC OBSTRUCTIVE LUNG DISEASES ASTHMA COPD
REVERSIBILITY OF AIR WAY OBSTRUTION FULL NONE ASTHMA EMPHYSEMA
CHRONIC BRONCHITIS
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3 PREVALENCE of MORTALITY In 2000, the WHO estimated 2.74
million COPD deaths worldwide. In 1990, COPD was ranked 12 th
leading cause of death. It is expected to be the third leading
cause of death by 2020. 10 lacs Indians die in a year due to
smoking related diseases. In India, 4,00,000 premature deaths
annually due to use of biomass fuels, like cow dung cakes, open
fires CauseDeaths CHD724,269 Cancer534,947 CVA158,060 COPD1,14,318
Accidents94,828 Diabetes64,574 (2000) * The Indian J Chest Dis
& Allied Sciences 2009; 43:139-47
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4 PREVALENCE of MORBIDITY Cigarette smoking is the primary
cause. WHO estimates 1.1 Billion smokers in world. In India
1,49,00,000 chronic cases of COPD in the age group of 30
YearConsultations 19806.1 million 19857.4 million 199010.1 million
199511.8 million 200013.9 million 2025 1.6 billion ?
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4000 chemicals (more than 60 carcinogens) are inhaled in
cigarette smoke
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Dr.Sarma@works6 Every day 55000 Indian youth start tobacco use
COLLEGE STUDENTS ( 2%) TENDER AGE GROUPS THE NUMBER OF WOMEN
SMOKERS& PASSIVE SMOKERS IS ON RISE Currently there are 94
million smokers in India
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7 Risk Factors for COPD Nutrition Infections Socio-economic
status Aging Populations Genes (alpha 1 - anti-trypsin)
Dr.Sarma@works14 PULMONARY VASCULAR CHANGES IN COPD Normal
Pulmonary Artery 1.THICK VESSEL WALL 2.INFALMMATORY CELLS
INFILTRATE 3.COLLAGEN DEPOSIT 4.DESTRUCTION OF CAPILLARY BED 3
4
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COPD Pathophysiology Fig. 29-7
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Did you know? The King of Pop suffered from Alpha-1 antitrypsin
deficiency,
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Centrilobular (central part of lobule) Dilation and destruction
of respiratory bronchioles and pulmonary capillary bed Prominent in
upper lobes Panlobular (destruction of whole lobule) Affects
respiratory bronchioles, alveolar ducts, and alveolar sacs.
Prominent in lower lobes
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Clinical Manifestations Develops slowly around 50 yrs of age
after 20 pack years of cigarette smoking Diagnosis is considered
with Cough Sputum production Dyspnea Exposure to risk factors *
Packets per day x Years of smoking = Pack Years
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Clinical Manifestations Intermittent Cough with expectoration
Progressive Dyspnea Described by the patient as an increased effort
to breathe, heaviness, air hunger, or gasping.
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Clinical Manifestations chest breathing Use of accessory such
as those in the neck and intercostal muscles Decreased abdominal
breathing flattened diaphragm from over distended lungs. Purse lip
breathing on expiration. It helps to prevent airway collapse by
increasing pressure.
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Clinical Manifestations Barrel Chest- Air gets trapped causing
increase in antero posterior dimensions of the chest
Characteristically underweight with adequate caloric intake Chronic
fatigue
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COPD Clinical Manifestations Tripod position Patient may sit
upright with arms supported on a fixed Surface.This optimises the
function of pectoral muscles to expand thoracic cavity. Bluish-red
color of skin Polycythemia and cyanosis Hemoptysis
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Poor ventilation and perfusion; unable to compensate leading to
hypoxia and cyanosis Clubbing
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Over ventilate to maintain relatively normal ABGs Red face
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DIAGNOSTIC EVALUATION *Percussion : Hyperresonant depressed
diaphragm, *Auscultation: Prolonged expiration reduced breath
sounds; The presence of wheezing during quiet breathing Crackle can
be heard if infection exist. The heart sounds are best heard over
the xiphoid area.
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Para clinical examination CT: highlighting the pulmonary
emphysema and emphysema bubbles. Blood examination In excerbation
or acute infection in airway, leucocytosis may be detected.
Screening for alpha 1 antitrypsin deficiency Sputum examination
streptococcus pneumonia Haemophilus influenzae klebsiella
pneumonia
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6-Minute walk test to determine O 2 desaturation in the blood
with exercise ECG can show signs of right ventricular failure ABG
typical findings Low PaO 2 PaCO 2 pH Bicarbonate level found in
late stages COPD
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Spirometry FEV 1 Forced expired volume in the first second FVC
Total volume of air that can be exhaled from maximal inhalation to
maximal exhalation FEV 1 /FVC% - The ratio of FEV 1 to FVC,
expressed as a percentage.
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Dr.Sarma@works29 NORMAL AND COPD SPIROMETRY
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Dr.Sarma@works30 CHEST SKIAGRAMS OF EMPHYSEMA
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Dr.Sarma@works31 V- P MISMATCH NUCLEOTIDE IMAGING
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Dr.Sarma@works32 HRCT NORMAL CHEST
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Dr.Sarma@works33 HRCT EMPHYSEMA
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Post-bronchodilator FEV1 (% predicted) Management based on
GOLD
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37 1.Assess and monitor disease 2.Reduce risk factors 3.Manage
stable COPD 4.Education 5.Pharmacologic 6.Non-pharmacologic
7.Manage exacerbations IF ONE QUITS SMOKING NO TOMORROW! 1.Studies
have shown that with smoking cessation The rate of decline in lung
function slows There will be definite clinical improvement in
symptoms
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Dr.Sarma@works38 REHABILITATION For the lungs to get more air
PURSED-LIP BREATHING (like breathing out slowly into a straw)
INHALEEXHALE
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Dr.Sarma@works39 1. Sit comfortably and relax your shoulders.
2. Put one hand on your abdomen. Now inhale slowly through your
nose. (Push your abdomen out while you breathe in) 3. Then push in
your abdominal muscles and breathe out using the pursed-lip
technique. (You should feel your abdomen go down) Note: Repeat the
above maneuver three times and then take a little rest. This
exercise can be done many times a day. REHABILITATION For the lungs
to get more air DIAPHRAGMATIC BREATHING Sit comfortably and relax
your shoulders Put one hand on your abdomen. Now inhale slowly
through your nose. (Push your abdomen out while you breathe in)
Then push in your abdominal muscles and breathe out using the
pursed-lip technique
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Positions for Postural Drainage 41
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Cupped-Hand Position 42
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Flutter Mucus Clearance Device 43
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Methods of Oxygen Administration Fig. 29-11 C-F D. Tracheostomy
Mask F. Standard Nasal Cannulas C. Venturi Mask E. Face Tent
44
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Simple Face Mask for Oxygen Administration Fig. 29-11 A 45
Plastic Face Mask with Reservoir Bag for Oxygen Administration
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You administer high flow supplemental oxygen to a patient with
COPD and the patient stops breathing. What Happened to your
patient?
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The single most important driver of ventilation is CO 2 But can
be deadly for the COPD Patient Microsoft clipart CO 2
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You removed his drive to breathe!
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DIET PLAN Calories -1300 to 1800 Kcal/day Protein - 1
gm/kg/body weight Fat - 50 gm Fibers - 30 to 35 gms Potassium rich
diet Salt 10 gm/day Hydration 3 litre /day
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51 SURGERY 1.Single lung transplant 1.LVRS - Lung volume
reduction surgery 1.Bullectomy
COPD Acute Respiratory Failure Caused by Exacerbations Cor
pulmonale Discontinuing bronchodilator or corticosteroid medication
Overuse of sedatives, benzodiazepines, and opioids Surgery or
severe, painful illness involving chest or abdomen
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Peptic Ulcer Disease Hyper secretion of gastric acid due to
increased arterial co2 and decreased arterial o2. Commonly in
duodenum and painless Depression may be four times more likely for
COPD patients Depression/Anxiety Anxiety complicates Respiratory
compromise Dyspnea Hyperventilation
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NURSING DIAGNOSES Impaired gas exchange related to ventilation
perfusion mismatch Ineffective breathing pattern related to
bronchoconstriction. Self care deficit (global) related to
generalised weakness secondary to increased work of breathing Sleep
pattern disturbance related to breathing difficulty Ineffective
individual coping related to dyspnea, and hospitalisation.
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NURSING DIAGNOSES Contd ... Interrupted family process related
to chronic condition. Risk for aspiration related to depressed
cough/ gag reflexs, impaired swallowing or delayed gastric
emptying. Risk for infection related to ineffective pulmonary
clearance Risk for impaired skin integrity related to prolonged bed
ridden. Anxiety related to outcome of disease Deficient knowledge
regarding self management to be performed at home.
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Assessment Nursing diagnosis ObjectiveNursing
interventionEvaluation Subjective data Patient verbalises that he
has breathing difficulty Objective data confused, use of accessory
muscles, restless Clinical findings Dyspnoea grade III, RR 26
/mtin, Auscultation: Wheeze both lung fields Documentary evidence
ABG-Resp.acidosis pH 45mmHg PaO2
Nursing assessmentNursin g diagno sis GoalNursing
interventionsEvaluation Subjective data: Patient verbalizes
difficulty in breathing, tiredness, not able to lie down flat and
cough Objective data: Dyspnoeic grade , shortness of breath,
frequent sighs, use of accessory muscles of breathing, nasal
flaring, cough Clinical findings: RR -> 24 breaths /minute
Irregular breathing rhythm Increased AP diameter of chest IE ratio
2:4 Documentary evidence Respiratory acidosis Chest skiagram
Consolidation of both lower lobes of lungs Ineffect ive breathi ng
pattern related to decreas ed lung expansi on Main tain effect ive
breat hing patte rn 1. Position patient in a semi to high Fowlers
position to promote maximum diaphragmatic descent and lung
expansion. Patient verbalized less breathing difficulty Patient
will maintain normal respiratory rate Regular breathing rhythm
Reduction in cough No use of accessory muscles for breathing IE
ratio 1:2 Normal and Spo 2 > 95 % 2. Use additional pillows as
needed to prevent slumping because slumping causes the abdominal
contents to be pushed up against the diaphragm and restrict lung
expansion. 3. Provide uninterrupted rest periods to increase
strength and activity tolerance which in turn promotes
participation in activities to improve breathing pattern. 4.
Instruct patient to do deep breathing exercise as follows. a.)Sit
up, stand or lean forward slightly while sitting on edge of bed or
chair.b.)Take in a slow, deep breath c.)Pause slightly or hold
breath for at least 3 secs. d.)Exhale slowlye.)Rest and repeat as
tolerated. 5. Instruct patient to do pursed-lip breathing as it
causes a mild resistance to exhalation, which creates positive
pressure in the airways. This pressure helps prevent airway
collapse and subsequently promotes more complete alveolar
emptying
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Assessment Nursing diagnosis Objectiv e Nursing
interventionEvaluation Subjective data: Patient verbalizes that I
am not able to perform daily activities Objective data: Patient is
unable to perform ADL Clinical findings: Limited ROM Muscle power-
reduced ADL scale-0/5 Documentary evidence: BP-140/90 mm Hg
PR-90/min RR-20/min Self care deficit global (Feeding, toileting,
bathing, grooming) related to lack of coordinatio n, muscular
weakness Resume s self care activitie s 1. Approach patient from
his unaffected side and arrange call light beside table, helps the
patient to compensate for alteration in sensory perception. Patient
will verbalizes that his self care activities are resumed. Patient
is able to perform activities of daily living. ROM, Muscle power,
ADL score- increased. 2. Encourage the patient to brush his teeth,
comb the hair, bathe and feed himself and to assist in toileting to
promote the self care activities. 3. Perform back massage by
following 5 steps to prevent the occurrence of bedsore. 4. Help the
patient to resume most normal eating position (may sit on chair
with pillow support) suited to the patients disability to ease the
feeding.
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Assessment Nursi ng diagn osis GoalIntervention Evaluatio n
Subjective data - Objective data Confusion, Altered gait/mobility
diminished cognitive process, Unable to carry out self care
activities, Clinical findings Blood pressure- 140/70 mm Hg Visual
field deficits Muscle strength score- upper and lower limbs -1/5
Documented evidence Radioimaging studies reveals Consolidation of
both the lower lobes of lung field, High risk for injury relate d
to altere d senso ry perce ption, dimin ished menta l status, Help
the patient to prevent from injury/ falls 1.Place articles within
easy reach of the patient to prevent from chance of fall. 2.Orient
the patient to surroundings in order to promote familiarity to the
situation. 3.Teach the patient about the importance of wearing
supportive shoes with good traction when ambulating because it
provides better balance and protect from instability on uneven
surfaces. 4.Ensure adequate lighting in all areas used by the
patient. 5.Use side rails of appropriate height and length which
decreases chance of fall from falls. 6.Involve family to aid with
activities of daily living and prevent from falls. 7.Avoid use of
restraints because they may increase agitation. 8.Provide safe
environment which allows the patient to move about as freely as
possible and relieves the family of constant worry of safety.
9.Educate the patient about certain medications that may affect the
balance or increase risk for falls because polypharmacy has been
associated with increased falls.. Patient regains normal range of
body Temp:99F Pulse:98ea ts/min Resp:20br eaths/min
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Assessment Nursing diagnosis Goal/ Objective Nursing
interventionsEvaluation Subjective data: Patient verbalizes on
difficulty swallowing a Objective data: presence of NG tube.
Clinical findings: Decreased/ absent gag reflex, Documentary
evidence: SpO2 90% with 6L of O2. Risk for aspiratio n related to
depresse d cough/ gag reflexs, impaired swallowi ng or delayed
gastric emptying. Prevent the risk of aspiration 1.Elevate the head
of bed at least 30 during feedings and for one hour after feeding
to prevent reflux by use of reverse gravity. Experien ce no
aspiratio n as evidence d by noiseless respirati ons, clear breath
sounds; clear, odorless secretion s. 2.Instruct individual and
family on activities that increase intra abdominal pressure.
Instruct on safety when feeding. 3. Use appropriate measures to
check the placement of nasogastric feeding tubes. Malplacement of
nasogastric feeding tubes may result in aspiration of enteral
formula. 4.Regulate gastric feedings using an intermittent
schedule, allowing periods for stomach emptying between feeding
intervals. 5. Aspirate the contents every 4 th hourly to determine
the amount of the residual volume.
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AssessmentNursin g diagno sis GoalNursing
interventionsEvaluation Subjective Data The patient verbalizes
itching over the site/all over the body. Objective Data Skin-moist
colour Skin turgor Clinical findings -Presence of excoriation
Dehydration (Stage-) -Chronic bed ridden status (immobility)
-Bradens scale-15/25 -Documented Evidence -Prolonged use of topical
applicants Risk for imp aire d skin inte grity relat ed to prol ong
ed bed ridd e n, patient maintai ns intact, moist and well-
lubricat ed skin 1. Inspect the skin frequently for areas of
redness, swelling. to detect early signs of infection The patient
mainta ins intact and well lubrica ted skin. 2. Provide meticulous
skincare to the skin folds that overlap and places where moisture
collects. (Abdomen folds, under and between breasts, between
buttocks or perineum)to reduce the skin breakdown. 3. Reposition
the patient Q 2 hrly to relieve pressure over bony prominences. 4.
Use pressure-reliving devices such as air/water mattress, pillows
etc. to promote comfort of the patient. 5.Clip patients nails short
and keep clean to prevent excoriation 6. Avoid use of perfumed
soaps, lotions, deodrants on involved skin surface to prevent skin
excoriation. 7. Encourage use of super fatted soap to maintain the
moisture content in the skin. 8. Decrease environmental irritants
such as heat, scratchy coverings to reduce vasodilatation and
sensory stimulation. 9. Encourage adequate fluid intake
(2000-3000ml/day) to prevent dehydration. 10. Elevate edematous
areas to promote venous drainage.
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Nursing Outcomes: Respiratory Status: Ventilation - movement of
air in and out of lungs Respiratory Status: Airway Patency - open,
clear tracheobronchial passages Knowledge: Medications - extent of
understanding conveyed about the safe use of medication