COPD

Chronic obstructive pulmonary disease (COPD) affects the lungs’ ability to allow air to flow freely. The nurse must work
with the health care team to improve the patient’s respiratory effort and prolong lung function to improve the patient’s
quality of life.

Upon completion of this lesson, the learner will be able to: manage the care of the patient with COPD.

COPD Etiology

COPD is characterized by persistent airflow limitation that is usually progressive. Patients with COPD have an enhanced
inflammatory response in the airways and lungs, typically caused by cigarette smoking and exposure to other noxious
particles or gases.

• Cigarette smoking: Cigarette smoking is the major risk factor for developing COPD. It affects about 15% of
smokers. Passive smoking is the exposure of nonsmokers to cigarette smoke, also known as environmental
tobacco smoke (ETS) or secondhand smoke.
• Exposure: if a person has intense or prolonged exposure to various dusts, vapors, irritants, or fumes in the
workplace, symptoms of lung impairment consistent with COPD can develop. If a person has occupational
exposure and smokes, the risk of COPD increases. High levels of urban air pollution are harmful to people with
existing lung disease. However, the evidence for outdoor air pollution as a risk factor for the development of
COPD is unclear.
• Preexisting Respiratory Conditions: Severe recurring respiratory tract infections in childhood have been
associated with reduced lung function and increased respiratory symptoms in adulthood. It is unclear whether
the development of COPD can be related to recurrent infections in adults. Asthma may be a risk factor for
development of COPD.
• Genetics: Genetic factors influence which smokers get the disease. α1-Antitrypsin (AAT) deficiency is a genetic
risk factor for COPD. The main function of AAT, an α1-protease inhibitor, is to protect normal lung tissue from
attack by proteases during inflammation related to cigarette smoking and infections.

COPD Pathophysiology

COPD is a chronic inflammation of the airways, respiratory bronchioles, alveoli, and pulmonary blood vessels associated
with:

• irreversible airflow limitation during forced exhalation

• caused by loss of elastic recoil and airflow obstruction from mucus hypersecretion
• mucosal edema
• bronchospasm

The inflammatory process starts with inhalation of noxious particles (e.g. cigarette smoke) that causes the release of
inflammatory mediators that damage lung tissue. This process causes tissue destruction and disrupts the normal
defense mechanisms and repair process of the lung. The irritating effect causes hyperplasia of cells, which subsequently
results in increased mucus production. Hyperplasia reduces airway diameter and causes difficulty in clearing secretions.
Smoking reduces ciliary activity and produces abnormal dilation of the distal air space with destruction of alveolar walls.

Cardiovascular diseases commonly occur along with COPD, because smoking is a primary risk factor for both.
COPD Clinical Manifestations

COPD typically develops slowly, but a diagnosis of COPD should be considered in a patient with chronic cough or sputum
production, dyspnea, and a history of exposure to risk factors for the disease (eg, tobacco smoke, occupational dusts
and chemicals).

• Cough: A chronic intermittent cough, often the first symptom to develop, may later be present every day.
• Dyspnea: Dyspnea with exertion is often progressive. In the late stages of COPD, dyspnea may be present at rest.
• Weight loss and fatigue: The patient with advanced COPD experiences weight loss, even with adequate caloric
intake, because of the increased energy expenditure required for breathing. Fatigue is a prevalent symptom that
affects activities of daily living.
• Respiratory effort: During physical examination, a prolonged expiratory phase of respiration, wheezes, or
decreased breath sounds will be noted in all lung fields. The anterior-posterior diameter of the chest is increased
from 1:1 to 2:1 (barrel chest) from chronic air trapping. The patient may assume a tripod position and use
pursed-lip breathing.
• Hypoxemia and hypercapnia: Over time, hypoxemia may develop with hypercapnia. The bluish-red color of the
skin results from polycythemia and cyanosis. Polycythemia develops as a result of increased production of red
blood cells as the body attempts to compensate for chronic hypoxemia.

Nursing Care Pearl

Patients with COPD who assume the tripod position often, using a hard surface like a table to lean on, are at high risk for
developing pressure ulcers on their elbows. Teach patients to use padding or other protection to prevent this from
happening.

COPD Diagnostic Studies

Several diagnostic studies are used to identify COPD:

• Pulmonary function test: A forced expiratory volume in 1 second/forced vital capacity ratio (FEV1/FVC) less than
70% along with the appropriate symptoms can help to diagnose COPD. A lower value of FEV1 indicates more
severe COPD.
• Oxygen saturation decreases progressively as the disease advances.
• Spirometric classification of COPD
❖ Stage I (Mild COPD) - FEV1/FVC is less than 70%; FEV1 is above 80% predicted.
❖ Stage 2 (Moderate COPD) - FEV1/FVC is less than 70%; FEV1 is between 50% and 80% predicted.
❖ Stage 3 (Severe COPD) - FEV1/FVC is less than 70%; FEV1 is between 30% and 50% predicted.
❖ Stage 4 (Very Severe) - FEV1/FVC is less than 70%; FEV1 is below 30% predicted, or FEV1 is less than 50%
with chronic respiratory failure.
• Electrocardiogram (ECG) and echocardiogram can be used to determine the presence of right- and left-sided
ventricular failure.
• Sputum culture and sensitivity are done if an acute exacerbation is present.
• Arterial blood gases (ABGs) in later stages usually indicate low partial arterial oxygen tension (PaO2), elevated
PaCO2, decreased or low normal pH, and increased bicarbonate levels. Expected ABG levels for patients with
COPD depend on the type of COPD.
❖ Patients with emphysematous lung tissue destruction: normal partial pressure of carbon dioxide (PaCO2),
PaO2 >60 mm Hg.
❖ Patients with pulmonary vasoconstriction: PaCO2 >45 mm Hg, PaO2 <60 mm Hg.
• Chest x-rays are not diagnostic but may show a flat diaphragm caused by hyperinflation of the lungs.
Key Points

• COPD is associated with an enhanced inflammatory response in the airways and lungs, primarily caused by
cigarette smoking and other noxious particles or gases.
• The defining features of COPD are irreversible airflow limitation during forced exhalation caused by loss of
elastic recoil and airflow obstruction caused by mucus hypersecretion, mucosal edema, and bronchospasm.
• A diagnosis of COPD should be considered for a patient who has symptoms of cough, sputum production, or
dyspnea and/or a history of exposure to risk factors for the disease.
• Diagnostic studies used to identify COPD include pulmonary function test, ECG, sputum culture, ABGs, and chest
x-rays.
• Diagnosis of COPD is made when the FEV1/FVC ratio is less than 70%.

QUIZ

1. The nurse understands that patients working in which occupations may have an increased risk for developing chronic
obstructive pulmonary disease (COPD)?
Exterminators: Exterminators are at increased risk for developing COPD because they are frequently exposed to dust,
vapors, chemical irritants, and fumes.
City bus drivers: City bus drivers are at increased risk for developing COPD because they are frequently exposed to dust,
vapors, chemical irritants, and fumes.
Construction workers: Construction workers are at increased risk for developing COPD because they are frequently
exposed to dust, vapors, chemical irritants, and fumes.

2. The nurse is caring for a patient with new-onset chronic obstructive pulmonary disease (COPD). Which assessment
findings would be expected?
Persistent cough: Persistent cough is a symptom of chronic bronchitis.
Increased red blood cell (RBC) count: An increased number of RBCs is indicative of polycythemia, which occurs as a
result of hypoxemia in patients with COPD.
Weight loss of 10 lb in 1 month: Unexplained weight loss occurs in patients with COPD as a result of an increase in
energy expenditure.

3. Which nursing assessment findings would indicate that the patient has severe chronic obstructive pulmonary disease
(COPD)?
Oxygen saturation of 82%: An oxygen saturation of 82% is hypoxemia, a sign of advanced COPD.
Forced expiratory volume in 1 second (FEV1) of 39%: An FEV1 between 30% and 49% indicates severe COPD.

Priority Actions to Prevent/Treat

Most patients with COPD are treated as outpatients. They are hospitalized for complications such as acute exacerbations
and acute respiratory failure.

• The nurse and respiratory therapist work together to evaluate the patient’s exposure to environmental or
occupational irritants and determine ways to control or avoid them.
• The patient with COPD and anyone who smokes should receive an influenza immunization yearly.
• The health care provider may order a pneumococcal vaccine for patients with COPD.
• Exacerbations of COPD should be treated as soon as possible, especially if the patient is in the severe stages.
• Cessation of cigarette smoking is the intervention that can have the biggest impact on reducing the risk of
developing COPD and on decreasing progression of the disease at any stage.
Oxygen therapy, breathing exercises and medications:

Long-term continuous (more than 15 hr/day) oxygen therapy (LTOT) increases survival and improves exercise capacity
and mental status in patients with COPD and hypoxemia. Prolonged hypoxemia can lead to fatigue and even confusion
and delirium.

The main types of breathing exercises commonly taught are pursed-lip breathing and diaphragmatic breathing. In
pursed-lip breathing, the patient is instructed to exhale though pursed lips, a positioned similar to that used to whistle,
and exhale twice as long as he or she inhales. However, patients with moderate to severe COPD with marked
hyperinflation may be poor candidates for diaphragmatic breathing. To perform diaphragmatic breathing, the patient
lies supine with the knees flexed. With the hands resting on the abdomen, the patient should focus on filling the lungs
completely using the diaphragm and should note the rise and fall of the abdomen with inhalation and exhalation.

• Airway clearance techniques: Airway clearance techniques loosen mucus and secretions for clearance by
coughing. A variety of treatments can be used to achieve airway clearance. Respiratory therapists, physical
therapists, and nurses are involved in performing these techniques. Chest physiotherapy (CPT) is primarily used
for patients with excessive bronchial secretions who have difficulty clearing them.
• Diaphragmatic breathing: Before diaphragmatic breathing is started, ensure that the patient is breathing deeply
from the diaphragm. Place the patient’s hands on the lower lateral chest wall and then ask the patient to
breathe deeply through the nose. The nurse should feel the patient’s hands move outward, which represents a
breath from the diaphragm.
• Postural drainage: Postural drainage is the use of positioning techniques that drain secretions from specific
segments of the lungs and bronchi into the trachea. Beds that can rotate and percuss in various postural
drainage positions are available, and these are quite effective.
• Percussion: Percussion is performed in the appropriate postural drainage position with the hands in a cuplike
position, with the fingers and thumbs closed. The cupped hand should create an air pocket between the
patient’s chest and the hand. Both hands are cupped and used in an alternating rhythmic fashion. If it is
performed correctly, a hollow sound should be heard.
• Vibration: Vibration is accomplished by tensing the hand and arm muscles repeatedly and pressing mildly with
the flat of the hand on the affected area while the patient slowly exhales a deep breath. The vibrations facilitate
movement of secretions to larger airways.
• High-frequency chest wall oscillation: For high-frequency chest wall oscillation, an inflatable vest with hoses
connected to a high-frequency pulse generator is used. The pulse generator delivers air to the vest, which
vibrates the chest. The high-frequency airwaves dislodge mucus from the airways, mobilize the mucus, and
move it toward larger airways.

Medications: Medications for COPD can reduce symptoms, increase exercise capacity, improve overall health, and
reduce the number and severity of exacerbations.

• Bronchodilators: Bronchodilator medications commonly used are β2-adrenergic agonists, anticholinergic

agents, and methylxanthines. When the patient has mild COPD or intermittent symptoms, a short-acting
bronchodilator is used as needed. Examples of short-acting bronchodilators are albuterol and ipratropium. In
the moderate stage of COPD, a long-acting bronchodilator is also used. Examples of long-acting bronchodilators
are salmeterol and formoterol.
• Corticosteroids: In patients with COPD associated with an FEV1 less than 60%, regular treatment with inhaled
corticosteroids (ICSs) is often prescribed, in addition to a long-acting β-agonist (LABA). Examples of combinations
of ICSs with LABAs are fluticasone/salmeterol and budesonide/formoterol.
• Roflumilast: Roflumilast is an oral medication used to decrease the frequency of exacerbations in patients with
severe COPD and chronic bronchitis. This drug is a phosphodiesterase inhibitor, which is an antiinflammatory
agent that suppresses the release of cytokines and other inflammatory mediators and inhibits the production of
reactive oxygen radicals.
Nursing Care Pearl
When multiple inhaled medications are ordered, the bronchodilator should be used first to open the airway. Wait about
2-5 minutes before administering each type of inhaled medication. If a corticosteroid has been prescribed, the patient
needs to be taught to rinse the mouth after use to prevent oral candida (yeast) infection.

Lifestyle and Dietary Changes

Weight loss and muscle wasting are common in the patient with severe COPD. To decrease dyspnea and conserve
energy, the patient should rest at least 30 minutes before eating and use a bronchodilator before meals. It is also
important for the patient to get an appropriate amount of physical activity to maintain muscle strength. The nurse
should encourage the patient to speak to the provider, and possibly a respiratory therapist and a physical therapist, to
determine how much activity is acceptable based on the stage of COPD. A diet high in calories and protein, moderate in
carbohydrates, and moderate to high in fat is recommended and can be divided into five or six small meals a day. The
nurse may recommend foods such as peanut butter sandwiches or baked chicken for meals.

Case Study: The Patient with COPD

Mr. Sanchez presents to the hospital with chest pain and dyspnea. Mr. Sanchez has been smoking approximately 4 packs
of cigarettes per week for 20 years and reports a persistent cough that produces sputum. Mr. Sanchez has an FEV1/FVC
of 60% and an SaO2 of 90%.

Key Points

• Treatment for COPD is typically done on an outpatient basis and involves preventing respiratory illnesses, such
as influenza and pneumonia, treating exacerbations, and smoking cessation.
• Patients with COPD are taught breathing exercises, such as pursed-lip breathing, to prevent hyperinflation.
• Airway clearance techniques, such as postural drainage and chest physiotherapy, are performed to prevent
collection of secretions in the lungs.
• Medications used to treat COPD include bronchodilators and corticosteroids.
• Patients with COPD should maintain a healthy lifestyle with a balanced diet and regular physical activity.
• Patients may need to increase caloric intake to meet the increased metabolic demands of the illness.

Quiz

1. Which intervention is the priority for Mr. Sanchez to inhibit progression of chronic obstructive pulmonary disease
(COPD)?
Encouraging smoking cessation:
Smoking causes damage to lung tissue, which can lead to progression of COPD. The nurse should focus on supporting
Mr. Sanchez through smoking cessation.

2. Mr. Sanchez reports thick sputum production with cough and difficulty breathing, which interferes with daily activities
and sleep at night. Which collaborative care interventions would address the excess sputum production?
Postural drainage: Postural drainage is the use of positioning techniques that drain secretions from specific segments of
the lungs and bronchi into the trachea.
Chest wall oscillation therapy: Chest wall oscillation generates a high-frequency pulse that vibrates the chest wall to
mobilize secretions and clear the airway.
3. Mr. Sanchez begins to exhibit mood swings and altered cognitive function. Which intervention is most appropriate?
Oxygen therapy: Confusion and irritability are signs of hypoxemia and should be treated with supplemental oxygen
therapy.

Nursing Goals

When caring for patients with COPD, the goals are for the patient to have:

• Knowledge of prevention of disease progression

• Ability to perform activities of daily living
• Improved exercise tolerance
• Relief from symptoms, such as dyspnea and fatigue
• No complications related to COPD, such as weight loss and respiratory failure
• Knowledge and ability to implement a long-term treatment regimen
• Overall improved quality of life

Nursing Assessment

Counseling the patient regarding smoking cessation is vital, because it is the only way to slow the progression of COPD.
Avoiding or controlling exposure to occupational and environmental pollutants and irritants is another preventive
measure to maintain healthy lungs. Early diagnosis and treatment of respiratory tract infections and exacerbations of
COPD help prevent progression of the disease. A diagnosis of COPD is made when the FEV1/FVC ratio is less than 70%.

Nursing Assessment: Subjective Data

• Exposure to respiratory irritants; recurrent respiratory tract infections

• Medications: Use of oxygen, bronchodilators, corticosteroids, antibiotics, anticholinergics, over-the-counter
(OTC) drugs, herbs
• Smoking (including passive smoking, willingness to stop smoking)
• Family history of respiratory disease
• Anorexia, weight loss or gain
• Increasing dyspnea, sputum volume or purulence
• Activity intolerance
• Respiratory symptoms
• Constipation, gas, bloating
• Insomnia, orthopnea, paroxysmal nocturnal dyspnea
• Headache, chest or abdominal soreness
• Anxiety, depression

Nursing Assessment: Objective Data

• Debilitation, restlessness
• Cyanosis, pallor or ruddy color, poor skin turgor, thin skin, digital clubbing, easy bruising, peripheral edema
• Rapid, shallow breathing; inability to speak; prolonged expiration; pursed-lip breathing; wheezing; rhonchi,
crackles, diminished or bronchial breath sounds; use of accessory muscles; hyperresonant or dull chest sounds
on percussion
• Tachycardia, dysrhythmias, jugular venous distention, distant heart tones, right-sided S3
• Ascites, hepatomegaly
• Muscle atrophy, increased anterior-posterior diameter (barrel chest)
Nursing Interventions

• Provide ventilation assistance to promote gas exchange, oxygenation, and perfusion.

• Teach cough enhancement techniques to promote expectoration of secretions.
• Encourage use of airway clearance techniques and provide airway management as necessary.
• Provide oxygen therapy and administer medication to prevent and treat hypoxemia.
• Monitor for signs of malnutrition and educate patients about proper nutrition and calorie intake.

Evaluation

• The nurse determines that treatment was effective if the patient:

• Experiences a return to baseline respiratory function
• Demonstrates an effective rate, rhythm, and depth of respiration
• Maintains a clear airway
• Experiences clear breath sounds

Education

The most important aspect of long-term care of the patient with COPD is patient teaching. Teaching related to smoking
cessation, for example, is critical. Energy conservation is another important component of patient teaching for patients
with COPD. Patients should understand that exercise training of the upper extremities may improve muscle function and
reduce dyspnea. Alternative energy-saving practices should be introduced, and scheduled rest periods should be
encouraged. Nurses should help patients with COPD to understand symptoms and conditions that require immediate
treatment, such as exacerbations of COPD, pneumonia, cor pulmonale, and acute respiratory failure.

Exercise: Walking or other endurance exercises (eg, cycling) combined with strength training are the best interventions
to strengthen muscles and improve the patient’s endurance. Teach the patient coordinated walking with slow, pursed-
lip breathing. Encourage the patient to walk 15 to 20 minutes per day at least three times a week, with gradual
increases.

Modification of sexual activity: It is also important to teach patients that modifying but not abstaining from sexual
activity can contribute to a healthy sense of overall well-being. Using an inhaled bronchodilator before sexual activity
can help ventilation.

Sleep: Encourage patients to get adequate sleep. The patient who is a restless sleeper, snores, stops breathing while
asleep, and has a tendency to fall asleep during the day may need to be tested for sleep apnea.

Coping: Healthy coping is a challenge for the patient and family. People with COPD frequently have to deal with many
lifestyle changes that may involve decreased ability to care for themselves, decreased energy for social activities, and
loss of a job. Encourage the patient to find support groups at local chapters of the American Lung Association, hospitals,
and clinics.

The nurse and patient should develop and write up a COPD management plan that meets the patient’s individual needs.

• Focus on self-management
• Need to report changes
• Cause of flare-ups or exacerbations
• Recognition of signs and symptoms of respiratory tract infection, heart failure
• Yearly follow-up evaluations
Treatments

• Pursed-lip breathing
• Airway clearance technique—huff cough
• Energy conservation techniques
• Medications (including mechanism of action and types of devices)
• Establishing a medication schedule
• Correct use of inhalers, spacer, and nebulizer
• Guide for home oxygen use and equipment

Health Promotion

• Influenza vaccine each year

• Pneumococcal vaccine
• Reduced exposure to household chemicals and outdoor air pollutants
• Frequent handwashing and other measures to minimize risk of infection

Lifestyle Modifications

• Good nutrition
• Reduction of risk factors, especially smoking cessation
• Exercise program of walking and arm strengthening
• Strategies to lose or gain weight, as appropriate
• Consultation with dietitian

Pyschological/Emotional Issues

• Concerns about interpersonal relationships (eg, intimacy)

• Problems with emotions (eg, depression, anxiety, panic)
• Dependency
• Treatment decisions
• Support and rehabilitation groups
• End-of-life issues

Case Study: Mrs. Strom, a 65-year-old patient who has been smoking heavily for 40 years and does not engage in
physical exercise, presents with a chronic productive cough, dyspnea on exertion, and wheezing on exhalation. She
reports that recently, the symptoms have interfered with the ability to work. Mrs. Strom’s FEV1/FVC is 60% and SaO2 is
at 80%. Her temperature is 98.6° F, heart rate is 90 beats/min, respiratory rate is 18 breaths/min, and blood pressure is
145/90 mm Hg.

Key Points

• The goals for patients with COPD include preventing disease progression, improving activity tolerance, relieving
symptoms, and improving the overall quality of life.
• The nurse should monitor the patient’s respiratory status and provide ventilatory support and oxygen therapy as
needed. Medications should be administered to treat respiratory compromise. The patient should be monitored
for signs of malnutrition.
• A thorough respiratory assessment and patient teaching on airway clearance techniques, lifestyle modifications,
and correct medication administration are important parts of nursing care for patients with COPD.
Quiz:

1. Which nursing goals are priorities for Mrs. Strom?

Relief from dyspnea: Care of patients with chronic obstructive pulmonary disease should be focused on relieving
dyspnea.
Prevention of complications: Mrs. Strom's symptoms and risk factors indicate the potential for other complications. Care
should be focused on preventing complications, such as secondary infections.
Ability to perform work-related tasks: Care of Mrs. Strom should be focused on the ability to perform work-related tasks
and activities of daily living independently.

2. Which patient education should the nurse provide Mrs. Strom to assist with long-term management of her
symptoms?
Make sleep a priority. Because of the increased energy expenditure, patients with chronic obstructive pulmonary
disease should get sufficient sleep.
Seek social or group support. Support groups can help patients with chronic obstructive pulmonary disease cope with
their diagnosis.
Use airway clearance techniques. Airway clearance techniques, such as huff coughing, should be taught.
Take scheduled breaks throughout the day. Patients should be taught to take regular breaks at work to conserve
energy.

3. A patient with chronic obstructive pulmonary disease (COPD) presents with a nonproductive cough, chest pressure,
and dyspnea. The nurse notes an oxygen saturation of 86% on room air. Which action should the nurse take first?
Obtain an order to apply supplemental oxygen. The nurse should obtain an order to apply supplemental oxygen to
improve oxygen saturation.

Summary

COPD is an obstructive respiratory illness that leads to excessive sputum production and air trapping in the lungs; it is
primarily caused by exposure to cigarette smoke and other noxious particles or gases. Patients with COPD often
experience a persistent cough, excessive sputum production, and shortness of breath.

Patients with COPD are typically treated in the outpatient setting. It is important to frequently assess the patient’s
respiratory status, prevent respiratory illnesses that can lead to exacerbations of COPD, and support the patient through
smoking cessation. Patient teaching is essential to ensure proper breathing techniques and airway clearance maneuvers,
as well as proper medication administration. The overall goal of care is to improve the patient’s quality of life.

Key Points

• COPD is associated with an enhanced inflammatory response in the airways and lungs, primarily caused by
cigarette smoking and other noxious particles or gases.
• The defining features of COPD are irreversible airflow limitation during forced exhalation caused by loss of
elastic recoil and airflow obstruction caused by mucus hypersecretion, mucosal edema, and bronchospasm.
• A diagnosis of COPD should be considered for a patient who has symptoms of cough, sputum production, or
dyspnea and/or a history of exposure to risk factors for the disease.
• Diagnostic studies used to identify COPD include pulmonary function test, ECG, sputum culture, ABGs, and chest
x-rays.
• Diagnosis of COPD is made when the FEV1/FVC ratio is less than 70%.
• Treatment for COPD is typically done on an outpatient basis and involves preventing respiratory illnesses, such
as influenza and pneumonia, treating exacerbations, and smoking cessation.
• Patients with COPD are taught breathing exercises, such as pursed-lip breathing, to prevent hyperinflation.
• Airway clearance techniques, such as postural drainage and chest physiotherapy, are performed to prevent
collection of secretions in the lungs.
• Medications used to treat COPD include bronchodilators and corticosteroids.
 • Patients with COPD should maintain a healthy lifestyle with a balanced diet and regular physical activity.
• Patients may need to increase caloric intake to meet the increased metabolic demands of the illness.
• The goals for patients with COPD include preventing disease progression, improving activity tolerance, relieving
symptoms, and improving the overall quality of life.
• The nurse should monitor the patient’s respiratory status and provide ventilatory support and oxygen therapy as
needed. Medications should be administered to treat respiratory compromise. The patient should be monitored
for signs of malnutrition.
• A thorough respiratory assessment and patient teaching on airway clearance techniques, lifestyle modifications,
and correct medication administration are important parts of nursing care for patients with COPD.

FINAL QUIZ

1. Which patient is at the highest risk for developing chronic obstructive pulmonary disease (COPD)?
A smoker who works as a coal miner whose mother had COPD. Exposure to cigarette smoke and coal dust increases the
risk for COPD.

2. Place the physical manifestations of chronic obstructive pulmonary disease in the order in which they appear in the
disease process.
Productive cough every few days for a month
Decreased endurance during morning walks
Difficulty breathing on awakening in the morning
Altered chest expansion
Bluish skin discoloration

3. The nurse is caring for a number of patients in the unit. Which patient most likely has chronic obstructive pulmonary
disease (COPD)?
A 65-year-old smoker with 1:2 anterior-posterior (AP) chest diameter.
Smokers are at increased risk for COPD, and hyperinflation from COPD increases the patient's AP chest diameter.

4. A patient with chronic obstructive pulmonary disease (COPD) reports a chronic productive cough and an unintended
weight loss of 15 lb over the previous month. Which recommendations should be made to this patient to address the
current symptoms?
High protein diet: A diet that is high in calories and protein should be recommended because additional calories are
needed to support increased energy expenditure and treat the patient's weight loss.
Increased oral fluid intake: Oral fluid intake thins lung secretions for better expectoration to treat the productive cough.
Use of diaphragmatic breathing: Diaphragmatic breathing helps the patient breathe deeply (from the diaphragm) and
can assist with clearing fluid and secretions from the airways.

5. A patient arrives at the hospital with a history of long-term exposure to caustic fumes. Assessment reveals a forced
expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio of 65% and a functional oxygen saturation of 88%.
The patient smokes 1 pack of cigarettes per day and reports a recent increase in sputum production and a change in
color from clear to green. In which order should the nurse initiate the collaborative care actions?
1) provide supplement oxygen
2) teach diaphragmatic breathing
3) administer intravenous corticosteroids
4) obtain a sputum culture

6. A patient with chronic obstructive pulmonary disease (COPD) presents with orthopnea and dyspnea that interferes
with daily chores and the patient's ability to care for himself. The nurse checks the forced expiratory volume in 1 second
(FEV1) and finds it to be 68%. The nurse would expect to administer which medications as part of the treatment
regimen?
Fluticasone/salmeterol: Fluticasone/salmeterol is an inhaled corticosteroid used to treat advanced COPD.
7. A patient diagnosed with chronic obstructive pulmonary disease (COPD) experiencing shortness of breath and a
cough asks the nurse the best way to prevent exacerbations. Which recommendations should the nurse make?
Effective handwashing: Effective handwashing can prevent secondary infections and prevent acute exacerbations.
Preventative vaccinations: Preventative vaccinations can decrease the risk for secondary infections and prevent acute
exacerbations.

8. The nurse is preparing to discharge a patient with chronic obstructive pulmonary disease (COPD) who reports weight
loss of 10 lb in the past month, fatigue, and dyspnea at rest. Which recommendations should the nurse include in
discharge teaching?
Adequate sleep: Adequate sleep is necessary to ensure the patient has energy and is able to perform activities of daily
living.
High-calorie diet: A high-calorie, high-protein diet and will promote energy.
Oxygen supplementation: Oxygen supplementation treats hypoxia, which is a priority when the patient has dyspnea at
rest.

9. The nurse is developing a teaching plan for a patient with newly diagnosed chronic obstructive pulmonary disease
(COPD) who lives alone. The patient has a 30-pack-year history of cigarette smoking, walks 30 minutes twice per week,
and is on a fixed income. Which part of the teaching plan is most important for the nurse to emphasize to the patient?
Assessment of readiness for smoking cessation: The nurse should assess the patient's readiness to begin smoking
cessation before providing education or medication.