This article discusses COPD, how to improve patient outcomes and important things to document.
Nurses are a significant factor in patients’ lives and outcomes. By nature, nurses educate on diseases, discuss preventative measures, assist in the stages of the disease process, and eventually provide comfort through the end stages of the disease.
COPD, or chronic obstructive pulmonary disease, is a disease that affects lung function and breathing ability. COPD is an umbrella term that covers several breathing issues, including bronchitis, emphysema, and chronic asthma. According to the CDC, nearly 15.7 million Americans have COPD, with another 50% having lower respiratory function scores, putting them at risk for COPD if no intervention is provided. One of the top causes of COPD is tobacco smoke, as well as environmental hazards. There is no cure for COPD, but there are many stages in treatment, as well as preventative measures. COPD is caused by the inability to get rid of C02 in the body, which causes a build-up and, eventually, toxicity. The most significant prevention is quitting smoking, but other factors include a balanced diet, exercise, and maintaining an overall healthy life. Treatments for COPD include oxygen use, c-pap, bi-pap, steroids, inhaled treatments, symptom control, and antibiotics. Depending on the stage of the patient will depend on which treatment(s) will be used.
Since nurses will see patients through every stage of COPD, they are vital to patient outcomes. Most people with COPD also have OSA or obstructive sleep apnea. Obstructive sleep apnea is where the airway becomes blocked during sleep producing a familiar sound… the snore. OSA is also more prominent in overweight (particularly in the abdominal region) back sleepers. One of the easiest ways to fix OSA is to raise the head of the bed at least thirty degrees while sleeping. If the patient has not yet been hospitalized, it is important to educate them. Frequent oxygen saturation checks while resting and during movement (most commonly referred to as 02 walks) are also important. This will determine if the patient requires additional oxygen to maintain daily living. If the patient had been diagnosed with OSA, there is a good chance that they will also have a c-pap, bi-pap, or in advanced stages, AVAPS. Education on compliance with prescribed machines is also important because these machines help eliminate C02 build-up in the body. One of the biggest education pieces that needs to be included is that if the patient uses supplemental oxygen and continues to smoke, they either need to stop smoking or not wear oxygen while smoking. Oxygen is a flammable gas and can cause burns if ignited. Educate patients, educate them, and then educate them some more. Nurses should educate and reeducate at every opportunity to help prevent poor outcomes.
Nurses are constantly assessing patients, and documentation is extremely important. Nurses everywhere just recited the golden rule. “If it’s not documented, it’s not done” Documentation is among the most underrated nursing tools. Every nurse sees documentation as the enemy, something added to the never-ending list of stuff to do. However, by properly documenting, a nurse can spot a change in the patient and intervene appropriately. Here are some tips on documenting an assessment for a COPD patient. A nurse can gather much information without touching the patient or pulling out a stethoscope. Mentation of the patient is the first assessment. Is the patient confused? Is this out of the normal for the patient? How is the patient’s speech? Are they mumbling, slurring, or getting the wrong words? This could be a sign of low oxygen levels. Skin color and warmth are the second assessment tool. Is the patient pink, blue, white, red, or gray? Do they have discolored lips or dark spots under their eyes? Is their skin warm, cool, dry, or sweaty? These signs are the body’s way of indicating there is something wrong. Vital signs are important as well. Keep in mind that end-stage COPD will retain C02, so lower 02 levels are acceptable and encouraged. Normal oxygen saturation levels range from 90-100%; an end-stage COPD patient will range from 88-92%. End-stage COPD patients may have lower blood pressure, especially if the patient is having C02 toxicity (respiratory acidosis). Lung sounds and cough are extremely important. Are they moving air in and out of their lungs? Are they diminished, or are other lung sounds present (rhonchi, expiratory wheezing, inspiratory wheezing, crackles)? Do they have a cough? Is it dry or wet sounding? Is it non-productive (meaning they are not coughing anything up) or productive? Some pulmonologists (lung specialists) will have the patient do an incentive spirometer which is a part of a pulmonary function test. This test will indicate how strong the patient’s lungs are. Patients with COPD are more prone to upper respiratory infections. Antibiotics and steroids are used in conjunction to help fight the infection and reduce inflammation in the lungs.
Many places have gone to computerized charting. Unfortunately, some places are still in the Stone Age and have paper charting. Either way, documentation is important. Most computerized charting covers many points throughout the assessment, so it is easy to click on the symptoms. Computerized charts also have a care plan or plan of care where the nurse can click on any interventions/education. If the program lacks this, a manual note must be made. Paper charting will depend on the status of the patient. Medicare charting is a flow sheet that is very similar to computer charting. If the patient isn’t on Medicare, a handwritten note describing everything will need to be placed. The nurse’s note should include the patient’s physical assessment. “Patient is alert and oriented, skin warm and dry, lungs clear, no cough noted” It should also include any supplemental oxygen or device used for OSA. “Patient continues on 3L/m nasal cannula,” If the patient is only supposed to wear the supplemental device at a certain time (wear c-pap during sleep), only document if they are wearing it during present care. Note any antibiotics or steroidal use and if there are any adverse symptoms noted. “Doxycycline P.O. 500mg daily continued as ordered for upper respiratory infection, no adverse reactions noted. Cough non-productive continued, but improving. Fluids encouraged.” For any patient who is on antibiotics, fluids should be encouraged because most antibiotics are filtered through the kidneys. Document any education and any non-compliance. “Educated patient on the importance of wearing c-pap at night; patient demonstrated how to put the machine on and operate easily. Questions answered.” Or “patient refused to wear c-pap, stating it hurts their face—adjusted straps to c-pap. Patient continued to refuse to wear. Educated on potential outcomes.”
COPD has no cure, but nurses can improve patient outcomes and patient comfort.