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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
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!!!!!