Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ

Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture

Module #1 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Lesson title: CHRONIC OBSTRUCTIVE PULMONARY DISEASE Materials:

Electronic gadget, pen, & notebook
Learning Targets:
At the end of the module, students will be able to: Reference:
1. Be acquainted with each other, orientation about the subject
and classroom regulations and procedures; Hinkle, J. L., & Cheever, K. H. (2018).
2. Describe the pathophysiology of the chronic obstructive Brunner & Suddarth’s textbook of
pulmonary disease (COPD); medical-surgical nursing (14th ed.).
3. Discuss major risk factors for developing COPD; and, Philadelphia, PA: Lippincott Williams
4. Describe nursing management of patients with COPD. &Wilkins.

A. LESSON PREVIEW/REVIEW

Introduction:
Hello, PHINMA Ed student! Welcome to Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations (Acute and Chronic) – Lecture. This professional subject of BS Nursing
deals with concepts, principles and techniques of nursing care of at-risk and sick adult clients with life-threatening
conditions, acutely ill/multi-organ problems, high acuity and emergency situation toward health promotion, disease
prevention, restoration and maintenance and rehabilitation.

In today’s session, you are tasked to set expectations as you get oriented with what the subjects is all about and to
determine the nature of your mode of learning. You may write in this area the vital policies, rules, and regulations to be
noted in this class. You may also refer to the Course Outline to be provided by your instructor.

B. MAIN LESSON

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

 This is a condition of chronic dyspnea with expiratory airflow limitation that does not significantly fluctuate.
 This has been defined by The Global Initiative as “a preventable and treatable disease with some significant
extrapulmonary effects that may contribute to the severity in individual patients.” This updated definition is a broad
description of COPD and its signs and symptom.

Classification
There are two classifications of COPD: chronic bronchitis and emphysema. These two types of COPD can be sometimes
confusing because there are patients who have overlapping signs and symptoms of these two distinct disease processes

Pathophysiology
 In COPD, the airflow limitation is both progressive and associated with an abnormal inflammatory response of the
lungs to noxious gases or particles
 An inflammatory response occurs throughout the proximal and peripheral airways, lung parenchyma, and
pulmonary vasculature.
 Due to the chronic inflammation, changes and narrowing occur in the airways.
 There is an increase in the number of goblet cells and enlarged submucosal glands leading to hypersecretion of
mucus.
 Scar formation. This can cause scar formation in the long term and narrowing of the airway lumen.
 Wall destruction. Alveolar wall destruction leads to loss of alveolar attachments and a decrease in elastic recoil.

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 Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #1 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

 The chronic inflammatory process affects the pulmonary vasculature and causes thickening of the vessel lining
and hypertrophy of smooth muscle.

Causes of COPD includes environmental factors and host factors. These includes
 Smoking depresses the activity of scavenger cells and affects the respiratory tract’s ciliary cleansing mechanism.
 Occupational exposure. Prolonged and intense exposure to occupational dust and chemicals, indoor air
pollution, and outdoor air pollution all contribute to the development of COPD.
 Genetic abnormalities. The well-documented genetic risk factor is a deficiency of alpha1- antitrypsin, an enzyme
inhibitor that protects the lung parenchyma from injury.

Clinical Manifestations: The natural history of COPD is variable but is a generally progressive disease.
 Chronic cough. Chronic cough is one of the primary symptoms of COPD.
 Sputum production. There is a hyperstimulation of the goblet cells and the mucus-secreting gland leading to
overproduction of sputum.
 Dyspnea on exertion. Dyspnea is usually progressive, persistent, and worsens with exercise.
 Dyspnea at rest. As COPD progress, dyspnea at rest may occur.
 Weight loss. Dyspnea interferes with eating and the work of breathing is energy depleting.
 Barrel chest. In patients with emphysema, barrel chest thorax configuration results from a more fixed position
of the ribs in the inspiratory position and from loss of elasticity.

Prevention of COPD is never impossible. Discipline and consistency are the keys to achieving freedom from chronic
pulmonary diseases.
 Smoking cessation. This is the single most cost-effective intervention to reduce the risk of developing COPD
and to stop its progression.
 Healthcare providers should promote cessation by explaining the risks of smoking and personalizing the “at-risk”
message to the patient.

Complications: There are two major life-threatening complications of COPD

 Respiratory failure. The acuity and the onset of respiratory failure depend on baseline pulmonary function, pulse
oximetry or arterial blood gas values, comorbid conditions, and the severity of other complications of COPD.
 Respiratory insufficiency. This can be acute or chronic, and may necessitate ventilator support until other acute
complications can be treated.

Assessment and Diagnostic Findings

 Health history. The nurse should obtain a thorough health history from patients with known or potential COPD.
 Pulmonary function studies are used to help confirm the diagnosis of COPD, determine disease severity, and
monitor disease progression.
 Spirometry is used to evaluate airway obstruction, which is determined by the ratio of FEV1 to forced vital
capacity.
 Arterial blood gas measurement is used to assess baseline oxygenation and gas exchange and is especially
important in advanced COPD.
 Chest x-ray may be obtained to exclude alternative diagnoses.
 CT scan may help in the differential diagnosis.
 Screening for alpha1-antitrypsin deficiency can be performed for patients younger than 45 years old and for
those with a strong family history of COPD.

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 Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #1 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

 Chest x-ray: May reveal hyperinflation of lungs, flattened diaphragm, increased retrosternal air space, decreased
vascular markings/bullae (emphysema), increased bronchovascular markings (bronchitis), normal findings during
periods of remission (asthma).
 Pulmonary function tests: Done to determine cause of dyspnea, whether functional abnormality is obstructive or
restrictive, to estimate degree of dysfunction and to evaluate effects of therapy, e.g., bronchodilators. Exercise
pulmonary function studies may also be done to evaluate activity tolerance in those with known pulmonary
impairment/progression of disease.
 Arterial blood gases (ABGs): Determines degree and severity of disease process, e.g., most often Pao 2is
decreased, and Paco2 is normal or increased in chronic bronchitis and emphysema, but is often decreased
in asthma; pH normal or acidotic, mild respiratory alkalosis secondary to hyperventilation
(moderate emphysema or asthma).
 DL CO test: Assesses diffusion in lungs. Carbon monoxide is used to measure gas diffusion across the
alveocapillary membrane. Because carbon monoxide combines with hemoglobin 200 times more easily than
oxygen, it easily affects the alveoli and small airways where gas exchange occurs. Emphysema is the only
obstructive disease that causes diffusion dysfunction.
 Bronchogram: Can show cylindrical dilation of bronchi on inspiration; bronchial collapse on forced expiration
(emphysema); enlarged mucous ducts (bronchitis).
 Lung scan: Perfusion/ventilation studies may be done to differentiate between the various pulmonary
diseases. COPD is characterized by a mismatch of perfusion and ventilation (i.e., areas of abnormal ventilation in
area of perfusion defect).
 Complete blood count (CBC) and differential: Increased hemoglobin (advanced emphysema), increased
eosinophils (asthma).
 Blood chemistry: alpha1-antitrypsin is measured to verify deficiency and diagnosis of primary emphysema.
 Sputum culture: Determines presence of infection, identifies pathogen.
 Cytologic examination: Rules out underlying malignancy or allergic disorder.
 Electrocardiogram (ECG): Right axis deviation, peaked P waves (severe asthma); atrial dysrhythmias
(bronchitis), tall, peaked P waves in leads II, III, AVF (bronchitis, emphysema); vertical QRS axis (emphysema).
 Exercise ECG, stress test: Helps in assessing degree of pulmonary dysfunction, evaluating effectiveness of
bronchodilator therapy, planning/evaluating exercise program.

Medical Management: Pharmacologic Therapy

Healthcare providers perform medical management by considering the assessment data first and matching the
appropriate intervention to the existing manifestation.
 Bronchodilators relieve bronchospasm by altering the smooth muscle tone and reduce airway obstruction by
allowing increased oxygen distribution throughout the lungs and improving alveolar ventilation.
 Corticosteroids. A short trial course of oral corticosteroids may be prescribed for patients to determine whether
pulmonary function improves and symptoms decrease.
 Other medications. Other pharmacologic treatments that may be used in COPD include alpha1-antitrypsin
augmentation therapy, antibiotic agents, mucolytic agents, antitussive agents, vasodilators, and narcotics.

Management of Exacerbations
 Optimization of bronchodilator medications is first-line therapy and involves identifying the best medications or
combinations of medications taken on a regular schedule for a specific patient.
 Hospitalization. Indications for hospitalization for acute exacerbation of COPD include severe dyspnea that does
not respond to initial therapy, confusion or lethargy, respiratory muscle fatigue, paradoxical chest wall movement,
and peripheral edema.

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 Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #1 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

 Oxygen therapy. Upon arrival of the patient in the emergency room, supplemental oxygen therapy is
administered and rapid assessment is performed to determine if the exacerbation is life-threatening.
 Antibiotics. Antibiotics have been shown to be of some benefit to patients with increased dyspnea, increased
sputum production, and increased sputum purulence.

Surgical Management
Patients with COPD also have options for surgery to improve their condition.
 Bullectomy. Bullectomy is a surgical option for select patients with bullous emphysema and can help reduce
dyspnea and improve lung function.
 Lung Volume Reduction Surgery. Lung volume reduction surgery is a palliative surgery in patients with
homogenous disease or disease that is focused in one area and not widespread throughout the lungs.
 Lung Transplantation. Lung transplantation is a viable option for definitive surgical treatment of end-stage
emphysema

Emphysema Chronic Bronchitis

PINK PUFFER BLUE BLOATER

Elastic recoil Alveolar detachment

FEV1V/FVC
Airway FEV1 Mucus
obstruction Hypersecretion
Lung compliance Destruction of Air trapping
Wheezing
capillary bed on expiration
Alveolar OXYGEN Productive cough with
Auto-PEEP hypoxia THERAPY
Perfusion copious sputum
Ventilation
Pursed-lip
breathing
Matched DLCO Pulmonary
End V:Q mismatch
V:Q defect vasoconstriction
Expiratory
volume

Relatively well- RV
oxygenated blood TLC
until late stage Hypoxemia Hypercarbia Pulmonary Hypertension
VC
LV output RHF

Work of
breathing Barrel chest Respiratory Circulating Cor
Polycythemia
acidosis volume pulmonale

Cyanosis Activation JVP Loud

Dyspnea Cachexia Osteoporosis Heart disease
of RAAS P2
Parasternal
Inflammation heaves
FOR ALL COPD Fluid retention Peripheral
edema

This document is the property of PHINMA EDUCATION

 Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #1 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

NURSING MANAGEMENT
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Assessment of Diagnosis of COPD Goals to achieve Maintain airway To achieve airway During evaluation,
the respiratory would mainly in patients with patency. Instruct clearance. the effectiveness
system should depend on the COPD include: patient in direct of the care plan
be done rapidly assessment data and controlled would be
yet accurately. gathered by the Improvement in coughing. measured if goals
healthcare team gas exchange. were achieved in
Assess members. Assist with This measure will the end and the
patient’s Achievement of measures to improve breathing patient:
exposure to risk Impaired gas airway clearance. facilitate gas pattern.
factors. exchange due to exchange. Identifies the
chronic inhalation of Improvement in hazards of
Assess the toxins. breathing pattern. Instruct patient on To determine cigarette
patient’s past inspiratory muscle informational smoking.
and present Ineffective airway Independence training, needs of the
medical history. clearance related in self- diaphragmatic client and Identifies
to care activities. breathing and significant others. resources for
Assess the bronchoconstriction, purse lip smoking
signs and increased mucus Improvement in breathing cessation.
symptoms of production, activity
COPD and their ineffective cough, intolerance. Enhance Enrolls in
severity. and other nutritional intake. smoking
complications. Ventilation/oxyge cessation
Assess the nation adequate Ascertain program.
patient’s Ineffective to meet self-care understanding on
knowledge of breathing needs. nutritional needs. Minimizes or
the disease. pattern related to eliminates
shortness of breath, Nutritional intake Assess dietary exposures.
Assess the mucus, meeting caloric habits &
patient’s vital bronchoconstriction, needs. nutritional needs. Verbalizes the
signs. and airway irritants. need for fluids.
Infection treated Prevent Is free of
Assess breath Self-care or prevented. complications, infection.
sounds and deficit related to slow progression
pattern. fatigue. Disease of condition. Practices
process/prognosi breathing
Activity s and therapeutic Encourage the Patient is prone to techniques.
intolerance related regimen patient to be respiratory
to hypoxemia and understood. immunized infection. Performs
ineffective breathing against S. activities with less
patterns. Plan in place to pneumonia. shortness of
meet needs after breath.
discharge.

This document is the property of PHINMA EDUCATION

 Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #1 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Discharge and Home Care Guidelines

It is important for the nurse to assess the knowledge of patient and family members about self-care and the therapeutic
regimen.
 Setting goals. If the COPD is mild, the objectives of the treatment are to increase exercise tolerance and prevent
further loss of pulmonary function, while if COPD is severe, these objectives are to preserve current pulmonary
function and relieve symptoms as much as possible.
 Temperature control. The nurse should instruct the patient to avoid extremes of heat and cold because heat
increases the temperature and thereby raising oxygen requirements and high altitudes increase hypoxemia.
 Activity moderation. The patient should adapt a lifestyle of moderate activity and should avoid emotional
disturbances and stressful situations that might trigger a coughing episode.
 Breathing retraining. The home care nurse must provide the education and breathing retraining necessary to
optimize the patient’s functional status.

Documentation Guidelines
Documentation is an essential part of the patient’s chart because the interventions and medications given and done are
reflected on this part.
 Document assessment findings including respiratory rate, character of breath sounds; frequency, amount and
appearance of secretions laboratory findings and mentation level.
 Document conditions that interfere with oxygen supply.
 Document plan of care and specific interventions.
 Document liters of supplemental oxygen.
 Document client’s responses to treatment, teaching, and actions performed.
 Document teaching plan.
 Document modifications to plan of care.
 Document attainment or progress towards goals.

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

1. The term “pink puffer” refers to the client with which of the following symptoms?
a. ARDS c. Chronic obstructive bronchitis
b. Asthma d. Emphysema.
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. The underlying pathophysiology of COPD is:

a. inflamed airways that obstruct airflow.
b. mucus secretions that block airways
c. overinflated alveoli that impair gas exchange.
d. characterized by variations of all of the above.
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

 Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #1 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

3. The abnormal inflammatory response in the lungs occurs primarily in the:

a. airways.
b. parenchyma.
c. pulmonary vasculature.
d. areas identified in all of the above.
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. Two diseases common to the etiology of COPD are:

a. asthma and atelectasis.
b. chronic bronchitis and emphysema.
c. pneumonia and pleurisy.
d. tuberculosis and pleural effusions.
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. The term “blue bloater” refers to which of the following conditions?

a. adult respiratory distress syndrome
b. asthma
c. chronic obstructive bronchitis
d. emphysema
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. The most important environmental risk factor for emphysema is:

a. air pollution. c. infectious agents.
b. allergens. d. cigarette smoking.
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. A 66-year-old client has marked dyspnea at rest, is thin and uses accessory muscles to breathe. He is tachypneic,
with a prolonged expiration phase. He has no cough. He leans forward with his arms braced on his knees to support
his chest and shoulder for breathing. This client has symptoms of which of the following respiratory disorder?
a. ARDS c. Chronic obstructive bronchitis
b. Asthma d. Emphysema
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

 Nursing Care of Clients with Life Threatening Conditions/Acutely Ill/Multi-Organ
Problems/High Acuity and Emergency Situations, Acute & Chronic - Lecture
Module #1 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

8. Clients with chronic obstructive bronchitis are given diuretic therapy. Which of the following reasons explains why?
a. reducing fluid volume reduces oxygen demand
b. reducing fluid volume improves clients’ morbidity
c. restricting fluid volume reduces sputum production
d. reducing fluid volume improves respiratory function
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Teaching for a client with chronic obstructive pulmonary disease (COPD) should include which of the following topics?
a. How to have his wife learn to listen to his lungs with a stethoscope
b. How to increase his oxygen therapy
c. How to treat respiratory infections without going to the physician
d. How to recognize the signs of impending respiratory infection.
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that the client is most likely to
experience what type of acid- base imbalance.
a. respiratory acidosis c. metabolic acidosis
b. respiratory alkalosis d. metabolic alkalosis
ANSWER: ________
RATIO:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

C. LESSON WRAP-UP

Thinking about Learning

MINUTE PAPER
This strategy provides feedback on whether or not you understand the lesson. Use the space provided in this activity
sheet to answer the following questions. Make sure to not miss a tiny detail!

1. What was the most useful or the most meaningful thing you have learned this session?

2. What question(s) do you have as we end this session?

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