New “Nurse Notes” App ready to hit iTunes


Access an overview of all your patients, their tasks, and demographics.

After much anticipation “Nurse Notes”, a new app created by Nurse Mastery, is ready to hit the iTunes store in November.  Nurse Notes is an innovative iPhone application developed by a team of nurses and programmers designed to help organize the daily tasks of nurses from all specialties.  This powerful tool will send you audible & visual reminders about patient care and scheduled tasks during your shift, as well as help you chart & assist during report.

View your patient related tasks.

View your scheduled tasks.

Do you rely on a piece of scratch paper to remember when & what to do throughout your shift? Stop writing everything down when you can easily program this app at the start of your shift. Take 5 minutes to plugin essential, patient specific reminders or quickly select from dozens of distinct choices within the following drop-down lists:



  • Assessments
  • Medications
  • Treatments
  • Procedures
  • Discharges
  • Dressings
  • Activities
  • Hygiene
  • Turning
  • Voiding
  • Studies
  • Orders
  • Fluids
  • Vitals
  • Labs
  • Diet
  • I/O
  • BG

Dial out directly from the app.

This comprehensive app can act as your brain sheet, sending you alerts throughout the day. “Complete” or “Delay” the alert to revisit it later. Set a task to “Repeat” for duties that recur throughout the day.  “Clock-out” at the end of your shift to pause all alerts.   “Clock-in” again to retain info and resume tasks for the patients you had during the previous shift. Easily view an organized task list of “Upcoming” duties and then slide them over to the “Completed” list for reporting later.  Use the “Notes” section to write important occurrences you wish to handoff to the next nurse. Compile that long list of phone numbers and store all your information in one place:


Enter new tasks from drop down lists.





  • Phone, beeper, & room codes (simply tap to call within the app)
  • Patient notes for report
  • Room Number
  • Code Status
  • Allergies
  • Weight
  • Gender
  • Diet
  • Age



Refer to your notes during report.





Nurse Notes is sure to make an impact on the industry as a comprehensive organizational app for nurses has been lacking since cell phone technology has become so ubiquitous in US hospitals.  The release date has yet to be announced but the buzz is building.  Check back for more details and a direct link to the app in the iTunes store.

Murse on the Run: A 3-Day Guide to Yosemite


This summer, my wife and I sat down to plan an epic running vacation.  We had heard of people taking trips where the main activity centered around running.  Although a grueling and pointless activity to some, running has always held a special appeal for us.  We each have extensive backgrounds in endurance sports and a love for racing.  My wife, Kristin, has qualified for the Boston Marathon 3 times and I have been just a few minutes shy on 3 of my 10 marathons.  Running has contained an element of competition for us for a long time but this summer we wanted to see what it would be like to let go of timing chips and race bibs and just run like Forrest.  Even with the best of intentions and a history of long-distance racing, nothing could have prepared us for thousands of feet of elevation gain and loss through the Yosemite Valley and up El Capitan, Half Dome, and Glacier Point.


The logistics of such a large endeavor were daunting.  We wanted to experience the intoxicating nature of Yosemite while staying relatively comfortable after each day’s run.  We decided to stay at Curry Village, a collection of tent cabins at the base of Glacier point equipped with common showers, electricity, and a provisional store.  The rustic feel of the un-air-conditioned canvas cabins and the untamed surroundings, hinted at by individual bear-bins to keep out the wildlife, were just what we were looking for.  After renting a car in San Francisco and driving 4 hours to the the heart of Yosemite we unpacked, inventoried our supplies, and basked in the grandeur of the surrounding peaks. Day One: Glacier Point

This was by far the most beautiful run of them all.

We took off at 0700 heading southwest along a bike path paralleling the main road to Curry Village.   After two miles we hit the trail head for Four Mile Trail.  The trail immediately soars into repeated switchbacks, winding its way up lung-busting grades, revealing more jaw-droppingly gorgeous views of the valley.  El Capitan can be seen looming to the west, while Half Dome casts a shadow to the north.  We were greeted repeatedly by friendly foreigners, vacationing in the iconic valley to get a sample of the beauty of America’s national park system.


After soaking in a few more views along the way we hit the 7214 foot Glacier Point.  Although accessibility is what keeps parks like these alive, it was a little anti-climactic being greeted at the top after our arduous run by a white-haired grandma with a walker, fresh off the tour bus that drove up the paved backside of the mountain.  The panoramic scene from the top is breathtaking, especially looking down the face of the granite monolith.  Curry Village can be viewed from this height by looking straight down the 90 degree flat wall that shoots downward in a perfect line.

We wound up running down the backside of the mountain to get away from the crowds via the Panorama Trail.   This trail rapidly descends for a couple of miles to a bridge above Illilouette Falls.  At this point, the trail ascended again, making us wander just what we had gotten ourselves into.


The trail reconnects with the John Muir Trail at Nevada Falls.  The final four miles back down to Curry Village were a little congested, as this portion connects with Happy Isles Trail, the most popular starting point for the Half Dome hike.  The entire route spanned 17 miles of ups and downs, taking us approximately dating methods of fossils 8 hours to devour.  We slunk back to our cabin feeling weary and tentative about our commitment to run two more challenging peaks before weeks end.

here Day Two: El Capitan

Our earlier drive past El Capitan on the way into the valley was a humbling experience.  We stopped to peak through a set of telescopes set up by local climbers.  Through them you can view the various climbers in different stages of elevation along their multi-day ascents.  Our little running adventure didn’t seem as extreme after seeing this!

We hopped in our rental and drove 45 minutes to Tamarack Flat campground, three miles past the Crane Flat intersection.  The trail begins along an old logging road.  We were immediately aware of how much more isolated this trail was than the others.  Kristin made sure I was sporting my bear bell to warn any potential predators of our approach.  It turns out I didn’t need the bear bell as I promptly tripped over the trailhead sign, bringing the entire metal apparatus crashing to the ground.  Seeing as it was 0600 and a campground was situated right at the trailhead, I was a little embarrassed to have probably woken up the entire site with my noisy exploit.

el cap

The trail starts with a two-mile drop to Cascade Creek.  We learned quickly that the quadriceps muscles are much more prone to fatigue, especially on downhill sections.  We were tired from the day before but also filled with reverence for the enormous sequoia trees that loomed large above us.  After crossing Cascade Creek we went left onto a single track trail.  The gradually climbing trail is marked with cairns, or small rocks stacked to mark the way.  Before opening up to reveal  the face of El Capitan, the trail winds through mossy areas filled with hanging branches giving it an eery feel.  It’s difficult to appreciate the peak of El Capitan because, unlike Glacier Point, it slopes gradually without providing a definitive drop off point over which you can ogle in amazement.  The clearest view of El Capitan is about a mile before reaching it, as the tip of the face comes into view above the valley below.

This run was much more isolated, methodical, and reflective.  Without photo-ops every half mile and fellow hikers eliminating the need for a selfies, the trail takes on a more meditative nature.  Viewing Half Dome and Glacier Point across the valley is an overwhelming sight well worth the long haul to the top.  The run back to our car was swift and uneventful, save for the overwhelming amount of mosquitoes.  We eventually snapped off a couple small pine tree branches to use as bug swatters.  The entire run took us rencontres running 7 hours.  Throughout the entire 17.5 miles we saw only one other hiker.

site rencontre france gratuite Day Three: Half Dome

We saved the beast for last.  Half Dome is a legendary hike and climb combination that draws enthusiasts from all over.  Most people hike half-way up, and with a back country permit, camp out overnight to get an early crack at the last section the following morning.  The lucky few, like us, entered a lottery and won a permit to climb the last portion.  The final 1000 feet is a greater than 45 degree angle scramble along a set of wooden foot holds and cables set up by park officials.  There are piles of rubberized gloves discarded by previous climbers that are free for the taking at the base of the cables to enhance grip.  However, no rangers or park personnel are present beyond this point to regulate hiker activity, for better or worse.

Since arriving early is essential to get up and down the cables without a bottle-neck effect, we woke up at 0430, boiled the water for our oatmeal, and strapped on our headlamps before setting off.  We ran one mile from Curry Village to the Happy Isles trailhead.  The paved portion up to Vernal Fall Bridge is quite steep and has restrooms available before it splits between the Mist and John Muir Trail.  We ran up the Mist trail as pitch darkness and stunning views of the stars gave way to sunrise.  Unfortunately, the California drought has depleted the once mighty falls that used to emit a vivid spray, lightly coating hikers along the path.  What remains is but a trickle.  In any case, the scenery was still amazing as we  climbed 4000 feet to Nevada Fall.


Beyond the falls, the Mist Trail turns back into the John Muir Trail.  Entering Little Yosemite Valley, the path opens up creating a nice flat stretch for easy running.  This brief interlude is quickly interrupted by more steep switchbacks.  The soft dirt that was so forgiving on our mileage-addled joints disappeared and was replaced with pure granite.


After being fooled by a false summit we finally reached the base of the monolith.  As the first hikers/runners to reach the base, we had first choice of second-hand gloves, slipping into the best fitting ones that we could find and setting off up the horizontally placed foot boards while gripping the cables on either side.  After about 1000 feet of terror-inducing climb, we finally reached the top.  We basked in the view of the valley below and reflected on our long run while being harassed by partially domesticated marmots vying for our trail mix.  After eating a little lunch we headed back down.  Several astonished hikers asked if we’d already been to the top.  We would briefly stop and give a trail report before resuming our slow jog back down the mountain, reveling in our bad-assery.  Half Dome was a formidable foe, taking binäre optionen webinar 8.5 hours over 18 miles.


Before leaving Yosemite we made sure to take a leisure day that ironically involved belaying one another with a guide as we crack climbed in our harnesses suspended over 800 feet in the air.  So much for a relaxing day off!  Looking back on the adventure, most people would doubt that it had anything to do with nursing.  I believe that it is a testament to how hard work, persistence, a belief in oneself, and the support of a loving wife and friends can get any nurse to the top of the world.





10 Nursing Hacks – Ain’t Nobody Got No Time for That!

Nurses are always trying to keep the plates spinning, as the saying goes.  Maybe in our case it’s bedpans, full of “output”, while paging a doctor, and getting the family member a cup of hot tea.

What exactly is a “nursing hack”?  It’s any simple tip that a nurse might stumble upon that changes the work routine and saves precious time and energy.  It’s basically a trick that will help make work easier.  Nursing hacks aren’t easy to come by and often surface at the most unexpected moments, like an “AHA” moment while inserting a foley catheter.  I’ve rounded up some of my favorites from your submissions, and even created a few of my own. They just might change the way you practice nursing.

  1. The Ring: Use an oxygen mask elastic strap to remove rings, eliminating the need to cut them off.  This technique acts as both a tourniquet and an anchoring technique.  I can’t really do it justice with an explanation so just watch the video below…

source 2. You only need 1 secondary IV tubing set: When it’s time to hang a new one, just lower and invert the existing secondary bag.  Gravity will force the fluid into the old bag and flush it out.  About 50 ml’s worth should do the trick, then re-spike a new secondary.  If you’re changing from one medication to another that’s not compatible, then change the tubing to avoid crystallization.

3.  Immaculate shaving cream:  If you have a patient covered in BM and it’s stuck in their body hair, lather the affected area with shaving cream, then wipe it off with a wet washcloth. It will come right out.  Be sure to avoid sensitive areas like mucous membranes.

seroflo cost calculator 4. Toothpaste sandwich: Next time you have a heinous code brown, take 2 preformed masks, spread a little toothpaste on one and sandwich the other on top.  When you wear it you will be impervious to stench.

finasteride 5 mg tab note 5. Bedpan maintenance: To prevent splashing onto the bed while your female patient is on the bedpan, place a sanitary wipe or disposable washcloth between patient’s legs.  Also, place powder along the bedpan before you put in under the patient.   It makes for easier extraction and is ideal for heavier patients.

pill omnicef 300 mg 6. Tiny bubbles: If you are priming new IV tubing, clamp the tubing first, then spike the bag and slightly fill the chamber before you commence priming.  This will prevent annoying air bubbles from being distributed all throughout the tubing.  Also, when you’re priming a pressure bag and tubing for an arterial line,  inflate the pressure bag with the fluid upside down.  This will force all remaining air out of the saline bag first, followed by the fluid, preventing more bubbles.

7. Phlebostatic axis: When you’re patient has an arterial line, ensure that the pressure reading is always accurate by locking the bed height.  This will ensure that the transducer remains at the level of the heart.

8. Climate control: Want to keep your elderly, demented patient exactly where you last placed them?  Turn down the temperature in the room and cover them with nice, cozy blankets.  They will not want to get out of bed and wander around if they’re super comfy and it’s cold outside of the sheets. They might even sleep!

9. TED talk:  Place the plastic wrapper that the TED hose comes in over the patient’s foot when applying the stockings.  This prevents sticking and helps them to slide right up.  This is especially helpful with edematous legs.

10. Helicopter family:  If the patient’s family is hovering like crazy, especially during a procedure, give them a task to perform.  If it’s an IV start or something painful, offer them the job of holding the patient’s hand.

These are just a few of the nursing hacks that save time and make a hectic shift more tolerable.  There are lots more out there so feel free to visit the Contact page or leave a comment below to let us know about your favorite tips, tricks, and hacks…

Nurse’s Guide to COPD: Patho, Assessments, Diagnosis, Interventions, & Medications



Chronic obstructive pulmonary disease (COPD) is the 8th leading cause of hospitalization in the United States and the 3rd leading cause of death. Nurses are involved with COPD care across the spectrum, from outpatient and home care education to intensive care and hospice management. COPD is a disease characterized by airflow limitation that is not fully reversible. COPD includes diseases that obstruct airflow, including emphysema and chronic bronchitis. Separate diseases like asthma, cystic fibrosis, and bronchiectasis were previously classified as types of chronic obstructive lung disease. Current guidelines place asthma in a separate category designated as an abnormal airway condition involving reversible inflammation.

Chronic bronchitis is defined as the presence of a chronic productive cough for a 3-month period during 2 consecutive years. Emphysema is defined as an abnormal, irreversible enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of alveolar walls. Airflow limitation in emphysema is due to loss of elastic recoil of the interstitial tissue that aids in exhalation. Chronic bronchitis is characterized by a narrowing of airways and an increase in airway resistance. Although these are 2 discrete diseases and some patients may display signs of both, most fall somewhere in the middle of the spectrum between the 2 conditions.


Risk factors for COPD include environmental exposures and host factors. Exposure to tobacco smoke accounts for an estimated 80 – 90% of all cases. Other risk factors include prolonged and intense exposure to occupational dusts and chemicals, indoor air pollution, and outdoor air pollution, which adds to the total burden of inhaled particles. The following are possible causative factors in COPD:

  • Cigarette Smoking: Induces macrophages to release neutrophil chemotactic factors and elastases, which destroy tissue integrity and elasticity. The lack of tissue elasticity compromises the patient’s ability to exhale sufficient volume at a necessary speed leading to air trapping.
  • Secondhand Smoke: Increases the risk of respiratory infections, increases asthma symptoms, and leads to appreciable reductions in pulmonary function.
  • Alpha 1 Antitrypsin Deficiency: Genetically susceptible patients become sensitive to environmental factors (smoking, pollution, allergens, etc.) and in time develop COPD symptoms. Carriers must be identified early to reduce exposure and delay symptoms. Alpha-protease inhibitor replacement therapy slows the progression.


  • Environmental Exposure: Long-term exposure from living near highly-trafficked areas creates exposure to air pollution and may produce COPD symptoms, especially in patients with asthma.
  • Airway Hyperresponsiveness: Patients who have nonspecific airway hyperreactivity and also smoke are at a significantly higher risk of symptoms of COPD.
  • Intravenous Drug Abuse: Approximately 2 – 3% of people who abuse IV drugs will develop emphysema secondary to pulmonary vascular damage produced by impurities injected directly into the circulatory system and carried to the lungs.
  • Connective Tissue Disorders: Marfan syndrome and other connective tissue disorders can harm elastin, collagen, and other connective tissues responsible for the dynamics of passive breathing.


In COPD, limited airflow is both progressive and associated with an abnormal inflammatory response to irritating particles and gases in the lungs. The inflammatory response occurs throughout the airways, parenchyma, and pulmonary vasculature. Narrowing of the airways occurs as the body attempts to repair the changes related to chronic inflammation. Eventually, scarring takes place due to this repeated process.

Airflow obstruction may also be due to parenchymal destruction from emphysema, most notably in the alveoli. Emphysema results in permanent enlargement of airspaces distal to the terminal bronchioles. This creates a decline in alveolar surface area as the walls between individual alveoli are destroyed. Elastic recoil is lost in this process as well as support structure. Airflow becomes limited when the lungs fail to deflate efficiently and surrounding tissue collapses, impeding movement of air.

Chronic bronchitis is characterized by deformed airways and narrow lumens. Airway structural changes include ciliary abnormalities, atrophy, smooth muscle hyperplasia, inflammation, and bronchial wall thickening. As damage accumulates to the mucociliary elevator, mobilization of secretions becomes difficult. Distortion of the airways from fibrosis warps their shape, creating a unique setting for the collection of mucous as well as mucous plugging.

Hyperinflation is the central mechanism that produces shortness of breath in this patient population. The ability for a patient with COPD to inhale is not altered. However, expelling air is hampered by damaged airways. During exercise or exertion the patient’s respiratory rate may rise creating less time to exhale before the next inhalation. The patient’s lungs begin to air-trap as a result of the unmet demand for additional time to exhale through poorly functioning airways. The oxygen is quickly extracted from this trapped air. The patient may become hypoxemic, especially if emphysema is present because the surface area needed to extract oxygen is significantly reduced in the alveoli.


In 2011, an estimated 12.5 million adults in the U.S. had COPD. However, under-diagnosis leads experts to believe that the number may be closer to 24 million based on documented impaired lung function. That same year, 10.1 million Americans had a diagnosis of chronic bronchitis. The highest rate of chronic bronchitis was in older adults age 65 years or greater. Emphysema affects a total of 4.7 million people. The prevalence of COPD varies considerably by state, from < 4% in Washington to > 9% in Alabama. Based on spirometry results, studies have determined that approximately 1 in 5 patients older than 30 years with at least a 10-year history of smoking are likely to have COPD.

A clinical scoring system was developed called the BODE index. This system was developed to approximate a patient’s risk of death or hospitalization. The point system is as follows:

  • BMI
    • > 21 = 0
    • < 21 = 1


  • FEV 1(post-bronchodilator % predicted)
    • > 65% = 0
    • 50-64% = 1
    • 36-49% = 2
    • < 35% = 3



  • Modified Medical Research Council (MMRC) dyspnea scale
    • MMRC 0: Dyspneic on strenuous exercise
      • 0 points
    • MMRC 1: Dyspneic on walking a slight hill
      • 0 points
    • MMRC 2: Dyspneic on walking level ground, must stop occasionally due to breathlessness
      • 1 point
    • MMRC 3: Dyspneic after walking 100 yards or a few minutes
      • 2 points
    • MMRC 4: Cannot leave house; dyspneic doing activities of daily living
      • 3 points


  • Six-minute walking distance
    • > 350 meters = 0
    • 250-349 meters = 1
    • 150-249 meters = 2
    • < 149 meters = 3


The predicted 4-year survival based on the BODE index:

  • 0-2 points = 80%
  • 3-4 points = 67%
  • 5-6 points = 57%
  • 7-10 points = 18%



A mixture of symptoms of reactive airway disease, emphysema, and chronic bronchitis are usually present in patients diagnosed with COPD. The following symptoms are typically found in this patient population:

  • Wheezing
  • Productive cough
  • Dyspnea
  • Respiratory infection


The following physical signs are present in more advanced stages of COPD:

  • JVD
  • Cyanosis
  • Dyspnea and tachypnea on exertion
  • Accessory muscle use
  • Peripheral edema


Chest exam:


  • Wheezes, crackles, & decreased breath sounds
  • Prolonged expiratory period
  • Hyperinflation
  • Percussive hyper-resonance


Chronic bronchitis:

  • Productive cough
  • Obesity & Cyanosis (“blue bloater”)
  • Accessory muscle use
  • Right-sided heart failure with edema
  • Wheezes & Rhonchi



  • Non-productive cough
  • Cachexia
  • Barrel chest with significant air-trapping
  • Pursed-lip breathing (“pink puffer”)
  • Hyper-resonance in chest




  • History: An accurate history, which will assist with the differential diagnosis, should include:


  • Family history of heart and lung disease
  • Childhood diseases
  • Environmental exposures to gas and dust
  • Occupational exposure
  • Tobacco use:
    • 1 pack-year = 20 cigarettes/day for 1 year
    • 10 pack-year = 1 pack/day for 10 years
  • Oxygen saturation: Goal pulse oximeter > 92%
  • ABG:
    • pH < 7.2 consider invasive or non-invasive positive pressure ventilation strategies
    • PaCO2 > 55 mmHg assess baseline and pH for correlation
    • PaO2 < 60 mmHg consider supplemental oxygen, be mindful of O2-induced hypoventilation
  • Infection:
    • temperature
    • sputum volume, color, tenacity, and smell
    • mucous membranes for hydration
    • palpate tactile fremitus
  • Skin:
    • cyanosis
    • clubbing
    • edema
  • Breathing:
    • dyspnea
    • pursed lip breathing
    • symmetrical chest expansion
    • intercostal retractions
    • tracheal deviation
    • respiratory rate > 20 bpm
    • ability to speak
    • tripod position: use of arms to press down and raise rib cage to produce greater diaphragmatic downward excursion
  • Breath Sounds:
    • rhonchi
    • wheezing
    • crackles
    • diminished/absent
  • Chest X-ray:
    • pulmonary congestion: heart failure
    • pneumothorax
    • secretions consolidation: infection
    • blunted costophrenic angle: hyperinflation
  • LOC: somnolence can be a byproduct of hypercapnia, exhaustion, or both. Patient may be in danger of impending respiratory failure
  • Level of Activity: exercise tolerance
  • Sleep Patterns: orthopnea may indicate right-sided heart failure and pulmonary congestion when recumbent
  • Nutrition:
    • obesity with chronic bronchitis
    • cachexia with emphysema
    • bowel sounds diminished from shunting of blood to more vital organs during periods of hypoxia
    • oral hygiene may lead to lowered appetite
  • Knowledge:
    • breathing exercises
    • coughing & deep breathing
    • oral care
    • risk for infection
    • triggers
      • cold air
      • pollen
      • smoke
    • smoking cessation
    • alternating rest & activity
    • pursed lip breathing
    • follow-up care
    • oxygen safety
    • inhaler technique



  • Arterial Blood Gas
    • May have mild to moderate hypoxemia
    • Hypercapnia develops with progression of disease
    • Renal compensation occurs with chronically elevated PaCO2 as evidenced by increased HCO3 & normalized pH
    • pH < 7.2 signals acute distress
  • Hematocrit
    • Polycythemia may develop due to chronic moderate hypoxemia
    • Hct > 52% for males, and 47% for females
  • Serum Chemistry
    • May retain Na
    • Diuretics & Beta-adrenergics may decrease K
    • Beta-adrenergics decrease Ca & Mg
    • Monitor increased HCO3 as a sign of compensated respiratory acidosis
  • B-Type Natriuretic Peptide
    • Elevation can differentiate CHF exacerbation from COPD
  • Alpha-1 Antitrypsin
    • AAT < 11 mmol/L can explain COPD symptoms in patients < 40 yrs
  • Cytologic Exam
    • Rule out malignancy
  • Sputum Sample
    • Chronic bronchitis = mucoid
    • Purulent = presence of neutrophils
    • Increased production = exacerbation
    • Streptococcus pneumoniae & Haemophilus influenza are common
  • Chest X-ray
    • Emphysema = hyperinflation, flattening of diaphragm, diminished heart shadow (pictured below)
    • Chronic bronchitis = bronchovascular markings & cardiomegaly


  • Bronchogram
    • Shows cylindrical dilation of bronchi on inspiration
    • Shows bronchial collapse on forced expiration (emphysema)
    • Show enlarged mucous ducts (chronic bronchitis)
  • Six-Minute Walking Distance
    • Part of BODE index described above
    • Desaturations predict mortality rates
  • Exercise ECG/Stress Test
    • Evaluate effectiveness of bronchodilator therapy
    • Plan & evaluate exercise regimen
    • Assess degree of pulmonary dysfunction
  • Pulmonary Function Test (PFT)
    • Total lung capacity = increased
    • Functional residual capacity = increased
    • Residual volume = increased
    • Vital capacity = decreased
    • FEV1 = no increased response to bronchodilator therapy
    • Carbon monoxide diffusing capacity (DLCO) = decreased with emphysema
    • FEV1/FVC = < 80%

Lungvolumedescriptions LungvolumesOvsR


The ultimate aim of care is to increase or maintain the patient’s functional status. Management focuses on optimizing lung function, avoiding infection, adhering to treatment schedules, and avoiding exacerbations. Education is essential for patient investment and ownership of treatment.

  • Ineffective Airway Clearance
    • Assist patient to comfortable position
    • Remove environmental gas, dust, smoke, micro-fibers
    • PO fluids 3000 mL/day between meals
    • Mucolytics: N-acetylcysteine


  • Impaired Gas Exchange
    • Elevate HOB
    • Provide rest
    • Encourage pursed-lip breathing
    • Encourage cough and suction PRN
    • Provide O2 if SpO2 < 92%
    • Home O2 for sustained PaO2 < 55 mmHg, educate on fire safety
    • Non-invasive positive pressure ventilation (NIPPV) = CPAP or BiPAP


  • Imbalanced Nutrition
    • Frequent oral care
    • Drink before or after meals
    • No carbonated beverages (bloating)
    • Supplemental O2 during meals


  • Risk for Infection
    • Encourage coughing & deep breathing
    • Document temp. & sputum character
    • Use spacer & rinse/spit after corticosteroid inhaler
    • Administer antibiotics as ordered


  • Smoking Cessation
    • Personalize the message
    • Choose quit date
    • Educate on expected effects: increased mucous production, lethargy, anxiety
    • Inquire about social support
    • Follow-up support from health care team or support group
    • Pharmacological support: chantix, wellbutrin, nicotine patch, etc.


  • Airway Inflammation
    • Inhaled corticosteroids
    • Azithromycin


  • Vaccination
    • Pneumococcal vaccine for all patients > 65 years
    • Influenza annually for all COPD patients



– Albuterol

  • Trade Name: Proventil, Ventolin, Proair
  • Indication: Acute bronchospasm
  • Action: Relaxes bronchial smooth muscle by activating beta-2 receptors with slight effect on beta-1 and heart rate, dilate bronchial airways
  • Class: Beta-2 agonist
  • Considerations:
    • 1 – 2 inhalations q4 – 6h
    • Duration 3 – 6h
    • May cause tremor or tachycardia
    • Take last dose several hours before bedtime
    • Review proper inhaler technique with patient

– Salmeterol

  • Trade Name: Serevent Diskus
  • Indication: Prevention of COPD or asthma related bronchospasms
  • Action: Long-acting beta-2 agonist stimulates receptors and relaxes bronchial smooth muscle with little effect on heart rate
  • Class: Beta-2 agonist
  • Considerations:
    • 2 inhalations aerosol (42 mcg) or 1 powder diskus (50 mcg) b.i.d. 12h apart
    • Duration 12h, do not use for acute asthma
    • Withhold and notify physician if bronchospasms occur after use
    • May cause tachycardia
    • Monitor LFT’s
    • Take 30 – 60 min prior to exercise

– Ipratropium

  • Trade Name: Atrovent
  • Indication: COPD
  • Action: Parasympatholytic agent that inhibits vagally mediated reflexes by antagonizing acetylcholine leading to bronchodilation
  • Class: Anticholinergic, Respiratory
  • Considerations:
    • 2 inhalations of MDI q.i.d. at no less than 4h intervals
    • Not intended for PRN use due to delayed onset
    • Anticholinergic effect may lead to blurred vision, nausea, dry mouth, and constipation
    • May change urinary pattern in older adults
    • Review proper inhaler technique with patient

– Fluticasone

  • Trade Name: Flovent
  • Indication: COPD, Asthma
  • Action: Exhibits anti-inflammatory effects on neutrophils, eosinophils, macrophages, mast cells, and histamine
  • Class: Corticosteroid
  • Considerations:
    • Inhaled powder 100 – 250 mcg q12h
    • Rinse mouth after use to prevent oral candidiasis
    • May increase intraocular pressure with cataracts and glaucoma
    • Adrenal insufficiency may occur after abrupt withdrawal
    • May suppress growth in children
    • Immune-suppression possible with long term use

– Prednisone

  • Trade Name: Rayos
  • Indication: Acute exacerbation of COPD
  • Action: Elicits mild mineralocorticoid activity and moderate anti-inflammatory effects by suppressing migration of PMN’s and fibroblasts, reversing capillary permeability, and stabilizing lysosomes
  • Class: Corticosteroid
  • Considerations:
    • PO 40 mg q12h X 3 – 5 days
    • Can lead to immune-suppression with prolonged use, monitor for poor wound healing
    • Give at mealtime to avoid gastric irritation
    • Do not abruptly stop, reduce dose gradually
    • Monitor BG, weight, sleep patterns, and blood pressure closely
    • Monitor for adrenal suppression
    • Monitor bone density

– Albuterol/ipratropium

  • Trade Name: Combivent
  • Indication: COPD patients who require second bronchodilator
  • Action: Bronchodilation through beta-2 adrenergic and anticholinergic mediated antagonization of vagal reflexes
  • Class: Respiratory inhalant combo
  • Considerations:
    • Aerosol 100 mcg/20 mcg 1 puff q6h, not to exceed 6 per day
    • Anticholinergic effect may lead to blurred vision, nausea, dry mouth, and constipation
    • May change urinary pattern in older adults
    • May cause tremor or tachycardia
    • Take last dose several hours before bedtime
    • Review proper inhaler technique with patient

– Budesonide/formoterol

  • Trade Name: Symbicort
  • Indication: COPD uncontrolled with mono-therapy
  • Action: Decreased inflammation of airways through inhibition of inflammatory cells and long-acting beta-2 adrenergic agonism with rapid onset leading to bronchodilation
  • Class: Respiratory inhalant combo
  • Considerations:
    • 160 mcg/9 mcg (2 puffs of 80 mcg/4.5 mcg) q12h
    • Implement step-down therapy as soon as possible to prevent long-term issues with corticosteroids like immune-suppression, adrenal suppression, and decreased bone density
    • Not for relief of acute asthma symptoms
    • Monitor blood pressure and heart rate
    • Rinse mouth after using to avoid oral candidiasis