Lewis - Ch 29 - Obstructive Pulmonary Diseases: Nursing Management

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What is Obstructive Pulmonary Disease?

The most common chronic lung disease, includes diseased characterized by increased resistance to airflow as a result of airway obstruction or airway narrowing.

What are the types of Obstructive Pulmonary Disease?

Asthma, COPD, cystic fibrosis, and bronchiectasis.

What is Asthma?

Is a chronic inflammatory lung disease that results in variable episodes of airflow obstruction, but is usually reversible.

What does chronic inflammation in Asthma lead too?

Recurrent episodes of wheezing, breathlessness, chest tightness, cough, particularly at night or in the early morning.

What are the risk factors of Asthma?

Related to the patient (e.g., genetic factors), or the environment. Obesity as well, and gender.

What are the gender differences for males with Asthma?

Male gender is a risk factor for asthma in children, but not adults for unclear reasons. Before puberty males are more affected.

What are the gender differences for females with Asthma?

After puberty and into adulthood, women are more affected then men. Women who are admitted to the ER are more likely to need hospitalization. Death rates in women are greater then men.

What are the cultural and ethnic health disparities in regards to Asthma with African Americans?

Higher prevelance rates over 38%, females have the highest mortality rate.

What are the cultural and ethnic health disparities in regards to Obstructive Pulmonary Diseases with Whites?

Highest incidence of COPD, highest incidence of Cystic Fibrosis.

What are the cultural and ethnic health disparities in regards to Obstructive Pulmonary Diseases with Puerto Ricans?

Higher asthma prevalence rates and age adjusted death rates than all other racial and ethnic subgroups.

What is the Genetic Risk factor with Asthma?

Asthma has a component that is inherited. Numerous genes are involved. Atopy the genetic predisposition to develop an allergic (IgE-mediated) response to common allergies, is a major risk factor.

What is the Immune Response Risk factor with Asthma?

Hygiene response hypothesis is thought to play a role in Asthma.

How do Allergies effect Asthma?

Indoor and outdoor allergens are well known to trigger asthma. House dust mites, cockroaches, furry animals, fungi and mold can trigger.

How does exercise effect Asthma?

Induced or exacerbated asthma. Occurs after vigorous exercise. Symptoms are pronounced during activities where there is exposure to cool, dry air.

How do air pollutants effect Asthma?

Cigarette or wood smoke, vehicle exhaust, elevated ozone levels, sulfur dioxide, and nitrogen dioxide can trigger an attack.

How does cigarette smoking effect Asthma?

Associated with an accelerated decline of lung function. Increases the severity of the disease, may cause patients to be less responsive to treatment with corticosteroids (systemic or inhaled), and reduces the chance of asthma being controlled.

What are occupational factors with Asthma?

Job-related exposures. Irritants cause a change in the responsiveness of the airways. Agricultural workers, painters, plastics manufacturing, and cleaning work are high risk. Arrive at work feeling well but experience gradual development of symptoms towards the end of the day.

How do Respiratory Infections effect Asthma?

Major precipitating factors in acute asthma attacks. RSV and rhinovirus are two factors in developing and increasing severity of Asthma. Cause an increase in hyperresponsiveness of the bronchial system.

How do nose and sinus problems effect Asthma?

Allergic rhinitis is a major predictor. Treatment of allergic rhinitis may reduce frequency of exacerbation. Chronic sinus problems can cause inflammation of the mucus membranes.

What is the Asthma Triad?

Nasal polyps, asthma, and sensitivity to aspirin and NSAIDS.

What happens when some asthmatics take aspirin or NSAIDS?

Wheezing will develop within two hours. Usually rhinorrhea, congestion, and tearing occurs. Facial flushing, GI symptoms, and angioedema can occur.

How can B-Adrenergic Blockers PO or topical eyedrops effect Asthma?

May trigger asthma because of bronchospasms.

How can ACE inhibitors effect Asthma?

May produce cough in susceptible individuals, making symptoms worse.

How does tartrazine (yellow dye #5) and sulfating agents effect Asthma?

Used as preservatives and sanitizing agents. Commonly found in fruits, beer, and wine used extensively in salad to prevent oxidation. Can cause asthma exacerbation.

How does GERD effect Asthma?

Postulated that reflux of stomach acid into the esophagus can be aspirated into the lungs, causing relfex vagal stimulation and bronchoconstriction.

What are the Psychological Factors with Asthma?

Emotional stress, extreme emotions such as crying, laughing, anger and fear can lead to hyperventilation and hypocapnia, which can cause airway narrowing.

What is the Pathophysiology of Asthma?

Persistent but variable inflammation of the airway. Airflow is limited because of inflammation results in bronchoconstriction, airway hyperresponsiveness, and edema of the airways.

What are the inflammatory cells that are involved with Asthma?

Mast cells, macrophages, eosinophils, neutrophils, T and B lymphocytes, and epithelial cells of the airways.

How long does it take for someone to have an early phase response with Asthma?

30 - 60 minutes after exposure to allergen or irritant.

How long does it take for someone to have an late phase response with Asthma?

4 - 10 hours after initial attack because of eosinophil and lymphocyte activation and their release of more inflammatory mediators. Epithelial cells also produce cytokines and other inflammatory mediators.. Can persist for 24 hours or more.

What is the allergic asthma response?

Triggered when an allergen cross links IgE receptors on Mast cells, which are activated to release histamine and other inflammatory mediators (early-phase response). A late phase response may occur due to further inflammation.

What are the clinical manifestations of Asthma?

Wheezing, cough, dyspnea, chest tightness after exposure to a precipitating factor or trigger. Expiration may be prolonged. Expiratory ration may be prolonged to 1:3, or 1:4. Bronchospasm, edema, and mucus in the brochioles, narrowing.

What does examination of the person with Asthma reveal?

Hypoxemia, restlessness, increased anxiety, inappropriate behavior, increased pulse and blood pressure, and pulsus paradoxus (a drop in systolic during during the inspiratory cycle greater than 10 mm Hg). Difficulty speaking, increased RR (^30), use of accessory muscles. Hyperresonance on percussion, auscultating with wheezing. Silent chest indicates severe obstruction and impending respiratory failure.

How can Asthma be classified?

Intermittent, mild persistent, moderate persistent, or severe persistent.

What are the diagnostic studies for Asthma?

H & P, pulmonary function studies including response to bronchodilator therapy, peak expiratory flow rate (PEFR), chest x-ray, measure of oximetry, allergy skin test if indicated, blood level of eosinophil and IgE.

What is collaborative therapy for Asthma?

ID and avoidance/elimination triggers, patient and caregiver teaching, drug therapy, asthma action plan, desensitization, assess for control.

What does a severe of life-threatening asthma exacerbation indicate?

SaO2, ABGs, inhaled B2-adrenergic agonists, inhaled anticholinergic agents, )2 by mask or nasal prongs, IV or oral corticosteroids, IV fluids, IV magnesium or/and heliox, intubation or assisted ventilation.

What do ABG's reveal with a person with Asthma?

Normal between exacerbation, increase in pH in exacerbation, then decrease if prolonged or severe exacerbation, decrease in PaO2, decrease early in exacerbation of PaCO2 and increase if prolonged severe exacerbation.

What is a Chest x-ray reveal with Asthma?

Hyperinflation.

What do Pulmonary Function Tests reveal with Asthma?

Total lung capacity is increased, residual volume is increased, FEV1 decreased, FEV1/FVC normal to decreased.

What are the goals in collaborative care with Asthma?

To achieve and maintain control of the disease.

What anti-inflammatory drugs are used for Long term Control of Asthma?

Anti-inflammatory drugs such as corticosteroids: inhaled (e.g., fluticasone [Floventil]), Oral (e.g., Prednisone). Leukotriene modifiers (e.g., montelukast [Singular]), Anti-IgE (omalizumab [Xolair]).

What bronchodilators are used for Long Term Control of Asthma?

Long acting inhaled b2-adrenergic agonists (e.g., salmeterol [Serevent]), Long acting oral b2-adrenergic agonists (e.g., albuteral [VoSpire ER]). Methylxanthines (e.g., theophyline [Uniphyl]), and Anticholinergics (inhaled) (e.g., tiotropium [Spirival]).

What bronchodilators are used for Quick Relief of Asthma?

Short-acting inhaled b2-adrenergic agonists (e.g., albuterol [Proventil HFA]), Anticholinergics (inhaled) (e.g., ipratropium [Atrovent]).

What antiinflammatory drugs are used for Quick Relief of Asthma?

Corticosteroids (systemic) (e.g., prednisone) - considered quick-relief when used in a short burst 3-10 days at the start of therapy or during a period of gradual deterioration.

How do Corticosteroids effect Asthma?

Antiinflammatory medications that reduce bronchial hyperresponsiveness, block the late-phase reaction, and inhibit migration of inflammatory cells. More effective in improving asthma control then any other long term drug.

How do Leukotriene Modifiers effect Asthma?

Leukotriene receptor blockers (antagonists) and leukotriene synthesis inhibitors interfere with the synthesis or block the action of leukotrienes - inflammatory mediators produced from arachidionic acid metabolism.

How do Anti-IgE medications effect Asthma?

Prevents IgE from attaching to mast cells, thus preventing the release of the chemical mediators.

What are the three classes of Bronchodilators?

B2-adrenergic agonists, methylxanthines and derivatives, and anticholinergics.

How do B2-Adrenergic Agonists Drug effect Asthma?

Can be short acting or long acting. Act by stimulating b-adrenergic receptors in the bronchioles, thus producing bronchodilation. They also increase mucociliary clearance.

How do Methylxanthines effect Asthma?

Bronchodilator with mild antiinflammatory effects, but the exact mechanism is unknown.

What is the main problem with Methylxanthines Theophylline?

Relatively high incidence of interaction with other drugs and the occurrence of side effects, which include nausea, headache, insomnia, GI distress, tachcardia, dysrhythmias, and seizures.

How do anticholinergic drugs effect Asthma?

Block the bronchoconstricting influence of the parasympathetic nervous system. Less effective than b2-adrenergic agonists.

What is a Nursing Assessment with Asthma?

If the patient can speak and is not in acute distress, a detailed health history, including ID of any precipitating factors and what has helped alleviate attacks in the past can be taken. Subjective and objective data. Assess patients asthma control using one of the validated self-questionnaires.

What are Nursing Diagnosis for Asthma?

Ineffective Airway Clearance, Anxiety, Deficient Knowledge.

What objective data should you look at during a Nursing Assessment of a patient with Asthma in regards to the respiratory system?

Nasal discharge, polyps, swelling, wheezing crackles, diminished or absent breath sounds, rhonchi, hyperressonance, sputum, increase work of breathing, use of accessory muscles, intercostal and supraclavicular retractions, tachypnea with hyperventilation, prolonged expiration.

What objective data should you look at during a Nursing Assessment of a patient with Asthma in regards to the Cardiovascular system?

Tachycardia, pulsus paradoxus, JVD, hypertension, or hypotension, premature ventricular contractions.

What objective data should you look at during a Nursing Assessment of a patient with Asthma in regards to General data?

Restlessness or exhaustion, confusion, upright or foward leaning body position.

What objective data should you look at during a Nursing Assessment of a patient with Asthma in regards to the Integumentary System?

Diaphoresis, cyanosis (circumoral, nail bed), eczema.

What overall goals do you plan for the patient with Asthma?

1. minimal symptoms during the day and night. 2. acceptable activity levels. 3. maintenance of greater than 80% of personal best PEFR or FEV. 4. few or no adverse effects of therapy. 5. no recurrent exacerbations of asthma, and 6. adequate knowledge to participate in and carry out management.

What do you teach the patient about Asthma with Preventing Asthma Attacks or decreasing the severity?

Identify and avoid known personal triggers, and irritants. Use of special dust covers on mattresses and pillow. Washing bedclothes in hot water or cooler water with detergent and bleach. Avoidance of furred animals. Avoid cold air, dress properly with scares and use masks. Avoid NSAIDS and OTC drugs with asprin. Maintain fluid intake of 2 - 3 L q day, good nutrition and adequat rest.

What are life threatening complications of Asthma?

Status asthmaticus.

What is Status Asthmaticus?

An acute exacerbation of asthma that does not respond to standard treatments of bronchodilators and steroids.

What are symptoms of Status Asthmaticus?

Wheezing may be present, hypoxemia, hypercapnia.

What are complications of Status Asthmaticus?

Pneumothorax, pneumomediastinum, cor pulmonale, respiratory arrest.

What is Pneumomediastinum?

A condition where air is present in the mediastinum.

What is Cor Pulmonale?

Pulmonary heart disease is enlargement of the right ventricle of the heart as a response to increased resistance or high blood pressure in the lungs.

What should teaching of patient and caregiver of a patient with Asthma include?

Why use a peak flow meter, info on peak flow meter, what is asthma, what is good asthma control, hindrances to asthma treatment and control, environmental and triggers, medications, correct use of medications, breathing techniques, asthma action plan.

What is Chronic Obstructive Pulmonary Disease?

COPD - a preventable and treatable disease state characterized by chronic airflow limitations that is not fully reversible.

What are the two types of COPD?

Chronic bronchitis and Emphysema.

What is Chronic Bronchitis?

Presence of chronic productive cough for 3 month in each of 2 consecutive years in a patient in whom other causes of chronic cough have been excluded.

What is Emphysema?

An abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.

What are the gender differences for Men with COPD?

More common in men than in women, but trend for men is not increasing. Fewer men are dying from COPD then women.

What are the gender differences for Women with COPD?

Number of women with disease is increasing. Increase is probably due to increased number of women smoking cigarettes and increased susceptibility. Lower quality of life, more exacerbations, increased dyspnea, and better response to 02 therapy.

What are the signs of Emphysema?

Loss of lung elasticity, proteases break down elastin, hyperinflation o flungs, air trapped in lungs, poor gas exchange, loss of aveolar tissue.

What is Chronic Respiratory Acidosis?

A medical condition in which decreased respiration (hypoventilation) causes increased blood carbon dioxide and decreased pH (acidosis).

Where is the inflammation located with Chronic Bronchitis?

In the bronchi and bronchioles.

How does the inflammatory response to irritants affect Chronic Bronchitis?

Affects small and large airways, hinders airflow and gas exchange.

What is the etiology of COPD?

Smoking, AAT deficiency, occupational chemicals and dust, air pollution, infection, genetics, aging.

What are the complications of COPD?

Hypoxemia, acidosis, respiratory tract infections, cardiac problems - cardiac failure and dysrhythmias.

What are the clinical manifestations of COPD?

Dyspnea with exertion, every day. Late stages dyspnea maybe at rest. Wheezing and chest tightness, vary by time of day. Weight loss and anorexia. Prolonged expiratory phase, decreased breath sounds. Hypoxemia, hypercapnia, polycythemia and cyanosis.

What established the diagnosis of COPD?

Spirometry whether or not the patient has chronic symptoms. The FEV1/FEV less than 70% establishes and the severity of obstruction.

What are the diagnostic studies for COPD?

H & P, pulmonary function tests, chest x-rays, serum a1-antitrypsin levels, ABGs, 6 minute walk test.

What is collaborative therapy for COPD?

Cessation of smoking, treatment of exacerbations, bronchodilator therapy, corticosteroids, airway clearance techniques, breathing exercises and retraining, hydration of 3L qday, patient and caregiver teaching, influenza immunization yearly, pneumovax, longer term 02, progressive plan of exercise, pulmonary rehab program, nutritional supplement if low BMI, surgery.

What does a nursing assessment for a patient with COPD involve?

Subjective health information past health history and medications, functional health patterns, general objective data with integumentary, respiratory, cardiovascular, gastrointestinal, musculoskeletal and diagnostic findings.

What should the health history contain of a patient with COPD during an assessment?

Long term exposure to chemical pollution, respiratory irritants, occupation fumes, dust, recurrent respiratory infections, previous hospitalizations.

What general objective data do you look at during a nursing assessment with COPD?

Debilitation, restlessness, assumption of upright position.

What integumentary objective data do you look at during a nursing assessment with COPD?

Cyanosis (bronchitis), pallor or ruddy color, poor skin turgur, thin skin, digital clubbing, easy bruising, peripheral edema.

What respiratory objective data do you look at during a nursing assessment with COPD?

Rapid, shallow breathing, inability to speak, prolonged expiratory phase, pursed-lip breahting, wheezing, rhonchi, crackles, diminished or bronchial breath sounds, decreased chest excursion and diaphragm movement, use of accessory muscles, hyperresonant or dull chest sounds on percussion.

What cardiovascular objective data do you look at during a nursing assessment with COPD?

Tachycardia, dysrhythmias, JVD, distant heart tones, right sided S2 (cor pulmonale), edema (esp in feet).

What Gastrointestinal objective data do you look at during a nursing assessment with COPD?

Ascites, hepatomegaly (cor pulmonale).

What Musculoskeletal objective data do you look at during a nursing assessment with COPD?

Muscule atrophy, increased anterior-posterior diameter (barrel chest).

What Possible Diagnostic findings do you look with a patient with COPD?

Abnormal ABGs (compensated respiratory acidosis), decreased PaO2 and SaO2, increased PaCO2, polycythemia, pulmonary function tests showing expiratory airflow obstruction (low FEV1, low FEV1/FVC, large RV), chest x ray showing flattened diaphragm and hyperinflation or infiltrates.

What are the main aspects of the psychosocial assessment with COPD?

Smoking (pack years), anxiety, depression.

What are diagnosis with COPD?

Ineffective breathing patterns, ineffective breathing clearance.

What are nursing goals with planning of a patient with COPD?

1. prevention of disease progression. 2. ability to perform ADLs and improved exercise tolerance. 3. relief of symptoms. 4. no complications related to COPD. 5. knowledge and ability to implement a long-term treatment regimen, and 6. overall improved quality of life.

What are the teaching subjects for the patient and caregiver with COPD?

Overall guide, what is COPD, breathing and airway clearance exercises, energy conservation techniques, medications, correct use of medications, psychosocial/emotional issues, management plan, health nutrition.

What are the surgical options for a patient with COPD?

LVRS, Lung transplantation.

What is LVRS?

Lung volume reduction surgery. Reduce the size of the lungs by removing the most disease lung tissue so the remaining healthy lung tissue can perform better.

What is the benefits of a Lung Transplant?

For carefully selected patients with advanced COPD. Single-lung transplant is most commonly used technique because of shortage of donors, bilateral transplantation can be performed.

What are the obstacles of lung transplant?

Organ rejection, effects of immunosuppressive therapy, and the high cost of surgery.

What are the different breahting techniques for COPD?

Pursed lip breathing, positioning, energy conservation.

What is the purpose of Pursed-Lip Breathing?

Prolongs exhalation and thereby prevent bronchiolar collapse and air trapping.

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