clinical teaching on copd, septic shock by Monika Devi Syal

1. PRESENTED BY
MONIKA DEVI
MSC.(N) 1ST YEAR
HCN , SRHU

2. COPD
COPD is a disease state characterized by the
presence of airflow obstruction caused by
chronic Bronchitis or emphysema. The
airflow obstruction is generally progressive,
may be accompanied by airway hyperactivity,
and may be partially reversible.

3. Chronic Bronchitis
Chronic bronchitis, a disease of the airways,
is defined as the presence of cough and
sputum production for at least 3 months
in each of two Consecutive years. In much
case, smoke or other environment
pollutants irritates the airways, resulting
in hyper secretion of mucus and
inflammation.

5. Emphysema
In emphysema, impaired gas exchanges
results from destruction of the walls of
over distended alveoli “emphysema in a
pathological form that describes an
abnormal distention of the air spaces
beyond the terminal bronchioles, with
destruction of the walls of the alveoli.

6. Pan Lobular (Panacinar)
There is destruction of the respiratory
bronchiole, alveolar duct, and alveoli. All
air space within the lobule are essentially
enlarged, but there is little inflammatory
disease. The patient shows hyper inflated
(hyper expended) chest (barrel chest on
physical examination), dyspnea and
weight loss.

8. Centrilobular
In this from, pathologic changes takes place
mainly in the center of the secondary
lobule. In which the respiratory
bronchioles enlarge, the walls are
destroyed and the bronchioles became
inflamed.

9. Causes
1)Cigarette Smoking
when cigarettes are smoked, Approximately 4000
chemicals and gases are inhaled into the lungs.
2) Infection
3) Occupational exposure
4) Air pollution
5) Heredity
6) Aging

11. Clinical Manifestation
COPD is characterized by three primary symptoms
1. Cough
2. Sputum production
3. Dyspnea on exertion
4. Weight loss
5. Hypoxemia during exercise
6. Cyanosis

12. Complications
OF COPD

13. Cor Pulmonale

14. Pneumothorax

16. STAGES
STAGE CHARACTERISITICS
O Normal Spirometry,
Chronic symptoms of
cough, sputum production
I (Mild COPD) FEV1/ FVC <70%
May or may not have
chronic symptoms of
cough, sputum production.

17. Cont..
II (Moderate COPD) FEV1/ FVC <70%
May or may not have
chronic symptoms of cough
and sputum production.
III (Severe COPD) FEV1/FVC <70%
FEV1 30% predicted plus
respiratory failure or clinical
signs of right heart failure.
[FEV1 = volume of air that the patient can forcibly exhale
in 1 second to forced vital capacity (FVC).

18. Diagnostic Finding
1. Extensive history collection
Exposure to risk factors
Past medical history
Family history of COPD
Pattern of symptoms development
History of previous hospitalizations
Current medical treatments
Potential for reducing risk factors

19. Cont..
Physical examination
Spirometry: - to evaluate airflow obstruction.
ABG analysis
Chest X-Ray
Bronchodilator reversibility Test
Alpha1, antitrypsin deficiency screening
Pulmonary function Test
ECG
Echo – cardiogram

20. Management
MEDICAL MANAGEMENT
1.Risk Reduction
Smoking cessation is the single most
effective intervention to prevent COPD.

21. 2.pharmacological therapy
1.Broncho dilators
A) Beta-adrenergic agonist agents
1. Albuterol
2. Terbutaline
B) anticholinergic agents
1. Ipratropium bromide
2. Oxitropium bromide
C) methylxanthines
1. Aminophylline
2. Theophylline

22. Cont..
2. Corticosteroids
 beclomethasone
 Budesonide
 Flunisolide
3. Alpha1antitrypsin augmentation therapy
4.Antibiotic agents
5. Anti tussive agents
6. Oxygen therapy

23. Surgical Management

24. Cont…
2. Lung Volume Reduction Surgery
3. Lung Transplantation

25. Dietary Management
Liquid, blenderized diet may be given
Foods that require a great deal of chewing should be
avoided
Avoid exercise before and after eating
Avoid gas-forming foods
High protein and calorie diet given
Avoid high CHO diet
Avoid sodium if this is heart failure.

26. Pulmonary Rehabilitation
1. Education
2. Exercise

27. Pulmonary Rehabilitation
Education
1. Diagnosis
2. Smoking Cessation
3. Pharmacology
4. Respiratory Therapy
5. Physical Therapy
6. Occupational Therapy
7. Therapeutic Recreation
8. Nutrition
9. Psychosocial

28. Pulmonary Rehabilitation
Exercise
1. Physical Therapy
2. Occupational Therapy
3. Respiratory Therapy

29. Pulmonary Rehabilitation
Inpatient
ADVANTAGES
1. 24 hour nursing
care
2. Sicker patients
3. No transportation
problems
4. Family
participation
5. Best for ventilator,
tracheostomy
patients
DISADVANTAGES
1. Cost and insurance
difficulties
2. Not suitable for less
severe patients
3. Family transportation
problems

30. Pulmonary Rehabilitation
OUTPATIENT
ADVANTAGES
1. Widely available
2. Less costly
3. Least intrusive to
family
4. Efficient use of staff
DISADVANTAGES
1. Potential transportation
problems
2. Cannot observe home
activities

31. Pulmonary Rehabilitation
HOME - BASED
ADVANTAGES
1. Convenience to patient
2. Transportation no issue
3. Exercise in familiar
environment may lead
to better adherence
long term
DISADVANTAGES
1. Cost/insurance issues
2. Lack of group support
3. Lack of full spectrum of
multidisciplinary
personnel

32. Pulmonary Rehabilitation
Adverse Effects
1. Musculoskeletal injury
2. Exercise-induced bronchospasm
3. Cardiovascular event (increased risk
among COPD patients)

33. Pulmonary Rehabilitation
Benefits in COPD
1. Improves exercise capacity
2. Improves perceived breathlessness
3. Improves quality of life
4. Reduces hospitalizations
5. Reduces anxiety and depression
6. Benefits extend beyond training period
7. Improves survival

34. Nursing Management
The nurses play a key role to manage the client
condition.
Assess the general and respiratory condition of the
patient.
Collect the important health information
Assess the functional health patterns
Physical examination.

35. Nursing Diagnosis
1. Impaired gas exchange and airway clearance
due to chronic inhalation of toxin.
INTERVENTION
Evaluates current smoking status, educate
regarding smoking cessation
Provide comfortable position
Administer and teach appropriate use of
bronchodilators
Administer O2 to increase O2 saturation.

36. Cont..
1. Impaired gas exchange related to ventilation –
perfusion inadequately.
INTERVENTION
Administer bronco dilators
Evaluate effectiveness of nebulizer
Instruct and encourage patient in diaphragmatic
breathing and effective coughing.
Administered O2
Instruct the patient to avoid smoking
Provide comfortable portion.

37. Cont..
3.Ineffective airway clearances related to bronco
constriction, increased mucus production.
INTERVENTION
Adequately hydrate the patient
Teach and encourage the use of diaphragmatic
breathing and coughing techniques.
Assist in nebulizer.
Avoid the smoking
Administer antibiotic

38. Cont..
4.Ineffective breathing pattern related to
shortness of breath, mucus and airway
irritants.
INTERVENTION
Facilitate deep breathing by elevating head
Provide semi fowler position
Encourage alternating activity with rest period

39. Cont…
5. Imbalance nutrition: less than body
requirement related to poor appetite.
INTERVENTION
Monitor calorie intake, weight.
Provide menu suggestion for high protein &
calorie foods
Give high protein and calorie diet.
Provide liquid and frequent diet.
Plan periods of rest after food intake.

40. Cont..
6.Self care deficits related to fateful secondary to
increased work of breathing.
INTERVENTION
Teach patient to coordinate diaphragmatic
breathing with activity.
Encourage patient to begin to bathe self, walk
Teach about postural drainage.

41. Cont..
7.Activity intolerance due to fatigue, hypoxemia.
INTERVENTION
Support the patient in establishing a regular
regimen of exercise.
Provide adequate ventilation

42. Cont..
8. Sleep pattern disturbance related to anxiety,
dyspnea, and hypoxemia.
INTERVENTION
Assess the sleeping habit, identify cause and
reduce them
Encourage exercise & activity during day time
Avoid day time sleeping
Instruct patient in maintaining an environment
conductive to rest.
Teach avoidance of alcoholic beverages, caffeine
products before bedtime.

43. Cont..
10.Deficient knowledge about self-management to
be performed at home.
INTERVENTION
Teach the patient about self-care.
Give strong message to stop smoking
Advise the patient to take regular treatment
Teach about exercise.

44. SEPTIC SHOCK

45. SHOCK
Definition
It is defined as a condition in which systemic blood
pressure is inadequate to deliver oxygen and
nutrient to support vital organs and cellular
function.

46. Septic Shock
It is most common type of circulatory shock and caused
by wide spread infection. Nosocomial infections in
critically ill patient frequently originate in blood
stream, lungs.
Septic shock = Presence of sepsis with hypotension
despite fluid resuscitation + Presence of tissue
perfusion abnormalities

47. Causes
 The common causative micro- organisms of septic
shock are :-
 Gram-negative and gram-positive bacteria
 Endotoxin stimulates inflammatory response

48. Patho Physiology
When microorganism invades the body tissue
↓
Patients exhibits the immune response
↓
Activation of Bio- chemical mediator associated
with an inflammatory response
↓
Increased capillary permeability
↓

49. It lead to fluid seeping from the capillary,
vasodilatation
↓
It interrupts ability of the body to provide
adequate perfusion, oxygen, nutrient to the
tissue and cells
↓
Shock occurs

50. Clinical manifestation
Two phases :-
1.“Warm” shock - early phase
1. Hyperdynamic response,
2. Vasodilation
2.“Cold” shock - late phase
1. Hypodynamic response
2. Decompensated State

51. Early - hyperdynamic state-
compensation.
1. Massive vasodilation
2. Pink, warm, flushed skin
3. Increased heart rate full bounding pulse
4. Tachypnea
5. Crackles

52. Late--- Hypodynamic State
Decompensation
1. Vasoconstriction
2. Skin is pale & cool
3. Significant tachycardia
4. Decreased BP
5. Chang Metabolic & respiratory acidosis
with hypoxemia
6. LOC

53. Diagnostic evaluation
 X-ray

55. Medical Management
1. Eliminating the causes of infection
2. Antibiotic-coated IV central line may be placed
3. Fluid replacement
4. Pharmacologic therapy
-Antibiotic drugs
5. Nutritional therapy
6. External feeding is preferred to the parenteral route

56. Collaborative treatment
1. Prevention !!!
2. Find and kill the source of the infection
3. Fluid Resuscitation
4. Vasoconstrictors
5. Inotropic drugs
6. Maximize O2 delivery Support
7. Nutritional Support
8. Comfort & Emotional support

57. Nursing Management
1. Maintain the personal hygiene of patient
2. Administered prescribed IV fluid and medication
3. Maintain intake and out of the patient
4. Elevated temperature may not be treated unless it
reaches dangerous level (more that 400C or 1040F)

59. Summary

60. References
BOOK :-
Lewis’s medical –surgical nursing , assessment and
management of clinical problems. Second edition.
Page no . 610-625. 1164,630,635,1722-1723.
Brunner and suddarth’s textbook of medical –surgical
nursing twelfth edition page no. 602-619.
NET :-
COPD, www.mpedia.com
Septic shock, www.Myoclinic.Org
Copd medlineplus.Gov/copd
Septic shock, wikipedia.Org/wiki/