Care of Patients with Chronic Airflow Limitations

Question 1

Not used lot in clinical prac
Group of chronic lung diseases
Prevalent in US and around world
Affects 40 million Americans
1 million people disabled secondary to CAL - disability causes; not only death from disease processes but how impairs their func; that when think about it because so much moved to community and pub health and these diseases have huge impact on healthcare as whole society

Answer 1

Chronic airflow limitation (CAL)

Question 2

Asthma -
Chronic Obstructive Pulmonary Disease (COPD) -

Answer 2

Group of chronic lung diseases

Question 3

chronic airflow limitation disease; restrictive/obstructive lung disease

Answer 3

Asthma -

Question 4

encompasses:
Chronic Bronchitis - very diff from acute bronchitis (acute inflammation of bronchial tubes secondary to URI); this is chronic and causes change in airways and not go away
Emphysema

Answer 4

Chronic Obstructive Pulmonary Disease (COPD)

Question 5

Causes:
History
Symptoms/Assessment
Diagnostic:
Treatment/Nursing Care

Answer 5

Asthma

Question 6

body/lungs are hyperresponding to something; something offensive to airways and triggers the response: constriction of bronchial (constricts muscles around the airways) and causes inflammation within airways in mucous membrane area - both make airways narrow; not able to move air into airways because constricted; causes air trapping and difficulty getting air out
Inflammation and hyperresponsiveness of airways to common stimuli
Inflammation in the mucous membranes and hyper responsiveness constricts the bronchial smooth muscle (bronchospasm)
Intermittent if well controlled to severe; depend on management of pat and how severe it is
Triggers: - big thing with this; everyone has diff ones; identify what are and how manage by identify and avoid or premed; not all same; talk identify triggers and interventions so avoid issues when exposed

Answer 6

Causes:

Question 7

Allergens
Cold air/ Poor air quality - pollution
Exercise
Respiratory illness/ URI
Smoke
General irritants
Microorganisms - bacteria/virus
GERD - reflux of gastric acid reflux into airway and further irritate bronchial tubes
Strong odors - not allow perfumes
Dust
Bugs - cockroaches - release items into air that exacerbate s/s

Answer 7

Triggers: - big thing with this; everyone has diff ones; identify what are and how manage by identify and avoid or premed; not all same; talk identify triggers and interventions so avoid issues when exposed

Question 8

Imp get good one
Family history; Smoking; Triggers; Frequency

Answer 8

History

Question 9

Dyspnea - SOB
Chest tightness - very common
Coughing - very common
Hypoxemia/Cyanosis - hypoxia; severe enough experience cyanosis
Low O2 sats
Tachypnea
Use of accessory muscles - any time has SOB = way get more air in and expelling more air
Retractions (suprasternal notch (bottom of neck - severe issues skin sucking in there) and intercostal spaces - sucking between ribs) - classic asthma signs
Lungs wheezing throughout - classic asthma signs; big sign with it because narrowing in airway and when air passes through there makes wheezing sound
Long breathing cycle (prolonged/extended exhalation period)
Barrel chest (with long standing, severe asthma) - long standing chronic lung disease; related to prolonged time with not fully exhaling and increased RV in lungs
Interventions targeted to relieve symp and helps understand interventions and meds used because reversing symp

Answer 9

Symptoms/Assessment

Question 10

Arterial blood gas (ABG)
Pulmonary function tests (PFT)

Answer 10

Diagnostic:

Question 11

Imp to Assess for hypoxemia or acidosis
See for all resp issues to assess for hypoxemia

Answer 11

Arterial blood gas (ABG)

Question 12

With asthma and restrictive lung diseases do this; done in resp dept; typ outpat; not want do in acute exacerbation; prefer do it as baseline to see norm
Able measure volume of air/speed of exhalation - measuring that
Forced vital capacity (FVC)
Forced expiratory volume (FEV1)
Peak expiratory flow (PEF)
Inflammation within airway and bronchoconstriction with smooth muscles on outside airway are reduced if having issues

Answer 12

Pulmonary function tests (PFT)

Question 13

Volume of air exhaled from full inhalation to full exhalation
How much air able fully inhale and fully exhale - shows how airways doing because if airways narrowed/obstructed going to have decreases in it

Answer 13

Forced vital capacity (FVC)

Question 14

Volume of air blown out as hard and fast as possible during the first second of the most forceful exhalation after the greatest inhalation
Take deepest breath in can and blow out as hard and fast as can and FEV in 1st sec tells how efficiently are with exhaling and getting all air out

Answer 14

Forced expiratory volume (FEV1)

Question 15

Fastest airflow rate reached at any time during exhalation
How fast can exhale

Answer 15

Peak expiratory flow (PEF)

Question 16

Big Goal: long term inpat and outpat control and/or prevent episodes - prevent when having episodes going to emergency sit, improve airflow in and out, relieve symptoms
Medications
Avoidance of Triggers
Inhalers/Nebulizers
Oxygen therapy

Answer 16

Treatment/Nursing Care

Question 17

Huge
Avoid triggers but also need meds
For resp diseases can Can be inhaled or systemic - pill: inpat: IV/IM - typ corticosteroid
Preventive therapy (controller drugs)
Rescue drugs
Educate importance of timing of preventative and rescue medications
Bronchodilators
Anti-inflammatory agents

Answer 17

Medications

Question 18

Want prevent from having episodes
Depending how severe asthma is and how extra responsive their airways are they may need to be on something every single day to decrease hyperresponsiveness of airway
Change airway responsiveness to prevent asthma attacks
Used every day, regardless of symptoms or having an asthma attack
Steroids (work as an anti-inflammatory within airway) - usually inhaled or long-acting bronchodilators (relaxes smooth muscle around bronchioles); opens airways and reduces symptom and improves items for pats
Usually inhaled or long-acting bronchodilators - take bronchodilator first before take steroid

Answer 18

Preventive therapy (controller drugs)

Question 19

Stop attack once it has started
Take when having acute onset of SOB or retractions or wheezing or increased coughing
short-acting bronchodilators - albuterol, MDI, nebulizer; need be aware so pats are aware; imp when educate to talk about timing

Answer 19

Rescue drugs

Question 20

One classes
Most common: albuterol - short-acting beta2 agonists; salmoterol - long-acting beta2 agonists
Short- and long-acting beta2 agonists - also cause severe increase in HR
Cholinergic antagonists: atrovent; seen often with albuterol; both bronchodilator response; without side effect of increase in HR
Methylxanthines - pnofelane - decfrease inflammation and bronchodilating
Short acting are “rescue drugs”

Answer 20

Bronchodilators

Question 21

One classes
Corticosteroids - biggest ones; inhaled ones: flovent; Prednisone - PO; Give IV - methylprednisone
NSAIDs - sometimes used but not used often
Leukotriene antagonists - blocks Leukotriene receptor and prevents inflammation
Immunomodulators - prevents inflammation: depresses immune sys because part inflammatory response
Inhaled corticosteroids are “preventative drugs” - controlling meds

Answer 21

Anti-inflammatory agents

Question 22

Big one - either avoiding all together or take med prior
Education to avoid triggers, pre medicate prior to or medicate after exposure
Review asthma action plan and peak flow - primarily in peds but sometimes in adult; identify triggers, s/s when worsening and put together a plan

Answer 22

Avoidance of Triggers

Question 23

Green - baseline, yellow - starting have issues and red - need go see HCP - zones; want catch before go in red zone
Peak flow

Answer 23

Review asthma action plan and peak flow - primarily in peds but sometimes in adult; identify triggers, s/s when worsening and put together a plan

Question 24

Right peak flow monitor - something pats can do at home: measuring exhalation - get baseline when feeling well and take deep breath in and blow out as hard and fast as can and moves bubble item in device and mark baseline; if notice going down go into yellow zone

Answer 24

Peak flow

Question 25

Teach proper use to pats
Nebulizers - use liquid bronchodilators/steroids; at home; acute care
Lot diff inhalers - pills, discs; not know how use it teach self before go teach pat
Use of spacer for meter dose inhalers - spacers: used for ped/older pats and trouble for MDI but always use for pats when using a MDI - allows get full dose of med; not want go in mouth because goes to throat and a lot going down esophagus and not in airway; if no spacer just hold outside of mouth when use it

Answer 25

Inhalers/Nebulizers

Question 26

If hypoxia is present
For acute asthma attack/status asthmaticus
Supplement with O2

Answer 26

Oxygen therapy

Question 27

Emergency of pat with asthma
Need be hospitalized
Severe and can be life-threatening
Treatment
Emergency situation
Prepare for emergency intubation because often times need to be because airway so obstructed and shut down cannot ventilate at all and need to intubate
Can develop pneumothorax and cardiac/respiratory arrest - related to needing intubation
Absence of wheezing can indicate complete airway obstruction - Severe enough and hear no air movement - worse than wheezing

Answer 27

Status asthmaticus

Question 28

Oxygen, IV fluids, give a potent systemic bronchodilators, give continuous bronchodilator nebulizer treatments, IV steroids in large doses, sometimes give epinephrine to open airway as quickly as can

Answer 28

Treatment

Question 29

3rd leading cause of mortality in US - huge impacts on societal health in gen
Causes - Chronic Bronchitis
Causes - Emphysema
Assessment/Symptoms - COPD pat look like
Diagnostic
Treatment/Nursing Care
Sig Complications

Answer 29

COPD

Question 30

Chronic exposure to irritants, commonly cigarette smoking, pollutants
Causes severe inflammation in inner part of airway, congestion, mucosal edema and bronchospasm; classic is tons congestion and secretions and bronchospasm related to that
Only affects are in the airways/bronchial tubes, not alveoli
Production of large amounts of thick mucus in addition to the inflammation

Answer 30

Causes - Chronic Bronchitis

Question 31

Chronic exposure to irritants cause damage to the alveoli and small airways - most common irritant is cigarette smoking
Emphysema damages alveoli and smaller airways
Air trapping occurs as alveoli lose elasticity and are destroyed and small airways collapse; lining alveoli lose elasticity: cannot get rid air as well as normally done - lose elastic recoil; walls collapse so not have good round bunches for SA for gas exchange have big mush - less SA for gas exchange so less gas exchange is occurring - alveoli where have gas exchange; lose functionality of alveoli lose functionality of gas exchange process; less elasticity and SA
Loss of surface area for gas exchange
Loss of lung elasticity and hyperinflation of lung - less elasticity leads to hyperinflation of the lungs - happens when lose elastic recoil not as much air expelled out of the lungs and have increased RV - not want left over air in lungs so lungs hyperinflate and cause barrel chest; AP diameter increases and more circle chest instead norm where transverse wider
Abnormal excretion of proteases, an enzyme that breaks down the elastin in the alveoli - breakdown of SA is excretion of proteases - breaks down walls and elastin

Answer 31

Causes - Emphysema

Question 32

Can be caused by chronic smoking or other irritant to the airways
Can be caused by an alpha anti-trypsin deficiency (genetics)

Answer 32

Abnormal excretion of proteases, an enzyme that breaks down the elastin in the alveoli - breakdown of SA is excretion of proteases - breaks down walls and elastin

Question 33

Do Blood test can be done to evaluate for this deficiency
Can break down elastin in the walls

Answer 33

Can be caused by an alpha anti-trypsin deficiency (genetics)

Question 34

Dyspnea - SOB
Orthopnea - SOB when laying flat - want sit up even when sleeping
Cough with sputum production - sputum production very much so with chronic bronchitis but not so much with emphysema
Use of accessory muscles - esp when SOB
Hypoxemia
Chronic acidosis - lost SA (decreases amount gas exchange occurring so increased CO2 levels which is an acid causes acidosis) and lack elastin - high levels CO2 causes acidosis and body starts to compensate and pH in pats is norm even with abnorm CO2
Weight loss - esp with COPD pat; any pat with severe resp disease has weight loss because metabolism using all energy to breathe and not able to take in as much and increased metabolism
Fatigue - very much so and sig for pats
Barrel chest (caused by hyperinflation of lungs also causes flat diaphragm - cannot go up to norm position where curved)
Cyanosis - sig if significantly hypoxemic
Clubbing of fingers - chronic hypoxia
ANXIETY

Answer 34

Assessment/Symptoms - COPD pat look like

Question 35

Arterial blood gas (ABG)
Sputum sample
Complete blood count (CBC)
Chest x-ray (CXR) - common
Chest computed tomography (CT)
Pulmonary function tests (PFT)

Answer 35

Diagnostic

Question 36

Assess for hypoxemia and acidosis
Common in these types of pats

Answer 36

Arterial blood gas (ABG)

Question 37

Higher risk for exacerbation of COPD higher risk for infection so always get sputum sample to make sure no active infections

Answer 37

Sputum sample

Question 38

Sometimes higher Hgb for compensatory mechanism - not as much O2 increase RBC production to compensate for it

Answer 38

Complete blood count (CBC)

Question 39

FEV1 look at for COPD pat to see how disease is progressing because see decline

Answer 39

Pulmonary function tests (PFT)

Question 40

Goal: Attain or maintain best gas exchange within the patient’s baseline and control/manage symptoms
Oxygen therapy
Positioning
Smoking cessation -
Energy conservation -
Breathing exercises
Nutritional counseling -
Chest physiotherapy (CPT)
Lung volume reduction surgery -
Medications

Answer 40

Treatment/Nursing Care

Question 41

Keep O2 saturation 88-90% - COPD pat goals lower
Big reason sats low Hypoxic vasoconstriction with emphysema pat - all damaged in alveoli - low O2 levels happens in blood vessels feed area lung constrict so not as much area going to damaged area lung and most going to healthy area lung so if increase O2 lose protective vasoconstriction
Diff in pats with COPD if have CO2 retention - drive to breathe and chronic levels of CO2 is switched to O2 levels so if O2 level decrease stims to breathe
Why keep O2 lower

Answer 41

Oxygen therapy

Question 42

Elevate head of bed - severe orthopnea so keep HOB up; not lay flat; barely have head flat for short period of time; tripod positioning - help if feeling SOB

Answer 42

Positioning

Question 43

huge; oftentimes smokers and encourage as much as can to stop smoking; very diff

Answer 43

Smoking cessation -

Question 44

severe fatigue; breaks in between and able pace themselve

Answer 44

Energy conservation -

Question 45

Diaphragmatic breathing - helps open up lungs and pushing air out; pursed lip breathing - helps exhale CO2 and RV

Answer 45

Breathing exercises

Question 46

if sig weight loss get most out food are eating

Answer 46

Nutritional counseling -

Question 47

very common in pats who have cystic fibrosis and lot of thick secretions; done multiple ways: vests shake chest cavity, manually hit on backs, machines that RT use that roll over back that breaks up secretions - helps control secretions

Answer 47

Chest physiotherapy (CPT) -

Question 48

not seen as much; put in endobronchial valve through bronchoscope to prevent air from getting into damaged lung; not open chest; do through scope and block off damaged area lungs and showing lot benefit

Answer 48

Lung volume reduction surgery -

Question 49

Bronchodilators
Anti-inflammatory agents
Mucolytic agents

Answer 49

Medications

Question 50

Short- and long-acting beta2 agonists - sometimes both to release bronchoconstriction on inside
Cholinergic antagonists
Methylxanthines

Answer 50

Bronchodilators

Question 51

Decrease inflammation within airway; keep airway as open as can
Corticosteroids
NSAIDs

Answer 51

Anti-inflammatory agents

Question 52

Do lot to help thin and Manage secretions better

Answer 52

Mucolytic agents

Question 53

Hypoxemia
Acidosis - very common comp which lead to resp failure quickly
Respiratory infection - very susceptible
Cardiac failure - high risk cardiac issues
Cardiac dysrhythmias - high risk cardiac issues; a fib common seen

Answer 53

Sig Complications

Question 54

Tricks to help people when having issues with breathing - taking care of pats who are SOB all time is very challenging - very anxiety ridden situation; not lot stamina to do things and is pat pop should have patience with it; always aware of breathing and always SOB but need special care
Provide rest periods between such activities as bathing, meals, and ambulation
Place the patient in an upright position for meals to prevent aspiration
Encourage nutritional fluid intake after the meal to promote increased calorie intake
Schedule drugs around routine activities to increase adherence to drug therapy
Arrange chairs in strategic locations to allow the patient with dyspnea to stop and rest while walking
Urge the patient to notify the health care provider promptly for any manifestation of infection
Encourage the pneumococcal vaccine and annual influenza vaccination

Answer 54

Nursing for the older adult with chronic resp condition