Chronic Obstructive Pulmonary Disease (COPD) Lily Che Nicole Keally Natalie Mariscal Katy Veliz Valerie Ward
Patient S.B. is a 62 YO female with Stage 1 COPD who has been admitted to the hospital on January 25, 2015
Chief of Complaint S. B. reports to have difficulty breathing when performing daily activities such as bathing, showering, and getting dressed. She coughs up dark-brownish phlegm. Complains of being confused in the morning
History of Present Illness Five years ago, S.B. was diagnosed with emphysema (Stage I COPD) During her last admission, medical records indicated pulmonary function tests: FEV1 (forced expiratory value) = 0.7L FVC (forced vital capacity) = 1.5L FEV1 and FVC = 46%
Physical Exam Temperature: 98.8 F Pulse: 92bpm Respiratory rate: 22 BP: 130/88 mmhg Height: 5 3 Weight: 119 lbs. Heart: regular rate/rhythm, mild jugular distension noted Genitalia: Deferred HEENT: Eyes - PERRLA, no hemorrhages Ears - Slight redness Nose - Clear Throat - Clear Rectal - Not performed Neurologic - Alert, oriented; cranial nerves intact
Physical Exam Continued Extremities: 1+ bilateral pitting edema. No cyanosis or clubbing Skin: warm Chest/lungs: Decreased breath sounds Percussion hyperresonant Prolonged expiration with wheezing Ronchi Using accessory muscles at rest Abdomen: Liver & spleen palpable Non-disoriented Non-tender Normal bowel sounds
Family History/Social History Mother and 2 aunts died from lung cancer Smoked cigarettes for 46 years, 1 pack per day (ppd) Has not smoked for the past year Married and lives with husband Buys and prepares meals for both husband and herself Daughters occasionally assist with meal preparation Meal preparation is a challenge - too tired once the meal is complete No occupational exposure
Pathophysiology COPD is progressive disease Limits airflow & causes difficulty breathing Leading cause: smoking air pollution, second-hand smoke, childhood infections, occupational exposure to industrial pollutants
Pathophysiology Emphysema is one of the two conditions of COPD breakdown of alveoli O2 & CO2 exchange permanent enlargement of airways breathing becomes increasingly difficult shortness of breath performing daily tasks
Chronic Bronchitis is the other condition of COPD inflammation of the bronchioles of the lungs impairs cilia function increase mucus buildup in lungs Mucus buildup interferes with breathing & allows for perfect living conditions for bacteria (lung infections) Pathophysiology
Common Diagnostic Tests/Procedures Physical Examination Appearance Chest Examination Environmental and Occupational Exposures Smoker Dust Toxic chemicals http://hawaiicopd.org/hear-the-lung-sounds-of-copd/#. VWizUtrpeko
Common Diagnostic Tests/Procedures Lung Function Tests: Spirometer Chest X-ray Chest CT scan Arterial Blood Gas (ABG)
Commonly Prescribed Drugs and Treatments Bronchodilators Short and long acting Glucocorticosteroids Vaccines Oxygen Therapy Lifestyle changes QUIT SMOKING! Exercise Diet Plan
Surgical Treatments Bullectomy Lung Volume Reduction Surgery (LVRS) Lung Transplant
Nutrition Assessment: Medical History Taken at home: Combivent (metered-dose inhaler) - 2 inhalations four times daily Diagnosed with Stage I COPD 5 years ago History of bronchitis and upper respiratory infections during the winter months for most adult life 4 live births 2 miscarriages
Nutrition Assessment: Lab Values 1/25 CO2 (meq/ml): 32 Protein (g/dl): 5.8 Albumin (g/dl): 3.3 Hgb (g/dl:) 11.5 Hct (%): 35 ph: 7.29 pco2 (mmhg): 50.9 SO2 %: 92 CO2 (mmol/l): 31 O2 content (%): 12 Base deficit (meq/l): 3.6 HCO3 (meq/l): 29.6
Nutrition Assessment: Lab Values 1/27 ph: 7.4 pco2 (mmhg): 40.1 SO2 (%): 90.2 CO2 content (mmol/l): 29.8 O2 content (%): 18 HCO3 (meq/l): 24.7
Nutrition Assessment: Anthropometric Data Weight: 119 Height: 5 3 BMI: 21.1 normal IBW:115 lbs. % IBW: 103% UBW:145-150 lbs. UBW%: 82%
Nutrition Assessment: Estimated Calorie and Protein Needs Mifflin= 10(54.1kg) + 6.25(160cm) - 5(62) - 161= 1070 kcal/day Activity factor 1.2 1070 kcal/day x 1.2= 1284 kcal/day Stress factor 1.4 1284 kcal/day x 1.4 = 1800 kcal per day Protein requirement 1.4 g/kg 1.4 g/kg (54.1kg) = 76 g/day
Diet History Breakfast: Coffee, fruit juice, dry cereal w/ small amounts of milk Lunch: meat; vegetables; rice, potato/pasta - only eats small amounts Dinner: soup, scrambled eggs or a sandwich - eats very light in the evening *Drinks Pepsi throughout the day (3 12-oz cans)
Nutrition Diagnosis 1) Inadequate energy intake RT poor appetite and altered taste perception AEB 24-hour recall indicating lower caloric intake than the recommended 1800 kcal/day. 2) Unintended weight loss RT early satiety, breathing and swallowing difficulties AEB fatigue at meal times and 20-lb weight loss in a year. 3) Impaired ability to prepare foods/meals RT COPD AEB fatigue during meal preparation.
Nutrition Intervention Nutrition Prescription: Recommend the patient meets 1800 kcal/day to maintain pt s weight and prevent further weight loss. Recommend 6 small frequent meals a day. Begin low intensity exercise to help build muscle strength Recommend pt visits dentist to resize dentures to ensure they fit properly.
Implementation of Goals 1. Nutrition education for SB, her husband, and daughters focusing on a. Ensuring adequate calories and nutrients b. Skill development to manage early satiety/fatigue/breathing/swallowing difficulties/impaired ability to prepare meals
Implementation of Goals Choosing appropriate nutrient-dense foods easy recipes to conserve energy: greek yogurt parfait, salad, fish etc. recommended to reduce consumption of carbonated beverages in between meals; may cause early satiety and bloating eat smaller, frequent meals to prevent fatigue (5-6 times a day) add more calories to meal: adding mayonnaise to salads, use butter, drinking milkshakes use innovative cooking utensils/gadgets to save time and energy family members should take turns helping with meal preparation to reduce fatigue make a weekly schedule may be eligible for Meals on Wheels Program
Implementation of Goals
Implementation of Goals 2. Nutrient Delivery of vitamins/antioxidants eating more fruits and vegetables vitamins/antioxidants: beneficial to prevent respiratory infections, to improve lung function 3. Nutrition Counseling to assist pt in maintaining weight keeping a daily food journal; helps with meeting caloric/nutrient needs
Monitoring/Evaluation SB is recommended to come back in a month for a check up Developed skills and behavior changes will be noted by maintenance of weight, subjective reports of reduced satiety, fatigue, etc. daily food journal will be evaluated to ensure her comprehension of adequate calorie and nutrient intake Data will be compared with previous stay If there are any barriers or problems, it will be used to reexamine PES statements, alter interventions and establish new goals.
Prevention?
Quiz Time! 1. What is the most common cause of COPD? a. Emphysema b. Smoking c. Asthma d. Chronic bronchitis
b) Smoking Answer
Quiz Time! 2) All of the following are common diagnostic tests and procedures for COPD EXCEPT: a. Spirometer b. Arterial Blood Gas (ABG) c. Spinal tap (lumbar puncture) d. Chest CT scan
Answer c. Spinal tap (lumbar puncture)
References Nelms, M., Sucher, K.P., & Lacey, K. (2016). Nutrition therapy and pathophysiology. (3rd ed.). Boston, MA: Cengage Learning. St. Florian, I. (2009). Nutrition and copd: dietary considerations for better breathing. Today s Dietitian, 11(2), 54. Retrieved from http://www.todaysdietitian.com/newarchives/td_020909p54.shtml Aetna InteliHealth. (2011). Emphysema. Retrieved from http://intelihealth.com/print-article/emphysema Cleveland Clinic. (2014). Nutritional guidelines for people with copd. Retrieved from http://mycleveland. org/health/diseases_conditions/hic_understanding_copd/hic_coping_with_copd/hic_nutrit ional_guidelines_for_people_with_copd National Heart, Lung, and Blood Institute. (2013). What is copd? Retrieved from http://nhibi.nih.gov/health/health-topics/topics/copd University of Maryland Medical Center. (2013), Chronic obstructive pulmonary disease. Retrieved from http://umm.edu/health/medical/reports/articles/chronic-obstructive-pulmonary-disease U.S. National Library of Medicine. (2014). Emphysema. Retrieved from http://www.nlm.nih.gov/medicineplus/emphysema.html
Thank You!