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HESI- Med Surg - Chronic Airflow Limitation (CAL)
Terms in this set (13)
Chronic Airflow Limitation (CAL): Description
Chronic lung disease includes chronic bronchitis, pulmonary emphysema, and asthma
What is COPD characterized by?
Emphysema and chronic bronchitis, termed chronic obstructive pulmonary disease (COPD), are characterized by bronchospasm and dyspnea. The damage to the lung is not reversible and increases in severity
Asthma, unlike COPD, is an intermittent disease with reversible airflow obstruction and wheezing
CAL: Nursing Assessment
- changes in breathing pattern (increase in rate with a decrease in depth)
- Overinflation of the lungs causes the rib cage to remain partially expanded (barrel chest)
- Generalized cyanosis of lips, mucous membranes, face, nail beds ("blue bloater")
- Cough (dry or productive)
- Higher CO2 than average
-Low O2 as determined by pulse oximetry (<90% to 92%)
- Decreased breath sounds
-Coarse crackles in lung fields that tend to disappear after coughing, wheezing
- Poor nutrition, weight loss
- Activity intolerance
- Anxiety concerning breathing manifested by: Anger, Fear of being alone, Fear of not being able to catch breath.
What can you do to facilitate a productive cough ?
Productive cough and comfort can be facilitated by semi-Fowler or high-Fowler position, which lessens pressure on the diaphragm by abdominal organs. Gastric distention becomes a problem in these clients because it elevates the diaphragm and inhibits full lung expansion.
Overinflation of the lungs
Overinflation of the lungs causes the rib cage to remain partially expanded, giving the characteristic appearance of a barrel chest. The person works harder to breathe, but the amount of O2 taken in is not adequate to oxygenate the tissues.
Insufficient oxygenation occurs with chronic bronchitis and leas to generalized cyanosis and often right-sided heart failure (HF; known as cor pulmonale)
Inadequate arterial oxygenation
Cells of the body depend on O2 to carry out their functions. Inadequate arterial oxygenation is manifested by cyanosis and slow capillary refill (<3seconds). A chronic sign is clubbing of the fingernails, and a late sign is clubbing of the fingers.
CAL: Nursing Plans and Interventions
- Teach the client to sit upright and bend slightly forward to promote breathing (Tripod position)
- Teach diaphragmatic and pursed lip breathing. Teach prolonged expiratory phase to prevent bronchiolar collapse and prevent air trapping.
- Administer O2 at 1 to 2 L per nasal cannula
- Pace activities to conserve energy
-Maintain adequate dietary intake: small, frequent meals, increase calories and protein but do not overfeed, Favorite foods, dietary supplements (Vitamin D necessary for smokers, COPD needs Magnesium and calcium, BMD needs monitoring of magnesium and phophorus levels)
- Provide an adequate fluid intake (minimum 3L a day) unless contraindicated
- Fluids should be taken between meals to prevent excess stomach distention and to decrease pressure on the diaphragm
-Instruct client in relaxation techniques (teach when not in distress)
- Teach prevention of secondary infections
- Teach about medication regimen
-Smoking cessation is imperative
-Encourage health-promoting activities
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