Comfort measures for an end stage COPD pt

[Blessed RN]

Hi Everyone,

I used to be thankfulnurse2b here on allnurses and haven't posted in a while. I finally finished nursing school in December and passed my boards this week!! So, I am working now as an RN on a Med/Surg floor.

My question is, what kind of advice can you all offer in how to provide comfort and to help decrease anxiety in a patient with severe end-stage COPD? I took care of this poor fellow last night, and all pharmacological remedies have been exhausted for him. We are basically offering palliative care, though he is still a full code. The story is quite sad; he is determined to stay alive to care for his sick wife at home.

I taught him breathing techniques and tried to provide distraction. What else can you all think of to make him more comfortable?

[leslie :-D]

Morphine, anxiolytics, steroids, o2 and fan.

Copd'ers usually have tremendously high anxiety levels (r/t fear of suffocation) and md needs to be aggressive with dosages...esp the morphine and ativan.

Many of my pts appreciate the circulating air of a fan.

Whether he's a code or dnr, these meds still need to be used.

Once anxiety and dyspnea is contained, neb txs may work as well.

[Blessed RN]

All pharmacologic treatments that can be administered have been administered. He refuses any more anxiolytics and he is on continuous nebs to q2hrs.

We already have an oscillating fan in the room, and I have the temp turned down as low as it will go but he still states that it feels too hot for him.

[Pat_Pat RN]

How about trying a BiPap machine? We've done that for COPD pts. before. Sometimes it helps, sometimes they hate it.

[leslie :-D]

Blessed RN said:

All pharmacologic treatments that can be administered have been administered. He refuses any more anxiolytics and he is on continuous nebs to q2hrs.

We already have an oscillating fan in the room, and I have the temp turned down as low as it will go but he still states that it feels too hot for him.

May I ask, what meds he's been on?

And why is he refusing the anxiolytics?

[heron, ASN, RN]

What do his gases look like? If he's a chronic co2 retainer and if his o2 is too high it might be inhibiting his hypoxic drive. I've had es copd pts c/o dyspnea and actually feel a tad better when I've turned down the o2 to maintain a pulse ox between 88 and 92.

Agree with Leslie about drugs ... though as a full code you'll have to be pretty ginger with the morphine, it still will help. Nebulized morphine is worth a shot, though it works better for cough than for dyspnea. I also like the idea of giving bipap a whirl, if he'll tolerate it. I, too, would like to know why he's refusing anxiolytics. Is he afraid to go to sleep?

The sad reality is that the lung damage is probably approaching being incompatible with life ... I'd keep the code cart handy.

[leslie :-D]

heron said:

What do his gases look like? If he's a chronic co2 retainer and if his o2 is too high it might be inhibiting his hypoxic drive. I've had es copd pts c/o dyspnea and actually feel a tad better when I've turned down the o2 to maintain a pulse ox between 88 and 92.

w/a diminished hypoxic drive, I normally see changes in ms/loc as well.

Do you, heron?

As for bipap, I find it useful w/non-anxious pts.

Otherwise, it tends to feel smothering.

[heron, ASN, RN]

earle58 said:

w/a diminished hypoxic drive, I normally see changes in ms/loc as well.

Do you, heron?

As for bipap, I find it useful w/non-anxious pts.

Otherwise, it tends to feel smothering.

Initially increased anxiety, then the ms changes and the crump.

[inland18mempire]

lots of morphine and ativan/versed/etc. i've had several end-stage COPDs and the morphine made all the difference. basically, they need to be sedated. and they should be! i don't want to be gasping for air or have the feeling i'm being smothered when it's my time.

[Virgo_RN, BSN, RN]

I echo the sentiments expressed by others here. The feeling of suffocation is extremely anxiety provoking. It is not something we have control over.

[crb613, BSN, RN]

When I see anything about COPD.....my hearts just about stops.

My dad died of COPD a little over a year ago. I know from personal experience, cold, cold rooms, fan running x 2, steroids & morphine helped his breathing. We made sure to keep smells as neutral as possible. We prepared soft easy to eat foods.....for when he felt like eating. Managing constipation is a biggie too. He had the usual neb & inhaler tx . He thought the 02 cannual in his mouth helped him get more 02 at times. Ativan gave him horrible nightmares....

Help your pt to be in control as much as possible....Does he have any family to sit with him?....Would going home w/Hospice be an option?

My dad was the strongest, most in control person I have truley ever met....... He was in the hospital one time ~ 4+ years before he died. His words exactly " you have to learn to control your emotions, & work on breathing" Beside the couple of doses of Ativan he never took anything for anxiety. When he got too weak to walk & breathe at the same time we got Hospice.....I cannot say enough good things about them!

He was always in control & told us how much morphine he needed...he would hold up his fingers. :chuckle He was a&o until the moment he died....he took 3 deep breaths & that was it. We were right there holding his hand, praying.....very peaceful.

[morte, LPN, LVN]

This man intends to go home and care for his wife, therefore he cant, in his mind, be overly sedated.....many things need to be done, not much can be until he acknowledges he is dying.......he needs to make provisions for his wife's care, or delegate such, and prob. is not going to do this, because it would be admission of his on inability.....and mortality.......