Nursing care plans Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible, sometimes referred to as chronic airway obstruction or chronic obstructive lung disease. The airflow limitation is generally progressive and is normally associated with an inflammatory response of the lungs due to irritants. COPD includes chronic bronchitis and pulmonary emphysema. Chronic bronchitis is a chronic inflammation of the lower respiratory tract characterized by excessive mucous secretion, cough, and Dyspnea associated with recurring infections of the lower respiratory tract. Pulmonary emphysema is a complex lung disease characterized by destruction of the alveoli, enlargement of distal airspaces, and a breakdown of alveolar walls. There is a slowly progressive deterioration of lung function for many years before the development of illness. 

Clinical Manifestations 

Chronic Bronchitis (usually insidious, developing over a period of years) : 

• Presence of a productive cough lasting at least 3 months a year for 2 successive years. 
• Production of thick, gelatinous sputum; greater amounts produced during superimposed infections. 
• Wheezing and dyspnea as disease progresses 

Emphysema (Gradual in onset and steadily progressive): 

• Dyspnea, decreased exercise tolerance. 
• Cough may be minimal, except with respiratory infection. 
• Sputum expectoration mild. 
• Increased anteroposterior diameter of chest (barrel chest) due to air trapping with diaphragmatic flattening. 

Causes

The etiology of Chronic Obstructive Pulmonary Disease COPD includes:

• Cigarette smoking. 
• Air pollution, occupational exposure. 
• Allergy, autoimmunity.
• Infection. 
• Genetic predisposition, aging. 

Etiology of emphysema includes: 

Exposure to tobacco smoke due to smoking preventable cause Secondhand smoke or passive smoking: nitric oxide, component of smoke, is a potent bronchodilator Ambient air pollution Alpha 1 -antitrypsin deficiency: genetic abnormality accounts for less than 1% of Chronic Obstructive Pulmonary Disease (COPD) 

Etiology of chronic bronchitis includes: 

Exposure to tobacco smoke due to cigarette smoking Secondhand smoke or passive smoking Ambient air pollution and occupational irritants Sex, race, and socioeconomic status: higher prevalence of respiratory symptoms in men, higher mortality rates in whites, and higher morbidity and mortality in blue-collar workers. Occupational dusts and chemicals: vapors, irritants and fumes, particulate matter, organic dust 

Complications 

Dyspnea Cor pulmonale Respiratory failure Pneumothorax Bronchiectasis: recurrent bouts of bronchitis Decreased quality of life and functional status Decreased independence due to difficulty breathing and increased oxygen demands resulting in fatigue Assistance with activities of daily living (ADLs) as disease progresses Pneumonia, overwhelming respiratory infection. Right-sided heart failure, Dysrhythmias Depression Skeletal muscle dysfunction 

Stages of COPD Based on the Global Initiative for Chronic Obstructive Lung Disease

Stage	Degree of COPD	Status of Airflow Post bronchodilator FEV1 (forced expiratory volume in 1 second)
0	At Risk	normal spirometry chronic symptoms cough and sputum production
I	Mild COPD	FEV 1/ FVC < 70%, FEV1 ≥ 80% predicted with or without chronic symptoms
II	Moderate COPD	FEV 1/ FVC < 70%, 50% ≤ FEV1 < 80% predicted with or without chronic symptoms
III	Severe COPD	FEV 1 / FVC < 70%, 30% ≤ FEV 1 or < 50% predicted plus respiratory failure or right heart failure
IV	Very Severe COPD	FEV 1 / FVC < 70% FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

Treatment for Chronic Obstructive Pulmonary Disease (COPD)

Treatment for Chronic Obstructive Pulmonary Disease (COPD) is designed to relieve symptoms and prevent complications. Because most COPD patients receive outpatient treatment, they need comprehensive patient teaching to help them comply with therapy and understand the nature of this chronic, progressive disease. If programs in pulmonary rehabilitation are available, encourage the patient to enroll.

If the patient is to continue oxygen therapy at home, teach the patient how to use the equipment correctly. Patients with COPD rarely require more than 3 L/minute to maintain adequate oxygenation. Higher flow rates will further increase the partial pressure of arterial oxygen, but patients whose ventilatory drive is largely based on hypoxemia commonly develop a markedly increased partial pressure of arterial carbon dioxide. In such patients, chemoreceptors in the brain are relatively insensitive to the increase in carbon dioxide.

Treatment for Chronic Obstructive Pulmonary Disease (COPD) includes:

Smoking cessation. Inhaled bronchodilators reduce Dyspnea and bronchospasm; delivered by metered dose inhalers (MDI) or handheld or mask nebulizer devices. Methylxanthines, such as theophylline (Theo-Dur), given orally as sustained-release formulation for chronic maintenance therapy (less commonly used). Inhaled corticosteroids are recommended for patients with symptomatic COPD with documented spirometric improvement from glucocorticosteroids, or in those with an FEV1 that is less than 50% of the predicted value and repeated exacerbations requiring treatment with antibiotics and/or oral glucocorticosteroids. Antibiotics help treat respiratory tract infections. Pneumococcal vaccination and annual influenza vaccinations are important preventive measures. Oral corticosteroids are used in acute exacerbations for anti-inflammatory effect; may also be given I.V. in severe cases. Chest physical therapy, including postural drainage for secretion clearance and breathing retraining for improved ventilation and control of dyspnea. Supplemental oxygen therapy for patients with hypoxemia. CO2 must be monitored to determine increased CO2 retention. Pulmonary rehabilitation to improve function, strength, symptom control, disease self-management techniques, independence, and quality of life. Antimicrobial agents for episodes of respiratory infection. Lung volume reduction surgery is under investigation for treatment of heterogeneous emphysema. Treatment for alpha1-antitrypsin deficiency: Prevent damage to lungs by quitting smoking. Lung transplantation may be considered for people with severely disabling alphaantitrypsin disease.

Nursing Assessment

The typical patient with Chronic Obstructive Pulmonary Disease (COPD), have a long-term cigarette smoker, remains asymptomatic until middle age. His ability to exercise or do strenuous work gradually starts to decline, and he begins to develop a productive cough. These signs are subtle at first, but become more pronounced as the patient gets older and the disease progresses. Eventually the patient may develop Dyspnea on minimal exertion, frequent respiratory infections, intermittent or continuous hypoxemia, and grossly abnormal pulmonary function studies.

Patient History: Exposure to risk factors Past medical history including asthma, allergy sinusitis, or nasal polyps Family history of COPD or other chronic respiratory disease Chronic cough: length of time, daily or intermittent, seldom noc turnal Chronic sputum production: characteristics of sputum, change with the season amount produced Dyspnea that is progressive, persistent, worse with exercise, worse during respiratory infections History of exposure to tobacco smoke, occupational dusts and chemicals, smoke from home cooking and heating fuels Smoking history: pack years (number of packs per day multiplied by number of years smoking) Age when fi rst noticed symptoms Current functional status and ability to perform ADLs Limitation of activities Pneumonia and other respiratory illnesses Use of oxygen: liter flow and years of usage Weight loss or weight gain Sleep pattern and position during sleep: number of pillows used

Physical Examination Potential abnormal physical exam findings (will vary based on severity of illness): Assessment of severity based on level of symptoms Severity of spirometric abnormalities Characteristics of respiratory pattern: rate, depth, symmetry, and synchrony; breathlessness due to airway narrowing and bronchoconstriction Use of pursed lip breathing Breath sounds: normal and adventitious: crackles, rhonchi and wheezes; hyperresonant lung fields; may be distant due to hyperinflation Cough due to increased sputum production: usually worse in the morning Sputum production: color, amount; usually increased with chronic bronchitis Shortness of breath with speech: two or three words per breath Dyspnea on exertion Barrel chest as a result of increased RV Use of accessory muscles Resting pulse oximetry with potential drop with activity Presence of complications such as respiratory failure and right heart failure Cor pulmonale: right-sided heart failure to include edema, heart rate, blood pressure, jugular venous pressure (JVP) Check for presence of murmurs, gallops, rubs, lifts, heaves, and/or thrills Fluid retention and edema Overall appearance: thin with muscle wasting and barrel chest or overweight with barrel chest Enlarged abdominal girth or cachetic appearance Enlarged liver with right-sided heart failure Posture: hunched over with rolled shoulders Pallor skin color Generalized edema

Diagnostic Test

Chest X-ray: air trapping; hyperinfl ation; increased A-P diameter; flattened diaphragms Postbronchodilator FEV 1 Pulmonary function test: show decreased FEV 1 (up to 50% loss) and decreased FEF 25%–75%; increased functional residual capacity (FRC) due to air trapping and hyperinflation Arterial blood gases: may show increased CO 2 due to inability to expel all of the air (air trapping) and low O 2 levels due to ventilation/ perfusion mismatch Assess Dyspnea using a valid tool such as the Modified Borg scale or the Visual Analog Scale Oxygen saturation at rest and with activity Quality-of-life measure: baseline measurement Six-minute walk distance: baseline measurement

Nursing Diagnosis

Common nursing diagnosis found in Nursing care plans for Chronic Obstructive Pulmonary Disease (COPD): Ineffective Airway Clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection Impaired Gas Exchange related to chronic pulmonary obstruction, abnormalities due to destruction of alveolar capillary membrane Imbalanced Nutrition: Less Than Body Requirements related to increased work of breathing, air swallowing, drug effects with resultant wasting of respiratory and skeletal muscles Deficient Knowledge [Learning Need] regarding condition, treatment, self-care, and discharge needs related to lack of information or unfamiliarity with information resources, Information misinterpretation, Lack of recall or cognitive limitation

Goal

Respiratory Status: Airway Patency Effective

Nursing interventions NCP COPD:

Auscultate breath sounds. Note adventitious breath sounds such as wheezes, crackles, or rhonchi. Assess and monitor respiratory rate. Note inspiratory-toexpiratory ratio. Note presence and degree of dyspnea, for example, reports of “air hunger,” restlessness, anxiety, respiratory distress, and use of accessory muscles. Use a 0 to 10 scale or American Thoracic Society’s Grade of Breathlessness Scale to rate breathing difficulty. Ascertain precipitating factors when possible. Differentiate acute episode from exacerbation of chronic dyspnea. Assist client to maintain a comfortable position to facilitate breathing by elevating the head of bed, leaning on or over bed table, or sitting on edge of bed. Keep environmental pollution from sources such as dust, smoke, and feather pillows to a minimum according to individual situation. Encourage and assist with abdominal or pursed-lip breathing exercises. Observe for persistent, hacking, or moist cough. Assist with measures to improve effectiveness of cough effort. Increase fluid intake to 3,000 mL/day within cardiac tolerance. Provide warm or tepid liquids. Recommend intake of fluids between, instead of during, meals. Administer medications, as indicated indicated, for example: Beta-agonists. Provide supplemental humidification, such as ultrasonic nebulizer and aerosol room humidifier. Assist with respiratory treatments, such as spirometry and chest physiotherapy. Monitor and graph serial ABGs, pulse oximetry, and chest x-ray.

Sample Nursing care plans Chronic Obstructive Pulmonary Disease (COPD)

NURSING DIAGNOSE	INTERVENTION	RATIONALE	EVALUATION
Ineffective Airway Clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection	·       Auscultate breath sounds. Note adventitious breath sounds such as wheezes, crackles, or rhonchi. ·       Assess and monitor respiratory rate. Note inspiratory-toexpiratory ratio. ·       Note presence and degree of dyspnea, for example, reports of “air hunger,” restlessness, anxiety, respiratory distress, and use of accessory muscles. Use a 0 to 10 scale or American Thoracic Society’s Grade of Breathlessness Scale to rate breathing difficulty. Ascertain precipitating factors when possible. Differentiate acute episode from exacerbation of chronic dyspnea. ·       Assist client to maintain a comfortable position to facilitate breathing by elevating the head of bed, leaning on or over bed table, or sitting on edge of bed. ·       Keep environmental pollution from sources such as dust, smoke, and feather pillows to a minimum according to individual situation. ·       Encourage and assist with abdominal or pursed-lip breathing exercises. ·       Observe for persistent, hacking, or moist cough. Assist with measures to improve effectiveness of cough effort. ·       Increase fluid intake to 3,000 mL/day within cardiac tolerance. Provide warm or tepid liquids. Recommend intake of fluids between, instead of during, meals. ·       Administer medications, as indicated indicated, for example: Beta-agonists, such as epinephrine (Adrenalin, AsthmaNefrin, Primatene, Sus-Phrine), albuterol (Proventil, Velmax, Ventolin, AccuNeb, Airet), formoterol (Foradil), levalbuterol (Xopenex); metaproterenol (Alupent), pirbuterol (Maxair), terbutaline (Brethine), and salmeterol (Serevent) ·       Provide supplemental humidification, such as ultrasonic nebulizer and aerosol room humidifier. ·       Assist with respiratory treatments, such as spirometry and chest physiotherapy. ·       Monitor and graph serial ABGs, pulse oximetry, and chest x-ray.	·       Some degree of bronchospasm is present with obstructions in 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). ·       Tachypnea is usually present to some degree and may be pronounced on admission, during stress, or during concurrent acute infectious process. Respirations may be shallow and rapid, with prolonged expiration in comparison to inspiration. ·       Respiratory dysfunction is variable depending on the underlying process; for example, infection, allergic reaction, and the stage of chronicity in a client with established COPD. ·       Elevation of the head of the bed facilitates respiratory function using gravity; however, client in severe distress will seek the position that most eases breathing. Supporting arms and legs with table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion. ·       Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. ·       Provides client with some means to cope with and control dyspnea and reduce air-trapping. ·       Cough can be persistent but ineffective, especially if client is elderly, acutely ill, or debilitated. Coughing is most effective in an upright or in a head-down position after chest percussion. ·       Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm. Fluids during meals can increase gastric distention and pressure on the diaphragm. ·       Inhaled β2-adrenergic agonists are first-line therapies for rapid symptomatic improvement of bronchoconstriction. These medications relax smooth muscles and reduce local congestion, reducing airway spasm, wheezing, and mucus production. Medications may be oral, injected, or inhaled. Inhalation by metered-dose inhaler (MDI) with a spacer is recommended, but medications may be nebulized in the event client has severe coughing or is too dyspneic to puff effectively. ·       Humidity helps reduce viscosity of secretions, facilitating expectoration, and may reduce or prevent formation of thick mucous plugs in bronchioles. ·       Breathing exercises help enhance diffusion; aerosol or nebulizer medications can reduce bronchospasm and stimulate expectoration. Postural drainage and percussion enhance removal of excessive and sticky secretions and improve ventilation of bottom lung segments. Note: Chest physiotherapy may aggravate bronchospasm in asthmatics. ·       Establishes baseline for monitoring progression or regression of disease process and complications.	Maintain patent airway with breath sounds clear or clearing. Demonstrate behaviors to improve airway clearance.
Impaired Gas Exchange related to chronic pulmonary obstruction, abnormalities due to destruction of alveolar capillary membrane	·      Assess respiratory rate and depth. Note use of accessory muscles, pursed-lip breathing, and inability to speak or converse. ·      Elevate head of bed and assist client to assume position to ease work of breathing. Include periods of time in prone position as tolerated. Encourage deep, slow or pursed-lip breathing as individually needed and tolerated. ·      Assess and routinely monitor skin and mucous membrane color. ·      Encourage expectoration of sputum; suction when indicated. ·      Auscultate breath sounds, noting areas of decreased airflow and adventitious sounds. ·      Palpate chest for fremitus. ·      Monitor level of consciousness and mental status. Investigate changes. ·      Evaluate level of activity tolerance. Provide calm, quiet environment. Limit client’s activity or encourage bedrest or chair rest during acute phase. Have client resume activity gradually and increase as individually tolerated. ·      Evaluate sleep patterns, note reports of difficulties and whether client feels well rested. Provide quiet environment and group care and monitoring activities to allow periods of uninterrupted sleep. Limit stimulants such as caffeine. Encourage position of comfort. ·      Monitor vital signs and cardiac rhythm. ·      Monitor and graph serial ABGs and pulse oximetry. ·      Administer supplemental oxygen judiciously via nasal cannula, mask, or mechanical ventilator, and titrate as indicated by ABG results and client tolerance.	·      Useful in evaluating the degree of respiratory distress and chronicity of the disease process. ·      Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing. Note: Recent research supports use of prone position to increase PaO2. ·      Cyanosis may be peripheral (noted in nailbeds) or central (noted around lips or earlobes). Duskiness and central cyanosis indicate advanced hypoxemia. ·      Thick, tenacious, copious secretions are a major source of impaired gas exchange in small airways. Deep suctioning may be required when cough is ineffective for expectoration of secretions. ·      Breath sounds may be faint because of decreased airflow or areas of consolidation. Presence of wheezes may indicate bronchospasm or retained secretions. Scattered, moist crackles may indicate interstitial fluid or cardiac decompensation. ·      Decrease of vibratory tremors suggests fluid collection or airtrapping. ·      Restlessness and anxiety are common manifestations of hypoxia. Worsening ABGs accompanied by confusion and somnolence are indicative of cerebral dysfunction due to hypoxemia. ·      During severe, acute, or refractory respiratory distress, client may be totally unable to perform basic self-care activities because of hypoxemia and dyspnea. Rest interspersed with care activities remains an important part of treatment regimen. An exercise program is aimed at improving aerobic capacity and functional performance, increasing endurance and strength without causing severe dyspnea, and can enhance sense of well-being. ·      Multiple external stimuli and presence of dyspnea and hypoxemia may prevent relaxation and inhibit sleep. ·      Tachycardia, dysrhythmias, and changes in BP can reflect effect of systemic hypoxemia on cardiac function. ·      PaCO2 is usually elevated in bronchitis and emphysema, and PaO2 is generally decreased, so that hypoxia is present in a greater or lesser degree. Note: A “normal” or increased PaCO2 signals impending respiratory failure for asthmatics. ·      Used to correct and prevent worsening of hypoxemia, improve survival, and quality of life. Supplemental oxygen can beprovided during exacerbations only, or as a long-term therapy.	Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within client’s normal range and be free of symptoms of respiratory distress. Participate in treatment regimen within level of ability and situation.
Imbalanced Nutrition: Less Than Body Requirements related to increased work of breathing, air swallowing, drug effects with resultant wasting of respiratory and skeletal muscles	·      Assess dietary habits, recent food intake. Note degree of difficulty with eating. Evaluate weight and body size or mass. ·      Auscultate bowel sounds. ·      Give frequent oral care, remove expectorated secretions promptly, and provide specific container for disposal of secretions and tissues. ·      Encourage a rest period of 1 hour before and after meals. Provide frequent small feedings. ·      Avoid gas-producing foods and carbonated beverages. ·      Avoid very hot or very cold foods. ·      Weigh, as indicated.	·      Client in acute respiratory distress is often anorectic because of dyspnea, sputum production, and medication effects. In addition, many COPD clients habitually eat poorly even though respiratory insufficiency creates a hypermetabolic state with increased caloric needs. As a result, client often is admitted with some degree of malnutrition. People who have emphysema are often thin, with wasted musculature. ·      Diminished or hypoactive bowel sounds may reflect decreased gastric motility and constipation (common complication) related to limited fluid intake, poor food choices, decreased activity, and hypoxemia. ·      Noxious tastes, smells, and sights are prime deterrents to appetite and can produce nausea and vomiting with increased respiratory difficulty. ·      Helps reduce fatigue during mealtime, and provides opportunity to increase total caloric intake. ·      Can produce abdominal distention, which hampers abdominal breathing and diaphragmatic movement and can increase dyspnea. ·      Extremes in temperature can precipitate or aggravate coughing spasms. ·      Useful in determining caloric needs, setting weight goal, and evaluating adequacy of nutritional plan. Note: Weight loss may continue initially despite adequate intake, as edema is resolving.	Display progressive weight gain toward goal as appropriate. Demonstrate behaviors and lifestyle changes to regain and maintain appropriate weight.
Deficient Knowledge [Learning Need] regarding condition, treatment, self-care, and discharge needs related to lack of information or unfamiliarity with information resources, Information misinterpretation, Lack of recall or cognitive limitation	·      Explain and reinforce explanations of individual disease process, including factors that lead to exacerbation episodes. Encourage client and SO to ask questions. ·      Identify individual environmental factors such as excessively dry air, wind, temperature extremes, pollen, tobacco smoke, aerosol sprays, and air pollution that may trigger or aggravate condition. Encourage client and SO to explore ways to control these factors in and around the home and work setting. ·      Provide information about benefits of regular exercise while addressing individual activity limitations. ·      Discuss importance of regular medical follow-up care, when to notify healthcare professional of changes in condition, and periodic spirometry testing, chest x-rays, and sputum cultures. ·      Discuss respiratory medications, side effects, drug interactions, and adverse reactions. ·      Demonstrate correct technique for using an MDI, such as how to hold it, pausing 2 to 5 minutes between puffs, and cleaning the inhaler.	·      Understanding decreases anxiety and can lead to improved participation in treatment plan. ·      These can induce or aggravate bronchial irritation, leading to increased secretion production and airway blockage. ·      Having this knowledge can enable client and SO to make informed choices and decisions to reduce client’s dyspnea, maximize functional level, perform most desired activities, and prevent complications. ·      Monitoring disease process allows for alterations in therapeutic regimen to meet changing needs and may help prevent complications. ·      Frequently, these clients are simultaneously on several respiratory drugs that have similar side effects and potential drug interactions. It is important that the client understands the difference between nuisance side effects (medication continued) and untoward or adverse side effects (medication possibly discontinued or dosage changed). ·      Proper administration of drug enhances delivery and effectiveness.	Verbalize understanding of condition and disease process and treatment. Identify relationship of current signs and symptoms to the disease process and correlate these with causative factors. Initiate necessary lifestyle changes and participate in treatment regimen.

Most Chronic Obstructive Pulmonary Disease COPD patients receive outpatient treatment, so provide comprehensive patient teaching to help them comply with therapy and understand the nature of this chronic, progressive disease. 

Patient Teaching For Patient With Chronic Obstructive Pulmonary Disease COPD: 

General Health 

Teach the patient and his family how to recognize early signs of infection; warn the patient to avoid contact with people with respiratory infections. Encourage good oral hygiene to help prevent infection. Pneumococcal vaccination and annual influenza vaccinations are important preventive measures Help the patient and his family adjust their lifestyles to accommodate the limitations imposed by this debilitating chronic disease. Instruct the patient to allow for daily rest periods and to exercise daily as directed. Teach good habits of well-balanced, nutritious intake. Encourage high-protein diet with adequate mineral, vitamin, and fluid intake. Advise against excessive hot or cold fluids and foods, which may provoke an irritating cough. Advise to avoid hard-to-chew foods (causes tiring) and gas-forming foods, which cause distention and restrict diaphragmatic movement. Encourage five to six small meals daily to ease shortness of breath during and after meals. Suggest rest periods before and after meals if eating produces shortness of breath. Warn against potassium depletion. Patients with COPD tend to have low potassium levels; also, patient may be taking diuretics; Watch for weakness, numbness, tingling of fingers, leg cramps, Encourage foods high in potassium include bananas, dried fruits, dates, figs, orange juice, grape juice, milk, peaches, potatoes, tomatoes. Advise patient on restricting sodium as directed. Limit carbohydrates if CO2 is retained by patient, because they increase CO2. Use community resources, such as Meals On Wheels or a home care aide if energy level is low. 

Avoid Exposure to Respiratory Irritants 

Advise patient to stop smoking and avoid exposure to second-hand smoke. Advise patient to avoid sweeping, dusting, and exposure to paint, aerosols, bleaches, ammonia, and other respiratory irritants. Advise patient to keep entire house well-ventilated. Warn patient to stay out of extremely hot/cold weather to avoid bronchospasm and dyspnea. Instruct patient to humidify indoor air in winter; maintain 30% to 50% humidity for optimal mucociliary function. Suggest the use of a HEPA air cleaner to remove dust, pollen, and other particulates; this is controversial as to the benefit to the patient. 

Breathing Exercises 

Explain that goal is to strengthen and coordinate muscles of breathing to lessen work of breathing and help lung empty more completely. To promote ventilation and reduce air trapping, teach the patient to breathe slowly, prolong expirations to two to three times the duration of inspiration, and to exhale through pursed lips. Stress the importance of controlled breathing. Teach diaphragmatic breathing and pursed-lip breathing for episodes of dyspnea and stress. To help mobilize secretions, teach the patient how to cough effectively. If the patient with copious secretions has difficulty mobilizing secretions, teach his family how to perform postural drainage and chest physiotherapy. If secretions are thick, encourage the patient to drink 12 to 15 glasses of fluid per day. Encourage muscle toning by regular exercise. If the patient use oxygen therapy at home, teach him how to use the equipment correctly.