Chronic obstructive pulmonary disease is a preventable and treatable respiratory disease of airflow obstruction involving the airways, pulmonary parenchyma, or both (GOLD, 2015). The airflow limitation or obstruction in COPD is not fully reversible. COPD may also include diseases such as chronic bronchitis and emphysema which can cause airflow obstruction. In COPD, the airflow limitation is both progressive and associated with the lungs’ abnormal inflammatory response to noxious particles or gases. The inflammatory response occurs throughout the proximal and peripheral airways, lung parenchyma, and pulmonary vasculature (GOLD, 2015). Changes and narrowing occurs in the airways because of the chronic inflammation and the body’s attempt to repair it. The number of goblet cells and enlarged submucosal glands happens in the proximal airways. In the peripheral airways, inflammation causes thickening of the airway wall and overall air way narrowing. In the lung parenchyma, inflammatory and structural changes also occur. The chronic inflammatory process affects the pulmonary vasculature and causes thickening of the lining of the vessel and hypertrophy of smooth muscle (Gold, 2015). This may lead to pulmonary hypertension. Emphysema is a destruction of alveoli due to a decreased surface area and chronic inflammation. Chronic bronchitis is a chronic airway inflammation that involves a productive cough and excess sputum production. Pneumonia happens when bacteria from the upper airways find their way to the lung parenchyma. Once it gets there, a combination of factors can lead to bacterial pneumonia. A patient may be more susceptible to infection because of an impairment to the immune response (such as COPD in this case). During pulmonary infection, acute inflammation results in the migration of neutrophils out of capillaries and into air spaces (Gamache, 2018).
As a nurse, it is important to obtain the health history from patients with known or potential COPD. When assessing the health history, it is important to ask if the patient has been exposed to risk factors, past medical history of respiratory diseases, smoking history, and how to reduce those risk factors. The three primary symptoms of COPD include chronic cough, sputum production, and dyspnea. These symptoms may worsen over time. Spirometry is used to evaluate the airflow obstruction. With obstruction, the patient either has difficulty exhaling or cannot forcibly exhale air from the lungs (Gold, 2015). Vital signs are important as well in assessing any patient. To assess for this patient, I would check the pulse and respiratory rates and check if they are within normal range. With respirations, I would make sure to evaluate the character and if the patient is using effort. When communicating with the patient, I would assess if the patient is out of breath after completing a sentence. It is also important to check if the patient is coughing and record the color, amount, and consistency of the sputum. In addition, I would assess for peripheral edema, types of breath sounds, clubbing of the fingers, if patient contracts abdominal muscles during inspiration, and if the patient takes a long time to exhale. For patients with pneumonia, changes in temperature and pulse, amount, odor and color of secretions, frequency and severity of cough, degree of tachypnea or shortness of breath and changes in physical assessment and chest x ray findings should all be assessed. It is also important to monitor for unusual behavior, altered mental status, dehydration, fatigue, and heart failure.
Pulmonary function tests are used to measure the amount of air you inhale and exhale. This also checks if your lungs are delivering enough oxygen to your blood. Spirometry is one of the most common used lung function tests. This measures how much air your lungs can hold and how fast you can blow air out of your lungs. A chest x-ray can show emphysema which is one of the main causes of COPD. An x-ray can also rule out other lung problems. A CT scan of the lungs can also detect emphysema. Arterial blood gas analysis measures how well your lungs are bringing oxygen into your blood and removing carbon dioxide. Lab tests are not used to diagnose COPD, but they can help determine the cause of a patient’s symptoms or rule out other conditions. Alpha-1-antitrypsin may be used if you have a genetic disorder. Blood culture and sputum examination would be used since the patient has developed pneumonia. For this patient, I would use spirometry, a chest x-ray, and arterial blood gas analysis to evaluate the disease since the patient has COPD and has developed pneumonia.
Medication used to manage COPD are based on the disease severity. For mild COPD, a short-acting bronchodilator may be prescribed. Bronchodilators are used for symptom management in stable COPD. Inhaled therapy is the preferred choice of bronchodilator. Bronchodilators also relieve bronchospasm by improving expiratory flow through widening of the airways (Gold, 2015). For grade II or III COPD, a short acting bronchodilator and regular treatment with one or more long acting bronchodilators may be used. For very severe COPD, medication therapy includes regular treatment with one or more bronchodilators and/or inhaled corticosteroids. Other pharmacologic treatments that may be used in COPD include alpha1-antitrypsin augmentation therapy, antibiotic agents, mucolytic agents, antitussive agents, vasodilators, and narcotics. Vaccines are also effective in that they prevent exacerbations by preventing respiratory infections (Gold, 2015). An antibiotic may be prescribed since this patient also has pneumonia. I would expect this patient to be on a corticosteroid and a bronchodilator since the patient has developed pneumonia.
The nursing role for this patient is to achieve airway clearance. Diminishing the quantity and viscosity of sputum can clear the airway and improve pulmonary ventilation and gas exchange. All pulmonary irritants should be eliminated or reduced, particularly cigarette smoke, which is the most persistent source of pulmonary irritation (Gold, 2015). Another role would be to improve activity tolerance. Patients with COPD experience progressive activity and exercise intolerance that may lead to disability. Education is focused on rehabilitative therapies to promote independence in executing activities of daily living. These may include pacing activities throughout the day or using supportive devices to decrease energy expenditure (Gold, 2015). The last role as a nurse would be to monitor and manage potential complications. As a nurse, I would assess for various complications of COPD, such as life-threatening respiratory failure. As a nurse, I would monitor for cognitive changes, increasing dyspnea, tachycardia, and tachypnea. The pulse oximetry would also be monitored to assess the patient’s need for oxygen. To prevent infection, the nurse encourages the patient with COPD to be immunized against influenza and pneumococcal pneumonia, because the patient is prone to respiratory infection (Bartlett & Sethi, 2016). Since the patient has developed pneumonia, it is important to take vital signs and observe how the patient responds to antibiotic therapy.