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Nursing Management of Nursing Management of Clients with Stressors Clients with Stressors of Respiratory Function of Respiratory Function Chronic Airflow Limitation Chronic Airflow Limitation (CAL) (CAL) Pneumonia Pneumonia Tuberculosis Tuberculosis NUR133 Lecture #5 K. Burger, MSEd, MSN, RN, CNE

Nursing Management of Clients with Stressors of Respiratory Function Chronic Airflow Limitation (CAL) Pneumonia Tuberculosis NUR133 Lecture #5 K. Burger,

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Nursing Management of Clients Nursing Management of Clients with Stressors of Respiratory with Stressors of Respiratory

FunctionFunctionChronic Airflow Limitation (CAL)Chronic Airflow Limitation (CAL)

PneumoniaPneumoniaTuberculosisTuberculosis

NUR133 Lecture #5K. Burger, MSEd, MSN, RN, CNE

Chronic Airflow Limitation (CAL)Chronic Airflow Limitation (CAL)

Term used for Chronic lung diseases:Term used for Chronic lung diseases:

   - - EmphysemaEmphysema

- Chronic Bronchitis- Chronic Bronchitis

- Bronchial Asthma- Bronchial Asthma

  

COPDCOPDChronic Obstructive Pulmonary DiseaseChronic Obstructive Pulmonary Disease

EmphysemaEmphysema Chronic BronchitisChronic Bronchitis

Bronchospasm, dyspneaBronchospasm, dyspnea

Non-reversible and progressiveNon-reversible and progressive

Continously symptomaticContinously symptomatic

AsthmaAsthma

Reversible airflow obstruction d/t:Reversible airflow obstruction d/t:

InflammationInflammationAirway hyperresponsivenessAirway hyperresponsiveness

Hyperresponsiveness leading to bronchospasmsHyperresponsiveness leading to bronchospasms

AsthmaAsthma

- stimulus or allergen- chemical mediators stimulus or allergen- chemical mediators released. Within minutes:released. Within minutes:

DyspneaDyspnea

WheezingWheezing

CoughCough

Mucus productionMucus production

Inflammatory processInflammatory process

TRIGGERAllergen binds to IgE

Release of inflammatory chemicals

WBCs come to the area

WBCs release Mediators whichproduce more inflammation

Blood vessel dilation/ Capillary leakTissue swelling / Increased secretion

AsthmaAsthma

Common agents or stimuli:Common agents or stimuli:

-fog, smog, smoke-fog, smog, smoke

-odors, aerosols-odors, aerosols

-exercise-exercise

-cold air-cold air Allergens- dust mites, animal dander, pollen, Allergens- dust mites, animal dander, pollen,

cockroaches, foods, medicines.cockroaches, foods, medicines.

AsthmaAsthma FOCUSED Respiratory assessmentFOCUSED Respiratory assessment

1. 1. ExpiratoryExpiratory and Inspiratory wheezing and Inspiratory wheezing 2. Dry or moist cough2. Dry or moist cough3. Dyspnea, signs of hypoxemia, 3. Dyspnea, signs of hypoxemia,

anxietyanxiety4. increased HR, BP, RR4. increased HR, BP, RR5. Diaphoresis, Pallor5. Diaphoresis, Pallor6. Cyanosis6. Cyanosis7. Nasal flaring 7. Nasal flaring 8. Use of accessory muscles8. Use of accessory muscles

AsthmaAsthma

Diagnostic AssessmentDiagnostic Assessment ABGs / PO2 low, PCO2 high, PH lowABGs / PO2 low, PCO2 high, PH low SaO2 lowSaO2 low Eosinophils / serum and sputumEosinophils / serum and sputum PFTs / FEV and PERFPFTs / FEV and PERF CXRCXR

Asthma Asthma

STEP SYSTEM

MILD INTERMITTENT

MILD PERSISTENT

MODERATE PERSISTENT

SEVERE PERSISTENT

Complications of AsthmaComplications of Asthma

- Respiratory infections- Respiratory infections

- Status Asthmaticus- Status Asthmaticus

- pneumothorax- pneumothorax

- respiratory arrest- respiratory arrest

- cardiac arrest - cardiac arrest

AsthmaAsthma

Nursing DiagnosesNursing Diagnoses1. 1. Impaired Gas ExchangeImpaired Gas Exchange related to related to alveolar alveolar membrane changes, airflow membrane changes, airflow limitation, respiratory muscle fatigue, limitation, respiratory muscle fatigue, excess production of mucus.excess production of mucus.2. 2. Ineffective Breathing patternIneffective Breathing pattern related related

to to airflow obstruction (narrowed airways), airflow obstruction (narrowed airways), and fatigue.and fatigue.3. 3. Ineffective Airway ClearanceIneffective Airway Clearance related related

to to excessive secretions, fatigue and excessive secretions, fatigue and ineffective cough.ineffective cough.

Asthma InterventionsAsthma Interventions

Client EducationClient Education

A. Identify causesA. Identify causesB. Proper environmental changesB. Proper environmental changes

C. Stress management, rest, and sleepC. Stress management, rest, and sleepD. Correct use of inhalersD. Correct use of inhalersE. Correct use of peak flow meter and step wise E. Correct use of peak flow meter and step wise

approach to med managementapproach to med managementF. What to do if an attack occursF. What to do if an attack occurs

AsthmaAsthma

– How to use a METERED DOSE inhaler (without How to use a METERED DOSE inhaler (without spacer) correctly:spacer) correctly:

1. Shake inhaler1. Shake inhaler

2. Tilt head back, breathe out fully2. Tilt head back, breathe out fully

3. Open mouth, mouthpiece 1-2” away 3. Open mouth, mouthpiece 1-2” away

4. As you begin to breathe in deeply, press down and 4. As you begin to breathe in deeply, press down and release medicine.release medicine.

5. Breathe in deeply and slowly for 3-5 sec.5. Breathe in deeply and slowly for 3-5 sec.

6. Hold your breathe for 10 sec6. Hold your breathe for 10 sec

7. Breathe out slowly7. Breathe out slowly

AsthmaAsthmaDrug TherapyDrug Therapy

BronchodilatorBronchodilator

Beta agonists Beta agonists short-acting short-acting long-actinglong-acting

Anti-cholinergicsAnti-cholinergics MethylxanthinesMethylxanthines

Anti-inflammatoryAnti-inflammatory

Corticosteroids Corticosteroids Anti-leukotrieneAnti-leukotriene Mast cell stabilizersMast cell stabilizers Monoclonal antibodiesMonoclonal antibodies Inhaled agentsInhaled agents

AsthmaAsthma

Pharmacologic stepped approach to treating Pharmacologic stepped approach to treating asthma symptomsasthma symptoms

Step 1- mild intermittent- beta 2 agonistStep 1- mild intermittent- beta 2 agonist Step 2.- mild persistent – add cromolyn Step 2.- mild persistent – add cromolyn Step 3.- moderate persistent- add inhaled Step 3.- moderate persistent- add inhaled

corticosteroid , may add theophylline.corticosteroid , may add theophylline. Step 4.- Severe persistent- add po steroidsStep 4.- Severe persistent- add po steroids

Chronic Obstructive Pulmonary DiseaseChronic Obstructive Pulmonary Disease

EMPHYSEMA EMPHYSEMA

Loss of lung elasticityLoss of lung elasticity Hyperinflation of lungs / air trappingHyperinflation of lungs / air trapping Diaphragm flatteningDiaphragm flattening Increased airflow resistanceIncreased airflow resistance Ineffective gas exchangeIneffective gas exchange Retained CO2 (hypercapnia) Retained CO2 (hypercapnia) Chronic respiratory acidosisChronic respiratory acidosis

Chronic Obstructive Pulmonary DiseaseChronic Obstructive Pulmonary Disease

CHRONIC BRONCHITISCHRONIC BRONCHITIS Chronic inflammation of airwaysChronic inflammation of airways Mucosol edemaMucosol edema Increased # of mucous glandsIncreased # of mucous glands Bronchial wall thickeningBronchial wall thickening Impaired airflow AND gas exchangeImpaired airflow AND gas exchange Hypoxemia, hypercapnia, respiratory acidosisHypoxemia, hypercapnia, respiratory acidosis

COPDCOPD FOCUSED assessmentFOCUSED assessment

1. Rapid, shallow respirations & dyspnea1. Rapid, shallow respirations & dyspnea 2. Irregular breathing patterns2. Irregular breathing patterns

3. Moist cough3. Moist cough4. Limited diaphragmatic excursion4. Limited diaphragmatic excursion5. Decreased fremitus5. Decreased fremitus6. Hyperresonant percussion6. Hyperresonant percussion7. Crackles 7. Crackles 8. Barrel chest8. Barrel chest9. Cyanosis9. Cyanosis

10.Clubbing10.Clubbing 11.Orthopneic posturing11.Orthopneic posturing

COPD COPD

DIAGNOSTIC ASSESSMENTDIAGNOSTIC ASSESSMENT

ABGsABGs SaO2SaO2 CXRCXR PFTPFT Serum AATSerum AAT ECGECG H&H, Electrolytes, WBCH&H, Electrolytes, WBC

Complications of COPDComplications of COPD

Respiratory infectionRespiratory infection Cor pulmonaleCor pulmonale Cardiac dysrhythmiasCardiac dysrhythmias

Nursing Diagnoses for COPDNursing Diagnoses for COPD

Impaired gas exchangeImpaired gas exchange Ineffective breathing patternIneffective breathing pattern Ineffective airway clearanceIneffective airway clearance Activity intoleranceActivity intolerance

Interventions for COPDInterventions for COPD

Airway maintenanceAirway maintenance Cough enhancementCough enhancement Oxygen therapyOxygen therapy Energy conservationEnergy conservation Drug therapyDrug therapy Surgical interventionsSurgical interventions

COPD Drug TherapyCOPD Drug Therapy

BronchodilatorsBronchodilators Anti-Inflammatory drugsAnti-Inflammatory drugs Inhalants AND systemic drugsInhalants AND systemic drugs

PLUS MucolyticsPLUS Mucolytics

PneumoniaPneumonia

Community acquired pneumonia (CAP)Community acquired pneumonia (CAP) VersusVersus Nosocomial pneumoniaNosocomial pneumonia

Higher incidence in:Higher incidence in:Elderly, immunocompromised, CAL, Elderly, immunocompromised, CAL, mechanically vented, chronically illmechanically vented, chronically ill

55thth leading cause of death in US leading cause of death in US

PneumoniaPneumoniaAssessmentAssessment

Chest pain, dyspnea, tachypnea, SOBChest pain, dyspnea, tachypnea, SOB Cough & hemoptysisCough & hemoptysis Crackles & wheezesCrackles & wheezes Tactile fremitus Tactile fremitus Percussion Percussion Fever and chillsFever and chills HypoxemiaHypoxemia

PneumoniaPneumoniaNursing DiagnosesNursing Diagnoses

Impaired gas exchangeImpaired gas exchange

Ineffective airway clearanceIneffective airway clearance

Potential for sepsisPotential for sepsis

Acute painAcute pain

PneumoniaPneumoniaInterventionsInterventions

C&DB q2h/ incentive spiro C&DB q2h/ incentive spiro O2 therapy / Positioning HOB elevatedO2 therapy / Positioning HOB elevated Maintain hydrationMaintain hydration Medications: bronchodilators, expectorants, Medications: bronchodilators, expectorants,

antibioticsantibiotics Client teaching: completion of med rx, Client teaching: completion of med rx,

influenza and pneumococcal vaccinnationsinfluenza and pneumococcal vaccinnations

TuberculosisTuberculosis

Causative organism: Causative organism: Mycobacterium tuberculosisMycobacterium tuberculosis

Incidence increasing worldwideIncidence increasing worldwide Highest prevalence: immunocompromised, Highest prevalence: immunocompromised,

people living in crowded and or poor living people living in crowded and or poor living conditionsconditions

ExposureExposure versus versus infectioninfection versus versus activeactive

TuberculosisTuberculosisAssessmentAssessment

Persistent, productive coughPersistent, productive cough HemoptysisHemoptysis Fever and night sweatsFever and night sweats Fatigue Fatigue AnorexiaAnorexia Weight lossWeight loss Progressive and persistent S & SProgressive and persistent S & S

TuberculosisTuberculosisDiagnostic AssessmentDiagnostic Assessment

Purified Protein Derivative PPDPurified Protein Derivative PPD Positive = 10mm induration or > generalPositive = 10mm induration or > general 5mm induration or > Hx HIV5mm induration or > Hx HIV CXRCXR Sputum for acid-fast bacillus AFBSputum for acid-fast bacillus AFB Sputum culture; BACTECSputum culture; BACTEC PCR assayPCR assay NEW: Quantiferon TB Gold Test QFT-GNEW: Quantiferon TB Gold Test QFT-G

TuberculosisTuberculosisNursing DiagnosesNursing Diagnoses

Impaired gas exchangeImpaired gas exchange Ineffective airway clearanceIneffective airway clearance FatigueFatigue

Deficient knowledgeDeficient knowledge Ineffective therapeutic regimen maintenanceIneffective therapeutic regimen maintenance

TuberculosisTuberculosisInterventionsInterventions

Combination drug therapyCombination drug therapyIsoniazid (INH)Isoniazid (INH)Rifampin (RIF)Rifampin (RIF)

PlusPlusPyrazinamide (PZA)Pyrazinamide (PZA)Ethambutol or StreptomycinEthambutol or Streptomycin

RIFATAR = NEW med combo of INH, RIF, & PZARIFATAR = NEW med combo of INH, RIF, & PZA LONG TERM THERAPY!!!!!LONG TERM THERAPY!!!!!

6-12 months duration6-12 months duration CLIENT EDUCATION!!!!!CLIENT EDUCATION!!!!!