Advanced Concept of Nursing- II

Advanced Concept of Nursing- IIUNIT- IV

Advance Nursing Managementof Respiratory diseases.

In The Name of God

(A PROJECT OF NEW LIFE COLLEGE OF NURSING KARACHI)

UNIT- IVAdvance Nursing Management

of Respiratory diseases.Shahzad Bashir

RN, BScN, DCHN,MScN (Std.DUHS)Instructor

New Life College of NursingUpdated on April 18, 2016

Objectives

• At the end of the unit, students will be able to:1. Utilize Functional health pattern to identify patients problems

related to respiratory disorders including:1.Asthma2.Chronic obstructive pulmonary disorder (COPD)3.Pneumonia4.Pulmonary tuberculosis (TB)

2. Integrate pathophysiology and pharmacology concepts ofrespiratory disease

3. Apply nursing process with support on Evidence-Based Nursing(EBN) to provide to the clients with respiratory disorders

4. Discuss the holistic approach for nursing management of thepatient with respiratory diseases

5. Develop a teaching plan for a client experiencing disorders of therespiratory disorders.

• At the end of the unit, students will be able to:1. Utilize Functional health pattern to identify patients problems

related to respiratory disorders including:1.Asthma2.Chronic obstructive pulmonary disorder (COPD)3.Pneumonia4.Pulmonary tuberculosis (TB)

2. Integrate pathophysiology and pharmacology concepts ofrespiratory disease

3. Apply nursing process with support on Evidence-Based Nursing(EBN) to provide to the clients with respiratory disorders

4. Discuss the holistic approach for nursing management of thepatient with respiratory diseases

5. Develop a teaching plan for a client experiencing disorders of therespiratory disorders.

8/22/2016 2Shahzad Bashir NLCON

• Asthma is a chronic inflammatory pulmonarydisorder that is characterized by reversibleobstruction of the airways.

• Chronic inflammatory disorder of airways,which causes airway hyper responsivenessleading to Bronchospasm, wheezing,breathlessness, chest tightness, and cough

• Asthma is a chronic inflammatory pulmonarydisorder that is characterized by reversibleobstruction of the airways.

• Chronic inflammatory disorder of airways,which causes airway hyper responsivenessleading to Bronchospasm, wheezing,breathlessness, chest tightness, and cough

38/22/2016 Shahzad Bashir NLCON

• Allergens – 40% of all cases• Exposure to animal fur, pollen grains, mites.• Exercise, worse with exposure to cold air• Air pollutants – cigarette or wood smoke,

vehicle exhaust, sulfur dioxide (SO4), NO4

• Occupational factors• Respiratory infections• Nose and sinus problems

• Allergens – 40% of all cases• Exposure to animal fur, pollen grains, mites.• Exercise, worse with exposure to cold air• Air pollutants – cigarette or wood smoke,

vehicle exhaust, sulfur dioxide (SO4), NO4

• Occupational factors• Respiratory infections• Nose and sinus problems


Cont…

• Drugs and Food– Asthma triad: nasal polyps, sensitivity to ASA and

NSAIDs, B-blockers, aerosol– Salicylates found in many foods and beverages– Most common in children

• GERD – exact mechanism unknown• Emotional stress – attacks can lead to panic

and anxiety.• Environmental factors

• Drugs and Food– Asthma triad: nasal polyps, sensitivity to ASA and

NSAIDs, B-blockers, aerosol– Salicylates found in many foods and beverages– Most common in children

• GERD – exact mechanism unknown• Emotional stress – attacks can lead to panic

and anxiety.• Environmental factors


• 1. Brochospasm (immediate stage) AntigenInduced mast cell degranulation-release ofHistamine & other mediators, which eitherdirectly or through neuronal reflexesleads to Broncho spasm.

• 2. Inflammation (Late stage) Factors+Eosinophils +other inflamatory cells maycause damage to epithelium-producingChronic Inflamatory response.

• 1. Brochospasm (immediate stage) AntigenInduced mast cell degranulation-release ofHistamine & other mediators, which eitherdirectly or through neuronal reflexesleads to Broncho spasm.

• 2. Inflammation (Late stage) Factors+Eosinophils +other inflamatory cells maycause damage to epithelium-producingChronic Inflamatory response.


1. Inflammatory cells and mediators• Airway smooth muscle contraction• Bronchospasm: largely reversible with

bronchodilators• Airway edema: increased microvascular

permeability

2. Increases in mucous production andinflammatory exudates may lead to airwayocclusion (“mucous plugging”)

1. Inflammatory cells and mediators• Airway smooth muscle contraction• Bronchospasm: largely reversible with

bronchodilators• Airway edema: increased microvascular

permeability

2. Increases in mucous production andinflammatory exudates may lead to airwayocclusion (“mucous plugging”)



8/22/2016 Shahzad Bashir NLCON 9



Pathophysiology


Extrinsic Asthma• In which the asthmatic episode is typically

initiated by a type I hypersensitivity reactioninduced by exposure to an extrinsic antigen.

• Three types of extrinsic asthma are recognized:atopic asthma, occupational asthma (manyforms), and allergic bronchopulmonaryaspergillosis (bronchial colonization withAspergillus organisms followed bydevelopment of immunoglobulin E [IgE]antibodies).

• In which the asthmatic episode is typicallyinitiated by a type I hypersensitivity reactioninduced by exposure to an extrinsic antigen.

• Three types of extrinsic asthma are recognized:atopic asthma, occupational asthma (manyforms), and allergic bronchopulmonaryaspergillosis (bronchial colonization withAspergillus organisms followed bydevelopment of immunoglobulin E [IgE]antibodies).


Cont….• Atopic asthma is the most common type of

asthma; its onset is usually in the first twodecades of life, and it is commonly associatedwith other allergic manifestations in the patientas well as in other family members.

• Serum IgE levels are usually elevated, as is theblood eosinophil count. This form of asthma isbelieved to be driven by CD4+ T cells.

• Atopic asthma is the most common type ofasthma; its onset is usually in the first twodecades of life, and it is commonly associatedwith other allergic manifestations in the patientas well as in other family members.

• Serum IgE levels are usually elevated, as is theblood eosinophil count. This form of asthma isbelieved to be driven by CD4+ T cells.


Intrinsic asthma• In which the triggering mechanisms are

nonimmune.

• In this form, a number of stimuli that have little orno effect in normal subjects can triggerbronchospasm.

• Such factors include aspirin; pulmonaryinfections, especially those caused by viruses;cold; psychological stress; exercise; and inhaledirritants such as sulfur dioxide.

• In which the triggering mechanisms arenonimmune.

• In this form, a number of stimuli that have little orno effect in normal subjects can triggerbronchospasm.

• Such factors include aspirin; pulmonaryinfections, especially those caused by viruses;cold; psychological stress; exercise; and inhaledirritants such as sulfur dioxide.


Cont…

• There is usually no personal or family historyof allergic manifestations, and serum IgElevels are normal. These patients are said tohave an asthmatic diathesis.

• There is usually no personal or family historyof allergic manifestations, and serum IgElevels are normal. These patients are said tohave an asthmatic diathesis.


Pathological Changes in Asthma



• Coughing• Wheezing,• Prolong expiratory time [1:3 or 1:4]• Shortness of breath• Chest tightness.

• Coughing• Wheezing,• Prolong expiratory time [1:3 or 1:4]• Shortness of breath• Chest tightness.


Four types:• Mild intermittent:

– Occurs in people with daytime symptoms thatoccur no more frequently than twice a week andnighttime symptoms that occur no more than twicea month. These people are usually asymptomatic.

• Mild persistent:– Characterized by daytime symptoms that occur

more than twice a week but less than once a daywith nighttime symptoms more frequent than twicea month. These people are asymptomatic but haveabnormal pulmonary function tests.

Four types:• Mild intermittent:

– Occurs in people with daytime symptoms thatoccur no more frequently than twice a week andnighttime symptoms that occur no more than twicea month. These people are usually asymptomatic.

• Mild persistent:– Characterized by daytime symptoms that occur

more than twice a week but less than once a daywith nighttime symptoms more frequent than twicea month. These people are asymptomatic but haveabnormal pulmonary function tests.


Conti…• Moderate persistent:

– Occurs in people who have daytime symptomsevery day and nighttime symptoms more than oncea week. Exacerbations limit their activity andoccur at least twice a week, and may last forseveral days.

•Severe persistent (Status Asthmaticus):–Characterized by continual daytime symptoms and frequent

nighttime symptoms. They experience limited physicalactivity and exacerbations are frequent. These people oftentake two medications daily for long term control. Also usingmedications for quick relief on a daily basis indicates a needfor additional long term therapy.

• Moderate persistent:– Occurs in people who have daytime symptoms

every day and nighttime symptoms more than oncea week. Exacerbations limit their activity andoccur at least twice a week, and may last forseveral days.

•Severe persistent (Status Asthmaticus):–Characterized by continual daytime symptoms and frequent

nighttime symptoms. They experience limited physicalactivity and exacerbations are frequent. These people oftentake two medications daily for long term control. Also usingmedications for quick relief on a daily basis indicates a needfor additional long term therapy.


COPD• COPD is a preventable and treatable disease state characterized

by chronic airflow limitation that is not fully reversible.• COPD is irreversible airflow limitation during forced exhalation

caused by loss of elastic recoil & airflow obstruction caused bymucus hyper secretion, & bronchospasm.

• The airflow limitation is usually progressive and associated withan abnormal inflammatory response of the lungs to noxiousparticles or gases, primarily caused by cigarette smoking.

• The irritating effect of the smoke causes hyperplasia of cells,including goblet cells, which subsequently results in increasedproduction of mucus.

• COPD patients may develop respiratory failure accompanied byhypoxemia, carbon dioxide retention resulting in respiratoryacidosis

• COPD is a preventable and treatable disease state characterizedby chronic airflow limitation that is not fully reversible.

• COPD is irreversible airflow limitation during forced exhalationcaused by loss of elastic recoil & airflow obstruction caused bymucus hyper secretion, & bronchospasm.

• The airflow limitation is usually progressive and associated withan abnormal inflammatory response of the lungs to noxiousparticles or gases, primarily caused by cigarette smoking.

• The irritating effect of the smoke causes hyperplasia of cells,including goblet cells, which subsequently results in increasedproduction of mucus.

• COPD patients may develop respiratory failure accompanied byhypoxemia, carbon dioxide retention resulting in respiratoryacidosis


Conti….• Used for two closely related diseases of the respiratory system,

chronic bronchitis and emphysema• Chronic bronchitis

– Narrowing of the large and small airways, making it moredifficult to move air in and out of the lungs

– Chronic bronchitis is the presence of chronic productivecough for 3 months in each of 2 consecutive years in apatient in whom other causes of chronic cough have beenexcluded.

• Emphysema– Permanent destruction of the alveoli because of irreversible

destruction of elastin, a protein in the lung that is importantfor maintaining the strength of the alveolar walls

• Used for two closely related diseases of the respiratory system,chronic bronchitis and emphysema

• Chronic bronchitis– Narrowing of the large and small airways, making it more

difficult to move air in and out of the lungs– Chronic bronchitis is the presence of chronic productive

cough for 3 months in each of 2 consecutive years in apatient in whom other causes of chronic cough have beenexcluded.

• Emphysema– Permanent destruction of the alveoli because of irreversible

destruction of elastin, a protein in the lung that is importantfor maintaining the strength of the alveolar walls


Etiology• Cigarette Smoking (Passive)• Genetics (ATT, α 1 -Antitrypsin), The most

common genotype associated with ATTdisease is ZZ.

• Occupational Chemicals and Dusts.• Air Pollution.• Infections.• Aging.

• Cigarette Smoking (Passive)• Genetics (ATT, α 1 -Antitrypsin), The most

common genotype associated with ATTdisease is ZZ.

• Occupational Chemicals and Dusts.• Air Pollution.• Infections.• Aging.


COPD Pathophysiology

• Walls of the small airways and alveoli losetheir elasticity and thicken

• Closes off some of the smaller air passagesand narrows the larger ones

• Air can enter the alveoli but becomestrapped due to the collapsed airways– Affects gas exchange and pathological changes

occur

• Walls of the small airways and alveoli losetheir elasticity and thicken

• Closes off some of the smaller air passagesand narrows the larger ones

• Air can enter the alveoli but becomestrapped due to the collapsed airways– Affects gas exchange and pathological changes

occur


COPD Pathophysiology• Blood is poorly oxygenated and tissue

perfusion is less efficient• Carbon dioxide may accumulate to critical

levels– Respiratory acidosis– Respiratory failure

• Strains the heart– Right ventricle can enlarge and thicken

• Blood is poorly oxygenated and tissueperfusion is less efficient

• Carbon dioxide may accumulate to criticallevels– Respiratory acidosis– Respiratory failure

• Strains the heart– Right ventricle can enlarge and thicken





COPD Symptoms• Early

– Early morning cough with clear sputum– Periods of wheezing during or after colds– Shortness of breath on exertion

• Late– Mouth breathing– Puffing– Use of accessory muscles of breathing– Inability to finish sentence without catching one’s

breath– Sleep in semi-sitting position

• Early– Early morning cough with clear sputum– Periods of wheezing during or after colds– Shortness of breath on exertion

• Late– Mouth breathing– Puffing– Use of accessory muscles of breathing– Inability to finish sentence without catching one’s

breath– Sleep in semi-sitting position


Pneumonia• Lung inflammation caused by bacterial or viral

infection, in which the air sacs fill with pus andmay become solid. Inflammation may affectboth lungs ( double pneumonia ) or only one(single pneumonia ).

• Most common type of infectious disease of thelung

• Lung inflammation caused by bacterial or viralinfection, in which the air sacs fill with pus andmay become solid. Inflammation may affectboth lungs ( double pneumonia ) or only one(single pneumonia ).

• Most common type of infectious disease of thelung


Pneumonia Pathogens

• Streptococcus pneumonia• Haemophilus influenza• Staphylococcus aureus• Enterobacteriaceae

• Streptococcus pneumonia• Haemophilus influenza• Staphylococcus aureus• Enterobacteriaceae


Pneumonia Risk Factors

• History of nosocomialpneumonia within thelast 6 to 12 months

• Diagnosed lung disease(COPD)

• Recent hospitalization• Nursing home residence• Smoking• Alcoholism• Neurologic disease

• Immunosuppression• Severe protein-calorie

malnutrition• Heart failure• Eating dependency• Enteral feeding by

nasogastric tube.

• History of nosocomialpneumonia within thelast 6 to 12 months

• Diagnosed lung disease(COPD)

• Recent hospitalization• Nursing home residence• Smoking• Alcoholism• Neurologic disease

• Immunosuppression• Severe protein-calorie

malnutrition• Heart failure• Eating dependency• Enteral feeding by

nasogastric tube.


Pneumonia Symptoms

• Cough• Fever• Sputum production• Fever• Changes in function,• Appetite

• Cough• Fever• Sputum production• Fever• Changes in function,• Appetite


Tuberculosis (TB) Overview

• An infectious bacterial diseasecharacterized by the growth of nodules inthe tissues, especially the lungs.

• Spread by droplets when an infectedperson coughs, sneezes, speaks, sings, orlaughs

• Adequate ventilation is the mostimportant measure to prevent transmission

• An infectious bacterial diseasecharacterized by the growth of nodules inthe tissues, especially the lungs.

• Spread by droplets when an infectedperson coughs, sneezes, speaks, sings, orlaughs

• Adequate ventilation is the mostimportant measure to prevent transmission



TB Risk Factors

• Living in an institution• Diabetes mellitus• Use of immunosuppressive drugs• Malignancy• Malnutrition• Renal failure

• Living in an institution• Diabetes mellitus• Use of immunosuppressive drugs• Malignancy• Malnutrition• Renal failure


Asthma Care• Assist the patient with spirometry testing• Educate the patient regarding proper Use

– Metered-dose inhaler– Nebulizer use– Spacer use– Peak flow meter– Care of the respiratory equipment

• Assist the patient with spirometry testing• Educate the patient regarding proper Use

– Metered-dose inhaler– Nebulizer use– Spacer use– Peak flow meter– Care of the respiratory equipment


Medications Used to Treat Asthma

• Inhaled corticosteroid therapy• Oral corticosteroids• Inhaled beta2-agonists• Methylxanthine (theophylline)• Ipratropium bromide

• Inhaled corticosteroid therapy• Oral corticosteroids• Inhaled beta2-agonists• Methylxanthine (theophylline)• Ipratropium bromide


Medications Used to Treat COPD• Are similar to those used to treat asthma

– Bronchodilators– Inhaled corticosteroids– Antibiotics– Influenza and pneumococcal vaccines– Expectorants– Other drugs to treat associated symptoms

such as diuretics, analgesics, coughsuppressants, and anxiolytics

• Are similar to those used to treat asthma– Bronchodilators– Inhaled corticosteroids– Antibiotics– Influenza and pneumococcal vaccines– Expectorants– Other drugs to treat associated symptoms

such as diuretics, analgesics, coughsuppressants, and anxiolytics


COPD Education• Additional methods used to help loosen

and remove secretions– Postural drainage– Chest percussion– Controlled coughing– Tracheal suctioning

• Smoking cessation

• Additional methods used to help loosenand remove secretions– Postural drainage– Chest percussion– Controlled coughing– Tracheal suctioning

• Smoking cessation


TB Treatment

• Several antibiotics that are prescribed for6 to 12 months

• Patients must take their medication at thesame time every day to prevent resistance

• Several antibiotics that are prescribed for6 to 12 months

• Patients must take their medication at thesame time every day to prevent resistance


• Detailed History and exposure• Pulmonary function tests• Peak flow monitoring• Chest X-ray• ABGs• Oximetry• Allergy testing• Blood testing• Sputum C & S

• Detailed History and exposure• Pulmonary function tests• Peak flow monitoring• Chest X-ray• ABGs• Oximetry• Allergy testing• Blood testing• Sputum C & S


• Bronchodilators (Sympathomimetics)• Bronchodilators (Anticholinergics)• Inhaled Corticosteroids• Biologic Response Modifiers (Monoclonal

Antibodies)• Leukotriene Receptor Antagonists• Mast Cell Stabilizers• Methylxanthene Derivatives

• Bronchodilators (Sympathomimetics)• Bronchodilators (Anticholinergics)• Inhaled Corticosteroids• Biologic Response Modifiers (Monoclonal

Antibodies)• Leukotriene Receptor Antagonists• Mast Cell Stabilizers• Methylxanthene Derivatives


• Albuterol• Salmeterol• Terbutalin• Ipratropium(anticholinnergic )

• Albuterol• Salmeterol• Terbutalin• Ipratropium(anticholinnergic )


• Beclamethasone• Flunisolide• Triamcinalone

• Beclamethasone• Flunisolide• Triamcinalone


• Montelukast• Zafirlukast• Montelukast• Zafirlukast


Take History:• History• Occupation (certain occupations have

increased risk for lung disease related toenvironmental work conditions)

• Allergies• Recent pulmonary infection

Take History:• History• Occupation (certain occupations have

increased risk for lung disease related toenvironmental work conditions)

• Allergies• Recent pulmonary infection


Assess S/S• Dyspnea• Decreased respiratory effort• Wheezing• Chest tightness• Accessory muscle use• Decreased breath sounds• Decreased oxygen saturation

Assess S/S• Dyspnea• Decreased respiratory effort• Wheezing• Chest tightness• Accessory muscle use• Decreased breath sounds• Decreased oxygen saturation


• Ineffective breathing pattern R/Lbronchospasm.

• Ineffective airway clearance R/L accumulationof secretion in airway passage.

• Activity intolerance R/L decreased O2 supplyto the tissues of the body.

• Risk for infection

• Ineffective breathing pattern R/Lbronchospasm.

• Ineffective airway clearance R/L accumulationof secretion in airway passage.

• Activity intolerance R/L decreased O2 supplyto the tissues of the body.

• Risk for infection


Desired out come– Control/eliminate symptoms– Attain normal lung function– Restore normal activities– Reduce/eliminate exacerbations and side effects

of meds

Desired out come– Control/eliminate symptoms– Attain normal lung function– Restore normal activities– Reduce/eliminate exacerbations and side effects

of meds


• Mild intermittent and mild persistent– Avoid triggers of acute attacks– Premedicate before exercising

• Acute episode– Medications for daily control including names,

dosages, and frequencies– O2 should be started and monitored with pulse

oximetry or ABGs– Metered dose inhaler (MDI) with ß-adrenergic

agonists, and antiinflamatory

• Mild intermittent and mild persistent– Avoid triggers of acute attacks– Premedicate before exercising

• Acute episode– Medications for daily control including names,

dosages, and frequencies– O2 should be started and monitored with pulse

oximetry or ABGs– Metered dose inhaler (MDI) with ß-adrenergic

agonists, and antiinflamatory


• Asthma Education• Cognitive Behavioral Therapy (New research)

– Relaxation Exercises

• Asthma Education• Cognitive Behavioral Therapy (New research)

– Relaxation Exercises


References• Porter, P. A & Perry, A. G. (2003). Basic

Nursing: Essentials for practice (5th ed.) St.Louis: Mosby.

• Erb, G. K., (2000). Fundamentals of Nursing:Concept, process and practice (5th ed.).Addison: Wesley.

• Bruner, L.S., & Suddarth, D.S. (2001). Textbook of Medical-Surgical Nursing (9th Ed.).Philadelphia: Lippincott.

• Porter, P. A & Perry, A. G. (2003). BasicNursing: Essentials for practice (5th ed.) St.Louis: Mosby.

• Erb, G. K., (2000). Fundamentals of Nursing:Concept, process and practice (5th ed.).Addison: Wesley.

• Bruner, L.S., & Suddarth, D.S. (2001). Textbook of Medical-Surgical Nursing (9th Ed.).Philadelphia: Lippincott.


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Advanced Concept of Nursing- II