Chronic obstructive pulmonary disease (COPD) is an umbrella term that also includes chronic bronchitis and emphysema. COPD causes the airways of the lungs to become narrow due to inflammation, mucus, or other damage. This affects the ability to breathe normally and often results in shortness of breath, especially on exertion.
COPD is a progressive disease that is treatable and controllable but cannot be cured. Exacerbations or flare-ups cause the most harm, as this is when there is an increase in symptoms that require prompt treatment and often inpatient care.
The Nursing Process
COPD is a common condition nurses will encounter in treating patients. It is often complicated by other comorbidities such as asthma, pneumonia, and heart failure. Nurses will most likely care for patients who are experiencing an exacerbation and must be vigilant in monitoring their respiratory status and administering antibiotics and steroids.
Nurses can use these opportunities to educate patients on the importance of quitting smoking, increasing their exercise tolerance, and instructing on medication adherence to prevent future exacerbations.
Nursing Care Plans Related to Chronic Obstructive Pulmonary Disease (COPD)
Ineffective Breathing Pattern Care Plan
The cardinal symptom of COPD is shortness of breath from airflow obstruction. It can be frightening for patients and requires prompt assessment and intervention.
Nursing Diagnosis: Ineffective Breathing Pattern
- Alteration in oxygen-carbon dioxide ratio (hyperventilation or hypoventilation)
- Inappropriate lung expansion/respiratory muscle fatigue
As evidenced by:
- Accessory muscle use
- Uneven respiratory rhythm
- Increased respiratory rate
- Pursed-lip breathing
- Sputum production
- Patient will maintain an effective respiratory pattern as evidenced by an even, unlabored respiratory rate and rhythm
- Patient will demonstrate techniques to improve breathing pattern
- Patient will verbalize factors contributing to an ineffective breathing pattern
Ineffective Breathing Pattern Assessment
1. Auscultate breath sounds and vital signs.
Monitor blood pressure, heart rate, and sp02 closely. Auscultate lungs to assess for adventitious sounds such as rhonchi which could signal retained secretions.
2. Note the type of breathing pattern.
Observe the rate, depth, and irregularity of the breathing pattern. Note accessory muscle use, audible wheezing, and nasal flaring.
3. Assess ABGs.
Arterial blood gases determine the degree of oxygenation and CO2 retention.
Ineffective Breathing Pattern Interventions
1. Decrease anxiety.
An ineffective breathing pattern may be caused by or due to anxiety. First, maintain a calming presence and stay with the patient to decrease their fear; breathlessness is scary. Create a relaxing environment with decreased stimuli.
2. Administer medications.
Bronchodilators relax the airways and inhaled steroids reduce inflammation to prevent exacerbations. IV or oral steroids may also be ordered to reduce inflammation.
3. Apply oxygen.
Apply supplemental oxygen at the lowest concentration necessary. COPD patients can be easily over oxygenated if their respiratory effort is inefficient leading to dangerous levels of O2 and CO2 (hypercapnia).
4. Instruct on pursed-lip breathing.
Instruct the patient to first relax and drop their shoulders so they aren’t tense. Pursed-lip breathing helps slow the respiratory rate and stay calm. Have the patient breathe in through their nose, pucker their lips like they are blowing out a candle, and exhale. The exhalation should be twice as long as the inhalation.
Activity Intolerance Care Plan
As COPD worsens, participating in physical activities may become more challenging. Patients often experience exercise intolerance due to dyspnea which negatively affects their strength and quality of life.
Nursing Diagnosis: Activity Intolerance
- Imbalance between oxygen supply and demand
- Sedentary lifestyle
- Weakened diaphragm
As evidenced by:
- Shortness of breath with minimal exertion
- Abnormal rise in BP or HR in response to activity
- Patient will participate in exercise while maintaining respiratory pattern and vital signs within normal limits
- Patient will report an increase in tolerance in performing tasks, ADLs, and exercise.
- Patient will verbalize techniques that aid in improved activity tolerance
Activity Intolerance Assessment
1. Evaluate current activity level.
Assess activities the patient currently partakes in. Observe the patient’s ability to perform ADLs, ambulation ability, and the degree of debility.
2. Assess emotional factors affecting activity.
Depression due to a loss of independence or anxiety from a fear of dyspnea can prevent the patient from attempting physical activity. Assess for these deeper concerns if a patient seems unmotivated or unwilling to participate.
3. Monitor cardiopulmonary response.
To ensure the patient is safe to partake in exercise, monitor vital signs and changes in the respiratory pattern as well as fatigue and an increased need for supplemental oxygen.
Activity Intolerance Interventions
1. Teach conservation techniques.
Increase activity gradually. Perform tasks that require the most effort when feeling the most energized. Take frequent rest breaks. Go at a slower pace. Perform tasks sitting such as brushing teeth or folding laundry.
2. Keep track of physical activity.
Many devices exist now that can track physical activity, known as accelerometers. They can be worn around the arm or waist and track posture, energy expenditure, and the quantity and intensity of body movements. Even simple pedometers can be useful in measuring physical activity over time.
3. Instruct on diaphragmatic breathing.
Diaphragmatic breathing can be useful to implement during daily activities such as climbing stairs, showering, and going on long walks. It takes time to learn but will strengthen the diaphragm. As you inhale, your abdomen should rise, and lower as you exhale. Placing your hands on your chest and abdomen will show if this is occurring.
4. Educate on medications to improve tolerance.
Long-acting bronchodilators such as Spiriva have been shown to increase exercise endurance as patients reported an increase in participation in physical activities, which consequently improved quality of life.
Deficient Knowledge Care Plan
A lack of knowledge related to the contributing factors, pathophysiology, symptoms, and treatments of COPD can lead to poor choices and worsening health outcomes.
Nursing Diagnosis: Deficient Knowledge
- Lack of information provided
- Lack of understanding
- Misinterpretation of education
- Lack of interest
As evidenced by:
- Request for additional information or clarification
- Verbalizes inaccurate information
- Demonstrates incorrect techniques
- Poor follow-through with tests or treatment
- Development of worsening conditions
- Patient will verbalize factors that contribute to worsening COPD
- Patient will demonstrate appropriate use of inhaler and oxygen
- Patient will verbalize symptoms that warrant assessment and intervention
Deficient Knowledge Assessment
1. Assess how the patient learns best.
Medical information can be complicated. Provide information without jargon that is easy to understand. Use repetition. Provide verbal and written education as well as pictures or videos that reinforce breathing techniques or how to properly use inhalers or oxygen.
2. Assess readiness and motivation.
Assess the patient’s interest in learning about their disease. If the patient is not mentally or emotionally ready to accept teaching it will be futile. Dig deeper into their motivation to learn or lack thereof.
3. Assess for a support system.
Chronic conditions can be difficult to manage alone. Assess for family members or friends that can support the patient in reinforcing teaching instructions.
Deficient Knowledge Interventions
1. Instruct on how to prevent and recognize exacerbations.
COPD exacerbations refer to a worsening in symptoms for days or weeks and often require hospitalization. Respiratory infections, pollution, and allergies can cause a flare-up. If the patient notices an increase in coughing, dyspnea, changes in sputum, and difficulty sleeping they should contact their provider.
2. Educate on hygiene practices.
Staying healthy will keep the immune system strong to prevent infections and viruses. Frequent hand washing, staying away from sick people, regular exercise, keeping the airways clear, and eating healthy should be encouraged.
3. Recommend pulmonary rehab.
Pulmonary rehabilitation educates on exercise training, nutrition advice, and counseling specific to controlling COPD. Pulmonary rehab can help reduce exacerbations and hospital readmissions.
4. Quit smoking.
If the patient smokes, this is one of the most important instructions that can be given. Quitting smoking is difficult but is essential in preserving lung function and preventing exacerbations.
References and Sources
- Breathing Exercises for COPD | UM BWMG – Pulmonary Care. (n.d.). University of Maryland Medical System. Retrieved February 15, 2022, from https://www.umms.org/bwmc/health-services/lung-health/copd/treatment/breathing-exercises
- Breathing Techniques. (n.d.). COPD Foundation. Retrieved February 15, 2022, from https://www.copdfoundation.org/Learn-More/I-am-New-to-COPD/Breathing-Techniques.aspx
- Chronic obstructive pulmonary disease (COPD). (2021, June 21). WHO | World Health Organization. Retrieved February 15, 2022, from https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd)
- COPD – Diagnosis and treatment. (2020, April 15). Mayo Clinic. Retrieved February 15, 2022, from https://www.mayoclinic.org/diseases-conditions/copd/diagnosis-treatment/drc-20353685
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- Rocker G. (2017). Harms of overoxygenation in patients with exacerbation of chronic obstructive pulmonary disease. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 189(22), E762–E763. https://doi.org/10.1503/cmaj.170196
- Troosters, T., van der Molen, T., Polkey, M. et al. Improving physical activity in COPD: towards a new paradigm. Respir Res 14, 115 (2013). https://doi.org/10.1186/1465-9921-14-115
- What is a COPD Exacerbation? (n.d.). COPD. Retrieved February 15, 2022, from https://www.copd.com/copd-progression/copd-exacerbations/