7 Chronic Obstructive Pulmonary Disease (COPD) Nursing Care Plans

Ineffective Airway Clearance

Common to many pulmonary diseases is bronchospasm which reduces the caliber of the small bronchi and may cause difficulty in breathing, stasis of secretions, and infection. Mucous gland hyperplasia is the histologic hallmark of chronic bronchitis. Airway structural changes include atrophy, focal squamous metaplasia, ciliary abnormalities, variable amounts of airway smooth muscle hyperplasia, inflammation, and bronchial wall thickening. These changes cause airflow limitation by allowing airway walls to deform and narrow the airway lumen (Mosenifar & Oppenheimer, 2022).

Nursing Diagnosis

• Ineffective Airway Clearance

May be related to

• Bronchospasm
• Increased production of secretions; retained secretions; thick, viscous secretions
• Allergic airways
• Hyperplasia of bronchial walls
• Decreased energy/fatigue

Possibly evidenced by

• Statement of difficulty breathing
• Changes in depth/rate of respirations, use of accessory muscles
• Abnormal breath sounds, e.g., wheezes, rhonchi, crackles
• Cough (persistent), with/without sputum production

Desired Outcomes

• The client will maintain airway patency with breath sounds clear.
• The client will demonstrate behaviors to improve airway clearance, e.g., cough effectively and expectorate secretions.

Nursing Assessment and Rationales

1. Assess and monitor respirations and breath sounds, noting rate and sounds (tachypnea, stridor, crackles, wheezes). Note the inspiratory and expiratory ratio.
Tachypnea is usually present to some degree and may be pronounced on admission or during stress or concurrent acute infectious process. Respirations may be shallow and rapid, with prolonged expiration in comparison to inspiration. Wheezing can be frequently heard on forced and unforced expiration with diffusely decreased breath sounds. Additionally, coarse crackles beginning with inspiration may be heard (Mosenifar & Oppenheimer, 2022).

2. Auscultate breath sounds. Note adventitious breath sounds (wheezes, crackles, rhonchi).
Some degree of bronchospasm is present with obstructions in the airway and may or may not be manifested in adventitious breath sounds such as scattered, moist crackles (bronchitis); faint sounds, with expiratory wheezes (emphysema); or absent breath sounds (severe asthma). Inspiratory or expiratory wheezes and chest tightness are symptoms that may vary between days, and over the course of a single day. Alternatively, widespread inspiratory or expiratory wheezes can be present during auscultation (Global Initiative for Chronic Obstructive Lung Disease, 2022).

3. Note the presence and degree of dyspnea for reports of “air hunger” or breathlessness.
Respiratory dysfunction is variable depending on the underlying process such as infection, allergic reaction, and the stage of chronicity in a client with established COPD. Chronic dyspnea is the most characteristic symptom of COPD. A dyspnea questionnaire, the modified Medical Research Council (mMRC) dyspnea scale was the first questionnaire developed to measure breathlessness, which is a key symptom in many clients diagnosed with COPD, although it is often recognized (Global Initiative for Chronic Obstructive Lung Disease, 2022).

4. Observe signs and symptoms of infections.
Acute exacerbations of COPD are common and usually occur due to a trigger, such as bacterial or viral pneumonia or environmental irritants. There is an increase in inflammation and air trapping often requiring corticosteroid and bronchodilator treatment (Agarwal, 2022).

5. Monitor and graph serial ABGs, pulse oximetry, and chest x-ray.
This establishes a baseline for monitoring the progression or regression of disease process complications. ABG analysis provides the best clues as to the acuteness and severity of disease exacerbation. Frontal and lateral chest radiographs of clients diagnosed with emphysema reveal signs of hyperinflation, including flattening of the diaphragm and increased retrosternal air space. And a long, narrow heart shadow. Chronic bronchitis is associated with increased bronchovascular markings and cardiomegaly (Mosenifar & Oppenheimer, 2022).

6. Observe for persistent, hacking, or moist cough.
Chronic cough is often the first symptom of COPD and is frequently discounted by the client as an expected consequence of smoking and/or environmental exposures. Initially, the cough may be intermittent, but subsequently, it may be present every day, often throughout the day. Chronic cough in COPD may be productive or unproductive. In some cases, significant airflow obstruction may develop without the presence of a cough (Global Initiative for Chronic Obstructive Lung Disease, 2022).

Nursing Interventions and Rationales

1. Educate the client regarding smoking cessation.
A significant proportion of people with COPD continue to smoke despite knowing that they have a disease, and this behavior has a negative impact on the prognosis and progression of the disease. Smoking cessation has the greatest capacity to influence the natural history of COPD. If effective resources and time are dedicated to smoking cessation, long-term quit success rates of up to 25% can be achieved (Global Initiative for Chronic Obstructive Lung Disease, 2022).

2. Provide an incentive spirometer for the measurement of airflow obstruction.
Forced spirometry is the most reproducible and objective measurement of airflow obstruction. It is a non-invasive, reproducible, cheap, and readily available test. Good quality spirometry measurement is possible in any healthcare setting and all healthcare workers who care for people with COPD should have access to spirometry. The spirometry criterion for airflow obstruction selected by GOLD remains a post-bronchodilator ratio of FEV1/FVC <0.7 (Global Initiative for Chronic Obstructive Lung Disease, 2022).

3. Assist the client to assume a position of comfort (elevate the head of the bed, have the client lean on an overbed table, or sit on edge of the bed).
Elevation of the head of the bed facilitates respiratory function by use of gravity; however, the client in severe distress will seek the position that most eases breathing. Supporting arms and legs with a table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion.

4. Keep environmental pollution to a minimum such as dust, smoke, and feather pillows, according to the individual situation.
Precipitators of an allergic type of respiratory reaction that can trigger or exacerbate the onset of an acute episode. COPD does occur in individuals who have never smoked. In developing countries, the use of biomass fuels for indoor cooking and heating is likely to be a major contributor to the worldwide prevalence of COPD. Long-term exposure to traffic-related air pollution may be a factor in COPD clients with diabetes and asthma (Mosenifar & Oppenheimer, 2022).

5. Encourage abdominal or pursed-lip breathing exercises.
This provides the client with some means to cope with or control dyspnea and reduce air trapping. Breathing exercises, as a self-management intervention strategy, are complex and diverse. They have been reported to not only effectively improve the strength and endurance of respiratory muscles and correct abnormal chest and abdomen movements but they also reduce dyspnea and pulmonary dynamic hyperinflation (Li et al., 2020).

6. Assist with measures to improve the effectiveness of cough effort.
Cough can be persistent but ineffective, especially if the client is elderly, acutely ill, or debilitated. Coughing is most effective in an upright or in a head-down position after chest percussion. Effective or controlled coughing has just enough force to loosen and carry mucus through the airways without causing them to narrow and collapse. This saves energy for clients diagnosed with COPD (Cleveland Clinic, 2018).

7. Increase fluid intake to 3000 mL per day within cardiac tolerance. Provide warm or tepid liquids. Recommend the intake of fluids between, instead of during, meals.
Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm. Fluids during meals can increase gastric distension and pressure on the diaphragm.

8. Demonstrate effective coughing and deep-breathing techniques.
Not all coughs are effective in clearing excess mucus from the lungs. Explosive or uncontrolled coughing causes airways to collapse and spasm, trapping the mucus. To cough effectively, the client should be sitting on a chair and leaning forward slightly. Both arms should be folded across the abdomen and a slow inhalation through the nose is done. The client should cough two to three times through a slightly open mouth. Coughs should be short and sharp (Cleveland Clinic, 2018).

9. Assist the client to turn every two hours. If ambulatory, allow the client to ambulate as tolerated.
Movement aids in mobilizing secretions to facilitate the clearing of airways. Aerobic activities such as walking can help improve cardiorespiratory fitness by strengthening large muscle groups in the body. Although exercise does not directly improve lung function, it can help strengthen the muscles which helps build up the client’s endurance level (Leader, 2022).

10. Suction secretions as needed.
Suctioning clear secretions that obstruct the airway, therefore, improves oxygenation. Using bronchoscopy to remove sputum is an effective way during invasive ventilation in respiratory failure clients with advanced exacerbation of COPD. Study shows that bronchoscopy sputum suction presents more encouraging results than negative pressure suction with a low mortality rate (Qiao et al., 2018).

11. Demonstrate chest physiotherapies, such as bronchial tapping when in cough, and proper postural drainage.
These techniques will prevent possible aspiration and prevent any untoward complications. Postural drainage and deep breathing-coughing exercises, which are part of the pulmonary rehabilitation program in the care and management of COPD, are effective in increasing oxygen saturation, triFlo volume, and pulmonary function tests (Arik & Cevik, 2021).

12. Administer medications as prescribed.

• 12.1. Bronchodilators
  Bronchodilators are medications that increase FEV1 and/or change other spirometry variables. They act by altering airway smooth muscle tone and the improvements in expiratory flow reflect the widening of the airways rather than changes in lung elastic recoil. Bronchodilators tend to reduce dynamic hyperinflation at rest and during exercise and improve exercise performance (Global Initiative for Chronic Obstructive Lung Disease, 2022).
• 12.2. Antimuscarinic drugs
  Antimuscarinic drugs block the bronchoconstrictor effects of acetylcholine on M3 muscarinic receptors expressed in the airway smooth muscles. Short-acting antimuscarinics (SAMAs), such as ipratropium and oxitropium, also block the inhibitory neural receptor M2, which potentially can cause vagally induced bronchoconstriction. Long-acting muscarinic antagonists (LAMAs), such as tiotropium, aclidinium, glycopyrronium bromide, and umeclidinium have prolonged binding to M3 receptors, with faster dissociation from M2 muscarinic receptors, thus prolonging the duration of bronchodilator effect (Global Initiative for Chronic Obstructive Lung Disease, 2022).
• 12.3. Mucolytics
  In COPD clients, regular treatment with mucolytics such as carbocysteine and N-acetylcysteine may reduce exacerbations and modestly improve health status (Global Initiative for Chronic Obstructive Lung Disease, 2022). Mucolytic agents reduce sputum viscosity and improve secretion clearance. When used as an inhalational therapy, N-acetylcysteine should be administered with a bronchodilator in order to counteract the potential induction of bronchospasm (Mosenifar & Oppenheimer, 2022).