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When breathing is a burden:
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How to help patients with
With COPD statistics worsening, you need to learn
everything you can about the causes, clinical features,
and management of this condition.
By Gerene S. Bauldoff, PhD, RN, FCCP
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) refers
to a condition of chronic airflow limitation. Actually, COPD is an umbrella
term for two separate diseases—
chronic bronchitis (airway disease)
and emphysema (parenchymal disease). Worldwide, COPD is a leading
cause of death and disability. Experts
predict that by 2020, it will be the
third most common cause of death—
up from sixth place in 1990.
COPD has an insidious onset,
with symptoms arising only after
50% to 70% of lung function is lost.
Lung changes cause increased work
of breathing. Persons with COPD
lose lung function at two to three
times the normal rate. COPD also
increases the risk of lung cancer.
COPD has both pulmonary and
comorbid components that contribute to disease severity and related disability. Comorbid components
may include cardiovascular disease,
malnutrition with skeletal-muscle
wasting, osteoporosis, anemia, increased gastroesophageal reflux
disease, and such psychological
processes as depression and anxiety.
teinases are inactivated, which reduces lung-tissue repair and promotes alveolar-wall destruction.
• In chronic bronchitis, the airways
thicken and the mucociliary elevator is inactivated while mucus production increases. As airway diameter narrows, airflow decreases.
• In emphysema, destruction of
the alveolar septa reduces the
surface area available for gas exchange. Elastic recoil (in which
the lungs return to their original
size after expanding during inspiration) decreases with loss of
lung-tissue structure, resulting in
air trapping and hyperinflation.
Risk factors
Cigarette smoking is the most significant risk factor for COPD development and progression. Smoking
plays a central role in disease pathogenesis and promotes lung-function
loss over the life span. (See Smoking cessation and COPD risk.)
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Pathophysiology
L EARNING O BJECTIVES
COPD is initiated by exposure to
cigarette smoke and other noxious
particles, which results in lung inflammation. Lung tissue is destroyed
in response to increased presence
of macrophages and CD-8 T lymphocytes. As part of the pathophysiologic cascade, protective antipro-
1. Describe appropriate assessment
for patients with COPD.
2. Discuss pharmacologic and
nonpharmacologic interventions
for COPD.
3. Explain nursing management of
patients with COPD.
www.AmericanNurseToday.com
Other risk factors include inhaled
pollution (occupational, indoor, and
outdoor), reduced lung development or severe lung infection during childhood, coexistence of asthma, and female sex. Some experts
include lower socioeconomic status
and nutrition as risk factors.
Genetic factors also are thought
to influence COPD severity. Alpha1antitrypsin (AAT) deficiency, for example, is a recessive trait resulting
in early COPD.
Clinical features
Dyspnea is the primary disabling
symptom of COPD—and the most
common. A complex phenomenon
that varies from person to person,
this unpleasant, persistent labored
breathing is triggered by increased
ventilation secondary to increased
work of breathing.
But dyspnea is more than just a
physiologic phenomenon. It also has
psychophysiologic components, triggered by such factors as anxiety and
fear. Persons with COPD fear the
sensation of dyspnea that results
from inefficient breathing. Therefore,
they avoid exercise; as dyspnea progresses, they begin to abandon activities, leading to a downward spiral
of disability. Ultimately, they suffer
increasing dyspnea even at rest.
Many COPD patients also experience cough, which may be productive or nonproductive. Chronic sputum production indicates chronic
bronchitis.
November/December 2009
American Nurse Today
17
Smoking cessation and COPD risk
This graph shows changes in lung function caused by smoking.
Never smoked
or not susceptible
to smoke
FEV1 (% of value at age 25)
100 –
75 –
Stopped smoking
at 45 (mild COPD)
Smoked regularly
and susceptible to
effects of smoke
50 –
Disability
25 –
Stopped smoking
at 65 (severe COPD)
Death
0–
25
50
Age (years)
75
From Fletcher C, Peto R. The natural history of chronic airflow obstruction. Br Med J. 1977;25;1(6077):1645-1648.
Reproduced with permission from the BMJ Publishing Group.
Screening and diagnosis
The U.S. Preventive Services Task
Force doesn’t recommend COPD
screening for the general population. However, it urges healthcare
providers to consider screening in
patients with a family history of
AAT deficiency to evaluate for clinical features of COPD or other pulmonary diseases, such as asthma.
Spirometry, the diagnostic tool of
choice, measures airflow obstruction. Specific spirometry tests include forced expiratory volume in
the first second (FEV1) and forced
vital capacity (FVC), which reflects
the change in lung volume from total lung capacity through sustained
expiration to residual volume. The
ratio of expired volume to vital capacity (FEV1/FVC) is calculated.
Normal FEV1/FVC is 70% or greater;
a lower ratio indicates airflow obstruction and is a sensitive indicator
of COPD. Generally, in the setting
of a reduced FEV1/FVC ratio, the
absolute FEV1, expressed as a percentage of the predicted value, is
used to assess disease severity. (See
Staging COPD.)
Intervention
The goals of COPD management
are to improve functional capacity,
treat or prevent secondary compli18
American Nurse Today
cations, and improve quality of life
by managing symptoms. With smoking the primary COPD risk factor,
smoking cessation is essential.
Pharmacologic treatment
Bronchodilators, corticosteroids, and
pneumonia and influenza vaccinations
are important in managing symptoms
and reducing complications.
Bronchodilators include beta2agonists, anticholinergics, and
methylxanthines. These drugs usually are introduced in a stepwise
approach.
• Beta2-agonists relax smooth airway muscle. They may be shortacting (for instance, albuterol)
or long-acting (for instance, formoterol).
• Anticholinergics promote bronchodilation by blocking acetylcholine on postganglionic cholinergic nerves. Tiotropium
(Spiriva), a long-acting anticholinergic, has a duration exceeding 24 hours and is the first
COPD drug that requires only
once-daily dosing.
• Methylxanthines inhibit phosphodiesterase, leading to increased
levels of cyclic adenosine
monophosphate, which in turn
causes bronchodilation. But
methylxanthines are metabolized
Volume 4, Number 9
in the liver to caffeine and can
reach toxic levels; therefore, inhaled bronchodilators are more
commonly used instead.
Although corticosteroids are used
to reduce inflammation, they have
limited value in COPD. Inhaled corticosteroids haven’t been shown to
slow declines in lung function, although they may be indicated to reduce airway inflammation in COPD
patients with chronic bronchitis.
Similarly, oral corticosteroids
haven’t been proven effective in
COPD but may be indicated for disease exacerbations.
COPD patients should receive
pneumonia and influenza vaccinations. Yearly influenza vaccinations
reduce serious complications by
50% in these patients. Patients older
than age 65 should get pneumococcal vaccine (Pneumovax) as well.
Antibiotics are recommended only
for acute exacerbations when a
bacterial infection is present.
For patients with stable COPD,
other drugs, such as mucolytics,
antitussives, antioxidant agents,
immunomodulators, and opioids,
aren’t recommended.
Oxygen
Oxygen therapy is reserved for patients with hypoxemia. While it
doesn’t improve lung function, it
can improve survival in hypoxemic
patients. The goal is to achieve an
oxygen saturation value of 90% or
higher. Oxygen should be prescribed in liters/minute for rest,
sleep, and activity, with the prescription determined by arterial
blood gas values and desaturation
and nocturnal desaturation studies.
Oxygen delivery systems include
liquid oxygen, compressed gas, and
concentrators. Each system carries
risks and benefits. Selection hinges
on patient mobility and functional
goals.
Portable oxygen concentrators
are the newest innovation in oxygen delivery, eliminating the need
for patients to carry oxygen with
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Staging COPD
The Global Initiative for Chronic Obstructive Lung Disease uses the staging system
shown here, which is based on spirometry results.
Severity
Stage I
Stage II
Stage III
Stage IV
Mild
Moderate
Severe
Very severe
Spirometric findings
FEV1/FVC
Less than 70% Less than 70%
Less than 70%
Less than 70%
FEV1
Greater than
80%
50% or less but
greater than
30%
Less than 30%;
or less than 50%
+ chronic
respiratory
failure
Less than 80%
but greater
than 50%
though limited by scarcity of organ
donors, transplantation has a favorable risk-benefit ratio, with good 1and 2-year survival rates. Lung
transplantation isn’t a cure for
COPD. Instead, the patient trades
end-stage COPD for lifelong immunosuppression therapy to prevent organ rejection. Candidate selection is based on disease severity,
comorbid conditions, and probability of surviving to receive a transplant and surviving after transplantation. (For more information, visit
www.unos.org.)
FEV1 = Forced expiratory volume in 1 second. FVC = Forced vital capacity.
Nursing management
them. These devices have been
shown to be safe and effective. In
2005, the Federal Aviation Administration adopted new rules that allow
patients to fly with portable concentrators. However, the rule doesn’t
require airlines to allow these systems on board; therefore, instruct
patients to check with the airline regarding oxygen use when planning
travel. The National Home Oxygen
Patients Association (www.homeoxygen.org/index.html) also provides information for patients.
Pulmonary rehabilitation
While optimal medical management
reduces symptoms, it can’t reverse
the pathologic changes secondary
to COPD. For patients with chronic
respiratory impairment, healthcare
providers may prescribe pulmonary
rehabilitation (PR). This multidisciplinary program is individually tailored to optimize the patient’s
physical and social functioning and
increase autonomy. It teaches patients how to manage symptoms
and reach their maximum functioning level. The scientific basis for PR
has been well-established through
multiple randomized, controlled
clinical trials. Improved activity tolerance reduces disabling symptoms
and improves quality of life.
Patients exercise three to five
times weekly, with each session
www.AmericanNurseToday.com
lasting 30 to 90 minutes. When the
patient completes PR, a home exercise prescription (maintenance exercise) is the usual care. Although
patients who complete PR don’t
routinely experience changes in
lung function, many have better exercise capacity, decreased dyspnea,
and improved quality of life.
Surgical options
For selected patients, lung-volume
reduction surgery (LVRS) is an option. As COPD progresses, the
lungs overdistend inside the chest
cavity. LVRS removes part of the
lungs, reducing overcrowding of
the chest cavity.
The procedure involves removal
of lung tissue at the apices, where
smoking-induced COPD commonly
is most severe. Subsequently, remaining lung tissue can reexpand
and function more efficiently. A
large, multicenter National Emphysema Treatment Trial that tested
LVRS efficacy found that patients
with upper-lobe-predominant emphysema and low initial exercise capacity got the most benefit. On the
other hand, patients with emphysema distributed in the lower lobes
failed to benefit from the surgery.
Lung transplantation is another
option for selected patients. (COPD
is the most common diagnosis in
lung-transplant candidates.) Al-
Nursing care for COPD patients focuses on managing symptoms,
maximizing function, and teaching
skills to enhance self-care. Appropriate referral of patients to community resources helps ensure continuity of high-quality care.
Be sure to include the patient’s
family in your teaching, as they play
a crucial role in care. Educate them
about COPD pathophysiology, including how lung changes relate to
symptoms. Teach patients to observe
their usual symptoms and to contact
their healthcare provider when
symptoms worsen. Reinforce the importance of good infection control,
such as frequent hand washing and
avoiding crowds when upper respiratory infections are prevalent.
Provide education on prescribed
medications, covering proper use of
inhaled drugs (including spacers if
indicated), proper sequence for taking medications to maximize their effects, and adverse effects. Make sure
patients know how to determine the
amount of inhaled medications left
so they can avoid running out. Stress
the importance of getting pneumococcal and influenza vaccines. Finally, urge any patient who smokes to
stop smoking. (See Smoking cessation recommendations.)
Coping suggestions
To help patients manage dyspnea,
teach them about activities that reduce
November/December 2009
American Nurse Today
19
Smoking cessation recommendations
If your patient with chronic obstructive pulmonary disease smokes, stress the importance of stopping. In its clinical guideline Treating Tobacco Use and Dependence:
2008 Update, the U.S. Department of Health and Human Services provides the following guidelines.
• Consistently identify and document the tobacco use status of all patients and
treat every tobacco user seen in a healthcare setting.
• Urge every patient who uses tobacco to try at least the tobacco dependence
treatments that have been shown to be effective, such as bupropion (sustainedrelease), varenicline, and nicotine gum, inhalers, nasal sprays, and patches.
• Be aware that individual, group, and telephone counseling is effective.
• Encourage patients to seek support from family, friends, and coworkers to help
them stop smoking.
• Know that a combination of counseling and medication is more effective than
either one alone.
Adapted from U.S. Department of Health and Human Services. Treating Tobacco Use and Dependence: 2008
Update. U.S. Department of Health and Human Services, Public Health Service. 2008. Rockville, MD.
www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.28163.
or control it, as described below.
• Breathing techniques. Techniques such as pursed-lip breathing help reduce respirations
while improving the expiratory
phase (by increasing laminar
flow of expired air). Tell the patient that slow, controlled expiration postpones small-airway
collapse, thereby reducing air
trapping that occurs with forced
expiration.
• Proper positioning. Explain that
the tripod position, in which the
patient sits or stands leaning forward with the arms supported,
forces the diaphragm down and
forward and stabilizes the chest
while reducing the work of
breathing. If the patient reports
increased dyspnea when performing activities of daily living
(ADLs), especially when raising
the arms above the head, recommend supporting the arms during ADLs, as by resting the elbows on a surface. Point out that
this reduces competing demands
of the arm, chest, and neck muscles needed for breathing.
• Energy-conservation techniques.
Advise patients to pace activities,
take frequent rests, use assistive
devices, and break activities into
smaller tasks to help reduce dys20
American Nurse Today
pnea development.
Also help identify the patient’s
best “breathing time” of the day, and
recommend reserving strenuous activities for this period. Finally, stress
the need to avoid environmental triggers of dyspnea, including temperature extremes and exposure to air
pollution, pollen, cigarette smoke,
chemical fragrances, and dust.
Nutritional guidance
COPD patients commonly have
problems maintaining adequate nutritional intake. As the disease progresses, many experience cachexia.
Inform patients with reduced nutritional status that the primary-care
provider is likely to monitor their hemoglobin and serum albumin levels.
To improve their nutritional status, advise them to eat small, frequent meals high in protein and
avoid gas-producing foods. Instruct
them to monitor their weight and
food intake. If recommended, advise them to use high-calorie nutritional supplements.
Oxygen therapy
Teach patients who need oxygen
therapy about the following:
• proper oxygen use, including the
importance of avoiding nearby
open flames
Volume 4, Number 9
• oxygen prescription instructions
• correct equipment care
• back-up oxygen system in case
of a power outage.
Psychosocial issues
Psychosocial concerns for COPD
patients include increasing dependence on others, lack of control over
symptoms, and decreased energy.
Also, they’re at high risk for depression and anxiety because of symptom burden and functional limitations. These problems can affect
their social interactions, role perception, and physical abilities.
Help them verbalize their feelings and develop healthy coping
behaviors. However, know that as
increasing dyspnea makes talking
more difficult, conversation may
grow burdensome.
Include family caregivers in your
discussions when appropriate. If the
patient has significant psychosocial
issues, consider a referral to a social
worker, psychologist, or psychiatrist.
Sexual intimacy is an area commonly overlooked by healthcare
providers. COPD can decrease certain aspects of sexual functioning.
Males may develop erectile dysfunction as lung function declines. What’s
more, the physical exertion of sexual
activity leads to dyspnea in most
COPD patients. The effort required
for intercourse resembles that needed
to climb one flight of stairs at a normal pace. However, point out that
sex doesn’t increase blood pressure,
heart rate, or respiratory rate to dangerous levels. (For patient teaching
related to sexual activity, see Teaching patients about sexual intimacy).
COPD is increasing in prevalence and burden worldwide. By
understanding its pathophysiology
and learning as much as you can
about treatment options, you can
help your patients stay independent
as long as possible.
✯
Selected references
American Association of Cardiovascular and
Pulmonary Rehabilitation. Guidelines for
www.AmericanNurseToday.com
Society, American Association of Transplant
Physicians, the European Respiratory Society.
Transplantation. 1998;66(7):951-956.
Teaching patients about sexual intimacy
Share the following suggestions when discussing sexual intimacy with patients
who have chronic obstructive pulmonary disease.
Managing symptoms during intimacy
• Plan sexual activity for the best “breathing time” of the day.
• Use your inhaler 30 to 45 minutes before planned sexual activity.
• Wait at least 2 or 3 hours after meals before having sex.
• Use massage to reduce muscle tension.
• Slow down or take a break if shortness of breath gets too severe.
• Experiment with positions for easiest breathing.
• Use oxygen during sex if it has been prescribed for activity.
• Avoid sexual positions that put pressure on your chest and abdomen or require
arm support.
• Allow extra time for foreplay so you can adapt gradually to the increased oxygen and circulation demands.
• Keep the room cool and well ventilated.
Medication effects
Drugs used to treat lung disease can affect sexual functioning and self-image. For
instance, bronchodilators can increase anxiety and nervousness; steroids can lead
to weight gain, mood swings, and depression; and antihypertensives, antidepressants, antianxiety drugs, and cardiovascular medications can alter sexual desire and
performance.
Pulmonary Rehabilitation Programs. 3rd ed.
Champaign, IL: Human Kinetics; 2004.
Barnes PJ, Celli BR. Systemic manifestations
and comorbidities of COPD. Eur Respir J.
2009;33(5):1165-1185.
Bauldoff GS, Diaz PT. Improving COPD outcomes. Nurse Practitioner. 2006;31(8):26-43.
Bradley JM, O’Neill B. Short term ambulatory
oxygen for chronic obstructive pulmonary
disease. Cochrane Database Syst Rev.
2005;2:CD004356.
Celli B, MacNee W; ATS/ERS Task Force.
Standards for the diagnosis and care of patients with COPD: a summary of the
ATS/ERS position paper. Eur Respir J.
2004;23:922-946.
Chapman KR, Mannino DM, Soriano JB, et
al. Epidemiology and costs of chronic obstructive pulmonary disease. Eur Resp J.
2006;27(1):188-207.
Deglin JH, Vallerand AH. Davis Drug Guide.
4th ed. Philadelphia, PA: F.A. Davis; 2009.
Fishman AL, Elias JA, Fishman JA, et al. Fishman’s Pulmonary Diseases and Disorders.
4th ed. New York, NY: McGraw Hill; 2008.
Global Initiative for Chronic Obstructive Lung
Disease. Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease. Medical Communication Resources, Inc; 2008.
Mauer J, Frost A, Estenne M, et al. International guidelines for the selection of lung transplant candidates. The International Society of
Heart & Lung Transplant, American Thoracic
CE POST-TEST —
When breathing is a burden: How to help patients with COPD
Instructions
To take the post-test for this article and earn contact hour credit,
please go to www.AmericanNurseToday.com. Simply use your
Visa or MasterCard to pay the processing fee. (Online: ANA members $15; nonmembers $20.) Once you’ve successfully passed the
post-test and completed the evaluation form, you’ll be able to
print out your certificate immediately.
If you are unable to take the post-test online, complete the
print form and mail it to the address at the bottom of the next
page. (Mail-in test fee: ANA members $20; nonmembers $25.)
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Murray CJ, Lopez AD. Alternative projections
of mortality and disability by cause, 19902020: Global Burden of Disease Study.
Lancet. 1997;349:1498-1504.
National Emphysema Treatment Trial Research Group. A randomized trial comparing
lung volume reduction surgery with medical
therapy for severe emphysema. N Engl J
Med. 2003;348(21):2059-2073.
Nici L, Donner C, Wouters E, et al. American
Thoracic Society/European Respiratory Society
statement on pulmonary rehabilitation. Am J
Respir Crit Care Med. 2006;173(12):1390-1413.
Nocturnal Oxygen Therapy Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Ann Intern Med. 1980;93:391-398.
Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: Joint ACCP/AACVPR
evidence-based clinical practice guidelines.
Chest. 2007;131:4S-42S.
Tibbals SC. Sexuality. In: Turner J, McDonald
G, Larter N. Handbook of Adult and Pediatric Respiratory Home Care. St. Louis, MO:
Mosby; 1994.
U.S. Department of Health and Human Services. Treating tobacco use and dependence:
2008 update. www.ncbi.nlm.nih.gov/books/
bv.fcgi?rid=hstat2.chapter.28163. Accessed
September 23, 2009.
For a table of drugs used to treat COPD, visit
www.AmericanNurseToday.com/Archives
.aspx.
Gerene S. Bauldoff is an associate professor of
Clinical Nursing and Specialty Program Director in
the Adult Health and Illness Programs in the College
of Nursing at The Ohio State University in Columbus.
The planners and authors of this CNE activity have
disclosed no relevant financial relationships with any
commercial companies pertaining to this activity.
Provider accreditation
The American Nurses Association Center for Continuing Education and Professional Development is accredited as a provider of continuing nursing education
by the American Nurses Credentialing Center’s Commission on Accreditation.
ANA is approved by the California Board of Registered Nursing,
Provider Number 6178.
Contact hours: 1.9
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Expiration: 12/31/12
Post-test passing score is 75%.
ANA Center for Continuing Education and Professional Development’s accredited provider status refers only to CNE activities and does not imply that
there is real or implied endorsement of any product, service, or company referred to in this activity nor of any company subsidizing costs related to the
activity. This CNE activity does not include any unannounced information
about off-label use of a product for a purpose other than that for which it
was approved by the Food and Drug Administration (FDA).
November/December 2009
American Nurse Today
21
CE
POST-TEST • When breathing is a burden: How to help patients with COPD
Earn contact hour credit online at www.AmericanNurseToday.com
Please circle the correct answer.
1. Which statement about emphysema pathophysiology is correct?
a. Destruction of the alveolar septa reduces the surface
area available for gas exchange.
b. The airways thicken and the mucociliary elevator is
inactivated.
c. Elastic recoil increases with loss of lung function.
d. Antiproteinases are activated, which reduces lungtissue repair.
2.
The most significant risk factor for COPD is:
a. coexistence of asthma.
b. severe lung infection in childhood.
c. pollution.
d. cigarette smoking.
3. Which statement about the clinical features of
COPD is correct?
a. Dyspnea is solely a physiologic phenomenon.
b. Chronic sputum production indicates emphysema.
c. Few patients with COPD experience cough.
d. Patients may avoid exercise because they fear dyspnea.
4. Which statement about the U.S. Preventive Services
Task Force is correct?
a. It recommends COPD screening for the general
population.
b. It doesn’t recommend COPD screening for the general population.
c. It urges healthcare providers to consider screening
patients with a family history of alpha5-antipepsin
deficiency.
d. It urges healthcare providers to consider screening
patients with a family history of beta2-antitrypsin
deficiency.
5. Normally, the ratio of forced expiratory volume in
the first second (FEV1) to forced vital capacity (FVC) is:
a. 60% or greater.
b. 70% or greater.
c. 80% or greater.
d. 90% or greater.
(ANA 091101)
6. An FEV1 of less than or equal to 50% but greater
than 30% indicates which COPD stage?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
7. Which COPD medication requires only once-daily
dosing?
a. Tiotropium
b. Albuterol
c. Ipratropium
d. Pirbuterol
8.
In patients with COPD, corticosteroids:
a. can cause seizures.
b. are not used for disease exacerbation.
c. slow decline of lung function.
d. have limited value.
9.
Which statement about methylxanthines is correct?
a. They decrease cyclic adenosine monophosphate.
b. They inhibit phosphodiesterase.
c. They cause bronchoconstriction.
d. They are metabolized in the kidney.
10. An example of a short-acting beta2-agonist is:
a. albuterol.
b. formoterol.
c. salmeterol.
d. methylprednisolone.
11. Which statement about vaccinations for patients
with COPD is correct?
a. They should receive pneumonia and influenza vaccinations.
b. Yearly influenza vaccinations do not reduce the
incidence of serious complications.
c. Patients younger than age 65 should receive the
pneumococcal vaccine.
d. All patients should receive the pneumococcal
vaccine.
Evaluation form (required)
1. In each blank, rate your achievement of each objective from 1 (low/poor) to 5
(high/excellent).
(1.) Describe appropriate assessment for patients with COPD. ____
(2.) Discuss pharmacologic and nonpharmacologic interventions for
COPD. ____
(3.) Explain nursing management of patients with COPD. ____
Purpose/goal: To provide nurses with information that promotes
CE: 1.9 contact hours
Rx: 0.5 contact hours
Rx
12. Which statement about lung-volume reduction surgery (LVRS) is true?
a. It benefits patients with emphysema predominantly
in the lower lung lobes.
b. It doesn’t benefit patients with emphysema predominantly in the upper lung.
c. It removes part of the lungs, reducing chest cavity
overcrowding.
d. It removes lung tissue at the bottom of the lungs.
13. Which of the following is an appropriate tip to help
patients who have dyspnea?
a. Try to exhale faster to reduce air trapping in the
lungs.
b. Avoid pursed-lip breathing.
c. Use the bipod position to ease dyspnea when it occurs.
d. Use the tripod position to reduce the work of
breathing.
14. Which nutritional strategy is beneficial for patients
with COPD?
a. Eating two meals each day—one in the morning
and one in the afternoon
b. Eating three high-carbohydrate meals each day
c. Eating small, frequent meals high in protein
d. Eating large meals high in fat
15. Which statement about sexual intimacy in patients
with COPD is correct?
a. The physical effort required for intercourse resembles that needed to climb a flight of stairs at a normal pace.
b. Sexual activity can increase the patient’s blood pressure to dangerous levels.
c. The physical effort of sexual activity rarely leads to
dyspnea.
d. Sexual activity can increase the patient’s respiratory
rate to dangerous levels.
Also rate the following from 1 to 5.
2. The relatedness and effectiveness of the purpose, objectives, content, and
teaching strategies. ____
3. The author(s)’competence and effectiveness. ____
4. The activity met your personal expectations. ____
5. The application to and usefulness of the content in your nursing practice. ____
6. Freedom from bias due to conflict of interest, commercial support, product
endorsement or unannounced off-label use. ____
7. State the number of minutes it took you to read the article and complete the
post-test and evaluation. ____
their effectiveness in caring for patients with COPD
Comments: ______________________________________________________
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Drugs used to treat COPD
This table shows pharmacologic agents used to treat chronic obstructive pulmonary disease (COPD), along with their common
adverse effects and potentially interacting drugs. Within each category, agents are listed in order from those most commonly to
less commonly used.
Drug class and specific agents
Adverse effects
Interacting drugs
Beta2-agonists:
Nervousness, restlessness, tremor,
palpitations, tachycardia
Beta2-agonists:
Adrenergics, MAO inhibitors,
beta blockers, digoxin, diuretics
Anticholinergics:
Dizziness, headache, nausea,
dry mouth
Anticholinergics:
Antihistamines, phenothiazines
Headache, hoarseness, upper
respiratory infections
ketoconazole, ritonavir
Systemic glucocorticosteroids
• prednisone
• methylprednisolone (Solu-Medrol, Medrol)
Depression, euphoria, hypertension,
peptic ulcer, hyperglycemia (more
common with higher-dose,
long-term use)
Thiazide and loop diuretics, digoxin,
insulins, oral hypoglycemics, phenytoin,
phenobarbital, hormonal contraceptives,
NSAIDs, fluoroquinolones
Methylxanthines
• aminophylline
• theophylline (Theo-dur, Slobid, Choledyl)
Anxiety, tachycardia, nausea,
vomiting.
With toxicity: seizures, arrhythmias
Increased toxicity with adrenergics,
allopurinol (high-dose), barbiturates, beta
blockers, calcium channel blockers,
cimetidine, disulfiram, erythromycin,
fluoroquinolones (selected), hormonal
contraceptives, isoniazid, lithium,
phenytoin, quinidine, smoking
Bronchodilators
Beta2-agonists (short-acting):
• albuterol (Proventil, Ventolin)
• terbutaline (Brethine, Brethair)
• pirbuterol (Maxair)
• levalbuterol (Xopenex)
• bitolterol (Tornalate)
Beta2-agonists (long-acting):
• formoterol (Foradil)
• salmeterol (Serevent)
Anticholinergics (short-acting):
• ipratropium bromide (Atrovent)
Anticholinergics (long acting):
• tiotropium (Spiriva)
Combination bronchodilators
• ipratropium bromide/albuterol
(Combivent, DuoNeb)
Inhaled corticosteroids
beclomethasone (Vanceril, Beclovent)
budesonide (Pulmicort)
fluticasone (Flovent)
triamcinolone (Azmacort)
flunisolide (AeroBid)
Combination beta2-agonist and
corticosteroid:
• formoterol/budesonide (Advair)
MAO = Monoamine oxidase. NSAIDs = Nonsteroidal anti-inflammatory drugs.
www.AmericanNurseToday.com
November/December 2009
American Nurse Today
23