BY. NUR ASNAH SITOHANG,S.Kep.Ns.M.KepBY. NUR ASNAH SITOHANG,S.Kep.Ns.M.Kep, p p, p p

DEFENISIDEFENISIDEFENISIDEFENISI

is a progressiveis a progressiveis a progressive is a progressive disease that makes disease that makes it h d t b thit h d t b thit hard to breathe. it hard to breathe. "Progressive" means "Progressive" means the disease gets the disease gets worse over time. worse over time.

To understand COPD, it helps To understand COPD, it helps , p, pto understand to understand how the lungs how the lungs workwork. The air that you breathe . The air that you breathe goes down your windpipe intogoes down your windpipe intogoes down your windpipe into goes down your windpipe into tubes in your lungs called tubes in your lungs called bronchial tubes, or airways.bronchial tubes, or airways.The airways are shaped like an The airways are shaped like an upsideupside--down tree with many down tree with many branches At the end of thebranches At the end of thebranches. At the end of the branches. At the end of the branches are tiny air sacs branches are tiny air sacs called alveoli called alveoli

The airways and air sacs are elasticThe airways and air sacs are elasticThe airways and air sacs are elastic. The airways and air sacs are elastic. When you breathe in, each air sac fills up When you breathe in, each air sac fills up with air like a small balloon When youwith air like a small balloon When youwith air like a small balloon. When you with air like a small balloon. When you breathe out, the air sac deflates and the breathe out, the air sac deflates and the air goes outair goes outair goes out.air goes out.

In COPD less air flows in and out of theIn COPD less air flows in and out of theIn COPD, less air flows in and out of the In COPD, less air flows in and out of the airways because of one or more of the airways because of one or more of the following:following:following:following:The airways and air sacs lose their elastic The airways and air sacs lose their elastic qualityqualityquality. quality. The walls between many of the air sacs The walls between many of the air sacs are destroyedare destroyedare destroyed. are destroyed. The walls of the airways become thick and The walls of the airways become thick and inflamed (swollen)inflamed (swollen)inflamed (swollen). inflamed (swollen). The airways make more mucus than The airways make more mucus than usual which tends to clog the airwaysusual which tends to clog the airwaysusual, which tends to clog the airways.usual, which tends to clog the airways.

In the United States, the term "COPD" includesIn the United States, the term "COPD" includesIn the United States, the term COPD includes In the United States, the term COPD includes two main conditionstwo main conditions——emphysemaemphysema and chronic and chronic obstructive bronchitis.obstructive bronchitis.In emphysema, the walls between many of the In emphysema, the walls between many of the air sacs are damaged, causing them to lose their air sacs are damaged, causing them to lose their shape and become floppy. This damage also shape and become floppy. This damage also can destroy the walls of the air sacs, leading to can destroy the walls of the air sacs, leading to fewer and larger air sacs instead of many tinyfewer and larger air sacs instead of many tinyfewer and larger air sacs instead of many tiny fewer and larger air sacs instead of many tiny ones.ones.

In chronic obstructive bronchitis, the liningIn chronic obstructive bronchitis, the liningIn chronic obstructive bronchitis, the lining In chronic obstructive bronchitis, the lining of the airways is constantly irritated and of the airways is constantly irritated and inflamed. This causes the lining to thicken. inflamed. This causes the lining to thicken. ggLots of thick mucus forms in the airways, Lots of thick mucus forms in the airways, making it hard to breathe.making it hard to breathe.Most people who have COPD have both Most people who have COPD have both emphysema and chronic obstructive emphysema and chronic obstructive b hiti Th th l t "COPD"b hiti Th th l t "COPD"bronchitis. Thus, the general term "COPD" bronchitis. Thus, the general term "COPD" is more accurate.is more accurate.

COPD is a major cause of disability, andCOPD is a major cause of disability, andCOPD is a major cause of disability, and COPD is a major cause of disability, and it's the fourth leading cause of death in the it's the fourth leading cause of death in the United States. More than 12 million people United States. More than 12 million people p pp pare currently diagnosed with COPD. An are currently diagnosed with COPD. An additional 12 million likely have the additional 12 million likely have the di d d 't k itdi d d 't k itdisease and don't even know it.disease and don't even know it.COPD develops slowly. Symptoms often COPD develops slowly. Symptoms often

ti d li it bilitti d li it bilitworsen over time and can limit your ability worsen over time and can limit your ability to do routine activities. Severe COPD may to do routine activities. Severe COPD may prevent you from doing even basicprevent you from doing even basicprevent you from doing even basic prevent you from doing even basic activities like walking, cooking, or taking activities like walking, cooking, or taking care of yourselfcare of yourselfcare of yourself.care of yourself.

Most of the time COPD is diagnosed inMost of the time COPD is diagnosed inMost of the time, COPD is diagnosed in Most of the time, COPD is diagnosed in middlemiddle--aged or older people. The disease aged or older people. The disease isn't passed from person to personisn't passed from person to person——youyouisn t passed from person to personisn t passed from person to person you you can't catch it from someone else.can't catch it from someone else.

Other Names for COPDOther Names for COPD

Chronic obstructive airway diseaseChronic obstructive airway diseaseChronic obstructive airway disease Chronic obstructive airway disease Chronic obstructive bronchitis Chronic obstructive bronchitis Ch i b t ti l diCh i b t ti l diChronic obstructive lung disease Chronic obstructive lung disease EmphysemaEmphysema

What Causes COPD?What Causes COPD?

Most cases of COPD develop after Most cases of COPD develop after pplonglong--term exposure to lung irritants that term exposure to lung irritants that damage the lungs and the airways. damage the lungs and the airways. In the United States, the most commonIn the United States, the most commonIn the United States, the most common In the United States, the most common irritant that causes COPD is cigarette irritant that causes COPD is cigarette smoke. Pipe, cigar, and other types of smoke. Pipe, cigar, and other types of tobacco smoke also can cause COPDtobacco smoke also can cause COPDtobacco smoke also can cause COPD, tobacco smoke also can cause COPD, especially if the smoke is inhaled. especially if the smoke is inhaled. Secondhand smokeSecondhand smoke——that is, smoke in that is, smoke in the air from other people smokingthe air from other people smoking——alsoalsothe air from other people smokingthe air from other people smoking also also can irritate the lungs and contribute to can irritate the lungs and contribute to COPD.COPD.Breathing in air pollution and chemicalBreathing in air pollution and chemicalBreathing in air pollution and chemical Breathing in air pollution and chemical fumes or dust from the environment or fumes or dust from the environment or workplace also can contribute to COPD.workplace also can contribute to COPD.

In rare cases, a genetic condition In rare cases, a genetic condition ggcalled called alphaalpha--1 antitrypsin deficiency1 antitrypsin deficiencymay play a role in causing COPD. may play a role in causing COPD. People who have this condition People who have this condition pphave low levels of alphahave low levels of alpha--1 1 antitrypsin (AAT)antitrypsin (AAT)——a protein made a protein made in the liver. in the liver. Having a low level of the AAT Having a low level of the AAT protein can lead to lung damage protein can lead to lung damage and COPD if you're exposed toand COPD if you're exposed toand COPD if you re exposed to and COPD if you re exposed to smoke or other lung irritants. If you smoke or other lung irritants. If you have this condition and smoke, have this condition and smoke, COPD can worsen very quicklyCOPD can worsen very quicklyCOPD can worsen very quicklyCOPD can worsen very quickly

Who Is At Risk for COPD? Who Is At Risk for COPD?

The main risk factor for COPD is smokingThe main risk factor for COPD is smokingThe main risk factor for COPD is smoking The main risk factor for COPD is smoking People who have a family history of COPD People who have a family history of COPD are more likely to get the disease if theyare more likely to get the disease if theyare more likely to get the disease if they are more likely to get the disease if they smoke. smoke. LL t t th l i it tt t th l i it tLongLong--term exposure to other lung irritants term exposure to other lung irritants also is a risk factor for COPD also is a risk factor for COPD a genetic condition a genetic condition

What Are the Signs and What Are the Signs and Symptoms of COPD?Symptoms of COPD?Symptoms of COPD?Symptoms of COPD?

The signs and symptoms of COPD include:The signs and symptoms of COPD include:The signs and symptoms of COPD include: The signs and symptoms of COPD include: An ongoing cough or a cough that produces An ongoing cough or a cough that produces large amounts of mucus (often called "smoker's large amounts of mucus (often called "smoker's g (g (cough")cough")Shortness of breath, especially with physical Shortness of breath, especially with physical , p y p y, p y p yactivity activity Wheezing (a whistling or squeaky sound when Wheezing (a whistling or squeaky sound when you breathe)you breathe)Chest tightnessChest tightness

How Is COPD Diagnosed?How Is COPD Diagnosed?Lung Function Test :spirometryLung Function Test :spirometry

AA chest x raychest x ray oror chest computedchest computedA A chest x raychest x ray or or chest computed chest computed tomography (CT) scantomography (CT) scan

Arterial blood gases : should be performedArterial blood gases : should be performedArterial blood gases : should be performed Arterial blood gases : should be performed in all patients with an FEV1 less than 40% in all patients with an FEV1 less than 40% predicted or when clinical signs ofpredicted or when clinical signs ofpredicted or when clinical signs of predicted or when clinical signs of respiratory failure/ rigth respiratory failure/ rigth ––sided heart sided heart failure are presentfailure are presentfailure are presentfailure are present

How Is COPD Treated?How Is COPD Treated?

Quitting smokingQuitting smokingQuitting smoking Quitting smoking Other treatments for Other treatments for COPD may include COPD may include yymedicines, vaccines, medicines, vaccines, pulmonary pulmonary rehabilitation (rehab), rehabilitation (rehab), oxygen therapy, oxygen therapy, surgery andsurgery andsurgery, and surgery, and managing managing complicationscomplicationscomplications.complications.

The goals of COPD treatmentThe goals of COPD treatmentThe goals of COPD treatmentThe goals of COPD treatment

Relieve your symptomsRelieve your symptomsRelieve your symptoms Relieve your symptoms Slow the progress of the disease Slow the progress of the disease I i t l (I i t l (Improve your exercise tolerance (your Improve your exercise tolerance (your ability to stay active)ability to stay active)Prevent and treat complicationsPrevent and treat complicationsImprove your overall health Improve your overall health p yp y

Stage of COPD and their treatmentStage of COPD and their treatmentStage Stage characteristicscharacteristics RecommendeRecommende

treatmenttreatment

allall oo avoidance oavoidance orisk factorrisk factoroo influenza facinfluenza fac

0: at risk0: at risk •• chronic symptomschronic symptoms••Exposure to risk factorExposure to risk factor

Short acting Short acting bronchodilatorbronchodilator••Exposure to risk factorExposure to risk factor

••Normal spyrometryNormal spyrometry

b o c od atob o c od atowhen neededwhen needed

1.Mild COPD1.Mild COPD --FEV1/FVCFEV1/FVC --short actingshort acting1.Mild COPD1.Mild COPD FEV1/FVC FEV1/FVC <70%<70%--FEV,>80% FEV,>80%

short acting short acting bronchodilator bronchodilator when neededwhen needed, %, %

predictedpredicted--With or without With or without symptomsymptom

2. Moderate 2. Moderate II AII A Regular Regular COPDCOPD -- FEV1/FVC FEV1/FVC

<70%<70%treatmen with treatmen with one/more one/more b h dil tb h dil t--FEV,<80% FEV,<80%

predictedpredicted

bronchodilatorbronchodilator--RehabilitationRehabilitation

IIBIIB --Regular Regular -- FEV1/FVC FEV1/FVC <70%<70%

ggtreatmen with treatmen with one/more one/more b h dil tb h dil t-- 30% 30%

FEV,<50% FEV,<50%

bronchodilatorbronchodilator--RehabilitationRehabilitation

predictedpredicted--With or without With or without

--Inhaled Inhaled glucocorticosterglucocorticosteroid if significantoid if significantsymptomsymptom oid if significant oid if significant symptom & lung symptom & lung functionfunctionfunction function respon/if respon/if repeated repeated exacerbationexacerbation

III. SevereIII. Severe -- FEV1/FVCFEV1/FVC --Idem stage II +Idem stage II +III. Severe III. Severe COPDCOPD

FEV1/FVC FEV1/FVC <70%<70%-- 30% 30%

Idem stage II Idem stage II ;;-- treatment of treatment of

FEV,predicted FEV,predicted or presence of or presence of

complicationscomplications-- rehabilitationrehabilitation

respiratory respiratory failure or right failure or right heart filureheart filure

-- long term O2 long term O2 therapy if therapy if

heart filureheart filure respiratory respiratory failurefailure-- consider consider surgical surgical treatmenttreatmenttreatmenttreatment

The 2001 GOLD gudelines for The 2001 GOLD gudelines for diagnosis management &diagnosis management &diagnosis,management & diagnosis,management &

prevention COPDprevention COPDNonpharmacological therapy :Nonpharmacological therapy :

11 Exercise trainingExercise training1.1. Exercise trainingExercise training2.2. Nutritional counselingNutritional counseling

Ed tiEd ti3.3. EducationEducation

Pharmacilogical therapy ;Pharmacilogical therapy ;Pharmacilogical therapy ;Pharmacilogical therapy ;1.1. BronchodilatorsBronchodilators

Gl ti idGl ti id2.2. GlucocorticoidsGlucocorticoids3.3. Other pharmacological agentsOther pharmacological agents4.4. O2 therapyO2 therapy55 Surgical therapySurgical therapy5.5. Surgical therapySurgical therapy

How Can COPD Be Prevented? How Can COPD Be Prevented?

you can take steps to preventyou can take steps to preventyou can take steps to prevent you can take steps to prevent complications and slow the progress of the complications and slow the progress of the diseasediseasedisease.disease.

Living With COPDLiving With COPD

Avoid lung irritantsAvoid lung irritantsAvoid lung irritantsAvoid lung irritantsGet ongoing careGet ongoing careM th di d it tM th di d it tManage the disease and its symptomsManage the disease and its symptomsPrepare for emergenciesPrepare for emergencies

PengkajianPengkajianPengkajianPengkajian

Sudah berapa lama pasien mengalamiSudah berapa lama pasien mengalamiSudah berapa lama pasien mengalami Sudah berapa lama pasien mengalami kesulitan pernapasan?kesulitan pernapasan?Apakah aktivitas meningkatkanApakah aktivitas meningkatkanApakah aktivitas meningkatkan Apakah aktivitas meningkatkan dispnea?dispnea?B j h b t i t h dB j h b t i t h dBerapa jauh batasan pasien terhadap Berapa jauh batasan pasien terhadap toleransi aktivitas?toleransi aktivitas?Kapan pasien mengeluh paling letih Kapan pasien mengeluh paling letih dan sesak napas?dan sesak napas?

Apakah kebiasaan makan dan tidurApakah kebiasaan makan dan tidurApakah kebiasaan makan dan tidur Apakah kebiasaan makan dan tidur terpengaruh?terpengaruh?Riwayat merokok?Riwayat merokok?Riwayat merokok?Riwayat merokok?Obat yang dipakai setiap hari?Obat yang dipakai setiap hari?Obat yang dipakai pada serangan akut?Obat yang dipakai pada serangan akut?Apa yang diketahui pasien tentang Apa yang diketahui pasien tentang p y g p gp y g p gkondisi dan penyakitnya?kondisi dan penyakitnya?

Data tambahan yang dikumpulkan Data tambahan yang dikumpulkan l l i b i d ikl l i b i d ikmelalui observasi dan pemeriksaanmelalui observasi dan pemeriksaan

Frekuensi nadi dan pernapasan pasien?Frekuensi nadi dan pernapasan pasien?Frekuensi nadi dan pernapasan pasien?Frekuensi nadi dan pernapasan pasien?Apakah pernapasan sama tanpa upaya?Apakah pernapasan sama tanpa upaya?Apakah ada kontraksi ototApakah ada kontraksi otot otot abdomenotot abdomenApakah ada kontraksi ototApakah ada kontraksi otot--otot abdomen otot abdomen selama inspirasi?selama inspirasi?Apakah ada penggunaan ototApakah ada penggunaan otot ototototApakah ada penggunaan ototApakah ada penggunaan otot--otot otot aksesori pernapasan selama aksesori pernapasan selama pernapasan?pernapasan?pernapasan?pernapasan?Barrel chest?Barrel chest?Apakah tampak sianosis?Apakah tampak sianosis?Apakah tampak sianosis?Apakah tampak sianosis?

Apakah ada batuk?Apakah ada batuk?Apakah ada batuk?Apakah ada batuk?Apakah ada edema perifer?Apakah ada edema perifer?A k h l h t k b ?A k h l h t k b ?Apakah vena leher tampak membesar?Apakah vena leher tampak membesar?Apa warna, jumlah dan konsistensi Apa warna, jumlah dan konsistensi sputum pasien?sputum pasien?Bagaimana status sensorium pasien?Bagaimana status sensorium pasien?g pg pApakah terdapat peningkatan stupor? Apakah terdapat peningkatan stupor? Kegelisahan?Kegelisahan?Kegelisahan?Kegelisahan?

Palpasi:Palpasi:Palpasi:Palpasi:Palpasi pengurangan pengembangan Palpasi pengurangan pengembangan

dada?dada?dada?dada?Adakah fremitus taktil menurun?Adakah fremitus taktil menurun?Perkusi:Perkusi:Adakah hiperesonansi pada perkusi?Adakah hiperesonansi pada perkusi?p p pp p pDiafragma bergerak hanya sedikit?Diafragma bergerak hanya sedikit?

Auskultasi:Auskultasi:Auskultasi:Auskultasi:Adakah suara wheezing yang nyaring?Adakah suara wheezing yang nyaring?Ad k h khi?Ad k h khi?Adakah suara ronkhi?Adakah suara ronkhi?Vokal fremitus nomal atau menurunVokal fremitus nomal atau menurun

Diagnosa KeperawatanDiagnosa KeperawatanDiagnosa KeperawatanDiagnosa KeperawatanBersihan jalan napas tidak efektif berhubungan Bersihan jalan napas tidak efektif berhubungan j p gj p gdengan bronkokontriksi, peningkatan produksi sputum, dengan bronkokontriksi, peningkatan produksi sputum, batuk tidak efektif, kelelahan/berkurangnya tenaga dan batuk tidak efektif, kelelahan/berkurangnya tenaga dan infeksi bronkopulmonal.infeksi bronkopulmonal.ppPola napas tidak efektif berhubungan dengan napas Pola napas tidak efektif berhubungan dengan napas pendek, mucus, bronkokontriksi dan iritan jalan napas.pendek, mucus, bronkokontriksi dan iritan jalan napas.Gangguan pertukaran gas berhubungan denganGangguan pertukaran gas berhubungan denganGangguan pertukaran gas berhubungan dengan Gangguan pertukaran gas berhubungan dengan ketidaksamaan ventilasi perfusi ketidaksamaan ventilasi perfusi Intoleransi aktivitas berhubungan dengan Intoleransi aktivitas berhubungan dengan k tid k i b t l i d k b t hk tid k i b t l i d k b t hketidakseimbangan antara suplai dengan kebutuhan ketidakseimbangan antara suplai dengan kebutuhan oksigen. oksigen.

Risiko perubahan nutrisi kurang dari Risiko perubahan nutrisi kurang dari p gp gkebutuhan tubuh berhubungan dengan kebutuhan tubuh berhubungan dengan anoreksia.anoreksia.Ganggua pola tidur berhubungan denganGanggua pola tidur berhubungan denganGanggua pola tidur berhubungan dengan Ganggua pola tidur berhubungan dengan ketidaknyamanan, pengaturan posisi.ketidaknyamanan, pengaturan posisi.Kurang perawatan diri berhubungan dengan Kurang perawatan diri berhubungan dengan k l tih k d kib t i k tk l tih k d kib t i k tkeletihan sekunder akibat peningkatan upaya keletihan sekunder akibat peningkatan upaya pernapasan dan insufisiensi ventilasi dan pernapasan dan insufisiensi ventilasi dan oksigenasi.oksigenasi.Ansietas berhubungan dengan ancaman Ansietas berhubungan dengan ancaman terhadap konsep diri, ancaman terhadap terhadap konsep diri, ancaman terhadap kematian keperluan yang tidak terpenuhikematian keperluan yang tidak terpenuhikematian, keperluan yang tidak terpenuhi.kematian, keperluan yang tidak terpenuhi.

individu tidak efektif berhubunganindividu tidak efektif berhubunganindividu tidak efektif berhubungan individu tidak efektif berhubungan dengan kurang sosialisasi, ansietas, dengan kurang sosialisasi, ansietas, depresi tingkat aktivitas rendah dandepresi tingkat aktivitas rendah dandepresi, tingkat aktivitas rendah dan depresi, tingkat aktivitas rendah dan ketidakmampuan untuk bekerja.ketidakmampuan untuk bekerja.Kurang pengetahuan berhubunganKurang pengetahuan berhubunganKurang pengetahuan berhubungan Kurang pengetahuan berhubungan dengan kurangnya informasi, tidak dengan kurangnya informasi, tidak mengetahui sumber informasimengetahui sumber informasimengetahui sumber informasi.mengetahui sumber informasi.

Masalah kolaboratif/Potensial Masalah kolaboratif/Potensial k lik i d j dik lik i d j dikomplikasi yang dapat terjadi komplikasi yang dapat terjadi

Gagal/insufisiensi pernapasanGagal/insufisiensi pernapasanGagal/insufisiensi pernapasanGagal/insufisiensi pernapasanHipoksemiaHipoksemiaAt l kt iAt l kt iAtelektasisAtelektasisPneumoniaPneumoniaPneumotoraksPneumotoraksHipertensi paruHipertensi paruHipertensi paruHipertensi paruGagal jantung kananGagal jantung kanan