March 1, 2008 | American Society of Registered Nurses®
Journal of Nursing

ICU Nursing-Nurse Interventions In Acute Exacerbations Of COPD

ICU Nursing
Intensive Care Unit (ICU) nursing is commonly referred to as critical care nursing. Critical care nursing deals specifically with the human response to life threatening conditions. Critical care nursing is challenging due to the life-threatening health situations in the ICU. Critical care nurses are often in high-stress situations which demands complex assessments, high-intensity therapies and interventions and continuous vigilance.

Acute Exacerbations of COPD
Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD), is a term used to describe progressive lung diseases, which include emphysema, chronic bronchitis and chronic asthma. The common symptoms of COPD are progressive limitations of the airflow into and out of the lungs and shortness of breath. Emphysema and chronic bronchitis are closely related and patients with COPD may have both, which affects lung function. Emphysema involves destruction of the alveoli in the lungs. Chronic bronchitis is characterized by chronic cough and mucus production. Over a period of time the patient experiences abnormal ventilation-perfusion, insufficient oxygenation of blood (hypoxemia), hypoventilation and right-sided heart failure. People with COPD have a variety of illnesses such as, atelectasis which occurs due to the collapse of part or all of a lung by blockage of the bronchus or bronchioles or by very shallow breathing; bronchiectasis, which is an acquired disorder of the large bronchi that become dilated due to destructive infections of the lungs; congestive heart failure (CHF),a disorder in which the heart loses its ability to pump and cor pulmonale ,where the right ventricle gets enlarged  because of pulmonary hypertension from lung disorders. COPD symptoms, when ignored, usually lead to hospitalization in intensive care (ICU) units. 

Nurse Interventions in Acute Exacerbations                                                                  
People with chest deformities or neurologic conditions that cause shallow breathing benefit from mechanical devices that assist breathing, such as continuous positive airway pressure, which delivers oxygen through a nose or face mask that prevent airways collapse, even at the end of a breath. Additional respiratory support can be provided with a mechanical ventilator. The primary treatment for acute massive atelectasis, a common complication in COPD is removal of the underlying cause (Brooks-Brunn, 1995). If the blockage cannot be removed by coughing or by suctioning the airways then it should be removed by bronchoscopy. Antibiotics are to be given for any detected infection as in chronic atelectasis, when infection is almost inevitable. Treatment of atelectasis due to deficient or ineffective surfactant is done by treating the low blood oxygen either with mechanical ventilation or positive end expiratory pressure. For cor pulmonale, supplemental oxygen can be administered to increase the level of oxygen in the blood. A low salt diet is recommended. Diuretics are given to remove excess fluid from the body. Calcium channel blockers, intravenous prostacyclin, or the oral medication bosentan are frequently used to treat pulmonary hypertension. Blood thinning anticoagulants are also useful. Oxygen administration relieves symptoms and prolongs survival. Careful intervention is essential because progressive pulmonary hypertension and cor pulmonale often leads to severe fluid retention, life-threatening shortness of breath, shock, and death. Benzodiazepines are not recommended to relieve anxiety in patients with COPD because they decrease respiratory drive and compromise lung function (Brooks-Brunn, 1995). An anxiolytic, buspirone, have been found to be safe in reducing anxiety in COPD patients. Dyspnea is common in individuals with chronic obstructive pulmonary disease. Respiratory assessment of the patient should include present level of dyspnea measured using a quantitative scale such as a visual analogue or numeric rating scale. Usual dyspnea is measured using a quantitative scale such as the Medical Research Council (MRC) Dyspnea Scale. The other assessments include Vital signs, pulse oximetry, chest auscultation, chest wall movement and shape/abnormalities, presence of peripheral edema, accessory muscle use, presence of cough and/or sputum, ability to complete a full sentence and the level of consciousness. By doing so, nurses should be able to detect stable and unstable dyspnea and acute respiratory failure (American Thoracic Society, 1998). Nurses should also be able to offer interventions for all levels of dyspnea including acute episodes of respiratory distress which includes acceptance of patients' self-report of present level of dyspnea, medications, controlled oxygen therapy, secretion clearance strategies, non-invasive and invasive ventilation modalities, energy conserving strategies, relaxation techniques, nutritional strategies and breathing retraining strategies. It is important for the nurses to remain with patients during episodes of acute respiratory distress. Nurses have to assess patients for hypoxemia/hypoxia and administer appropriate oxygen therapy for individuals for all levels of dyspnea. Medications include bronchodilators, beta 2 agonists, anticholinergics and methylxanthines, corticosteroids, antibiotics, psychotropics and opioids (www.guidelines.gov).

Patient safety checks
Patient safety checks include circuit leaks; maintenance of positive pressure; adequate inspiratory air flow and not leaving the patient alone. Continuous Positive Airway Pressure Oxygen therapy is part of any ICU and requires absolute attention. Managing the therapy involves  maintenance of  the desired FIO2; level of positive airway pressure and time period for CPAP therapy, attaching CPAP machine medical air and oxygen gas lines to wall sources, preparation of humidification source ,selection of prescribed FIO2 on oxygen blender, turning flow on to level above 25 litres / min., positioning of rubber securing band behind the patient's head, centred on occiput, positioning of  face mask over the patient, adjusting the  level of positive expiratory pressure to prescribed level, adjusting inspiratory gas flow so that minimal fluctuations are present on pressure gauge, observing and documenting respiratory rate; work of breathing and SpO2, increasing inspiratory flow if respiratory work is excessive or the patient complains of continuing dyspnea, maintaining continuous SpO2 monitoring with alarm function in place, maintaining humidification temperature at 36 degree C or at temperature tolerated by the patient (American Thoracic Society, 1998). Patient observations include, visual check every half an hour, documentation of respiratory rate, SpO2, nausea and vomiting, monitoring pulse rate and rhythm; blood pressure; peripheral circulation and proper functioning of humidification system every hour, checking the condition of skin around and under mask and rubber securing band, documentation of condition and interventions, condition of conjunctivae every two hours, auscultation of lungs for equal air entry and palpitation of abdomen for distension every four hours (Vollman,1997). Ventilator-Associated Pneumonia is a common nosocomial infection in the ICU accounting for 13% to 18% of all nosocomial infections (Rello et.al, 1996). Infection may be even due to improper hand washing, not changing the gloves from patient to patient, and contamination of respiratory devices like nebulizers, spirometers, oxygen sensors, bag-valve mask devices, and suction catheters (Shelby Hixson, 1998). Oral care includes brushing the patient’s teeth, use of solutions and mouthwash to cleanse the mouth, and periodical suctioning of oral secretions. Nasal care and proper cleansing of the nasopharynx reduces bacterial infection.  

Conclusion
The ICU setting demands stressful nursing interventions and constant monitoring of the patients especially with conditions like COPD. Nurse interventions should be based on assessment of dyspnea, vital signs, pulse oximetry, chest auscultation, chest wall movement and presence of peripheral edema, cough and/or sputum, ability to complete a full sentence and the level of consciousness. Proper oral and nasal care reduces lung infection. 

 

Reference

  • American Thoracic Society (1998).Research Priorities in Respiratory Nursing. Am. J. Respir. Crit. Care Med.158 (6): 2006-2015.
  • Brooks-Brunn, J. A (1995). Postoperative atelectasis and pneumonia. Heart Lung 24: 94-115.
  • http://www.guidelines.gov/summary/summary.aspx?
    doc_id=5061&nbr=003545&string=copd.Nursing care of dyspnea: the 6th vital sign in individuals with chronic obstructive pulmonary disease (COPD).
  • Kingston GW, Phang PT and Leathley MJ (1991). Increased incidence of nosocomial pneumonia in mechanically ventilated patients with subclinical aspiration. Am J Surg 161: 589-593.
  • Metheny N (1993). Minimizing respiratory complications of nasoenteric tube feedings: State of the science. Heart Lung 22:213-223.
  • Rello J, Sonora R, Jubert P, Artigas A, Rue M, Valles J (1996). Pneumonia in intubated patients: Role of respiratory airway care. Am J Respir Crit Care Med 154:111-115.
  • Shelby Hixson, Tracey King, Nursing Strategies to Prevent Ventilator-Associated Pneumonia. AACN Clinical Issues: Advanced Practice in Acute and Critical Care 9 (1).
  • Vollman, KM (1997). Prone positioning for the ARDS patient. Dimens Crit Care Nurs 16: 184-193.
  • Zaloga GP (1991). Bedside method for placing small bowel feeding tubes in critically ill patients: A prospective study. Chest 100:1643-1646.


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