Class 3 Respiratory system: Asthma Flashcards
Long-term drugs used to treat asthma
-Leukotriene receptor antagonists, theophylline, mast cell stabilizers, anticholinergics
-Inhaled/PO glucocorticosteroids, long-acting β2-agonists (LABAs)
-Combination of glucocorticoid OR corticosteroid AND LABA
Rapid relief asthma drugs
-SAβA
-Corticosteroid and LABA; budesonide and formoterol combination (>=12 years old)
-Ipratropium (rarely used)
Asthma management step 1 (mild, intermittent)
-SABA PRN and low dosage glucocorticoids
Asthma management step 2 (moderate; persistent)
-SABA PRN and medium-dosage of corticosteroid
-LABA & corticosteroid combination (>=12 years old)
-Leukotriene receptor antagonist
Asthma management step 3-4 (severe; uncontrolled)
-Step 1&2 + PO prednisone if FEV<60%
-Anti-IgE antagonist if >=12 years old
Antiasthmatics
-Leukotriene receptor antagonist, anticholinergics, corticosteroids
-B-agonist & xanthine derivatives
-Mast cell stabilizers (Na+ cromoglycate & nedocromil)
Anticholinergic MOA
Block cholinergic receptors, thus preventing the binding of cholinergic substances that cause constriction and increase secretions
Leukotriene receptor antagonist MOA
Disrupt leukotrienes, which decreases arachidonic acid-induced inflammation and allergen-induced bronchoconstriction
B-agonists & xanthine derivatives MOA
Raise intracellular levels of cyclic adenosine monophosphate, which promotes smooth muscle relaxation and dilates bronchi & bronchioles
Corticosteroids MOA
Prevent the inflammation commonly provoked by the substances released from mast cells
Mast cell stabilizers (Na+ cromoglycate & nedocromil) MOA
Stabilize mast cells membranes in which the antigen–antibody reactions take place, thereby preventing the release of substances such as histamine
Bronchodilators
-Beta-adrenergic agonists
-Anticholinergics
-Xanthine derivatives
Non-bronchodilating respiratory drugs
-Leukotriene Receptor Antagonists
-Corticosteroids
Bronchodilators: B-agonists
-AKA sympathomimetic bronchodilators
-Stimulate β2-adrenergic receptors, used in acute asthma attacks
Types of bronchodilators
-Nonselective adrenergics
-Nonselective β-adrenergics
-Selective β2 drugs
-Nonselective adrenergic bronchodilators
-Stimulate α, β1 (cardiac), and β2 (respiratory) receptors
-Include epinephrine (Adrenalin)
Nonselective β-adrenergics bronchodilators
-Stimulate both β1 and β2 receptors
-Include isoproterenol
Selective β2 drugs: Bronchodilators
-Stimulate only β2 receptors
-Include salbutamol (Airomir, Ventolin)
B-agonist MOA
-Begins at the specific receptor stimulated & ends with the dilation of the airways
-Activation of β2 receptors activates cyclic adenosine monophosphate (cAMP)
B-agonist indications
-Relief of bronchospasm related to asthma, bronchitis, and other pulmonary diseases
-Treatment and prevention of acute attacks, hypotension & shock
-To produce uterine relaxation to prevent premature labor
-Treatment of hyperkalemia (stimulates potassium to shift into the cell)
Adrenergic receptor responses to stimulation: A1
-Vasoconstriction
Adrenergic receptor responses to stimulation: B2
-Vasodilation
Adrenergic receptor responses to stimulation: Heart muscle B1
-Increased contractility
Adrenergic receptor responses to stimulation: AV&SA node B1
Increased HR
Adrenergic receptor responses to stimulation: Pupillary muscles of iris a1
-Mydriasis (dilated pupils)
Adrenergic receptor responses to stimulation: Kidney B1
-Increased renin secretion
Adrenergic receptor responses to stimulation: Liver B2
Glycogenolysis
Adrenergic receptor responses to stimulation: Muscle a2&B2
Decreased motility
Adrenergic receptor responses to stimulation: Bladder sphincter a1
Constriction
Adrenergic receptor responses to stimulation: Penis a2
Ejaculation
Adrenergic receptor responses to stimulation: Uterus a2
Contraction
Adrenergic receptor responses to stimulation: Uterus B2
Relaxation
Adrenergic receptor responses to stimulation: Bronchial muscles B2
Dilation
B-agonist contraindications
-Uncontrolled cardiac dysrhythmias
-High risk of stroke (because of the vasoconstrictive drug actions)
B-agonist adverse effects a-B
-Epinephrine: anorexia, insomnia, vascular headache, cardiac stimulation, tremor, restlessness, hyperglycemia
B-agonist adverse effects B1&B2
-Isoproterenol: Cardiac stimulation, anginal pain, vascular headache, hypotension & tremor
B-agonist adverse effects B2
-Salbutamol: aBP, vascular headache, tremor
B-agonist interactions
-Require an adjustment to antihyperglycemic drugs
-Increase risk for HTN & cardiac toxicity
B-agonist derivatives: Nursing implications
-Avoid excessive fatigue, extremes in temperature, caffeine, take in adequate fluids
-Salbutamol can lose its β2-specific actions at larger doses… As a result, β1 receptors are stimulated, causing nausea, anxiety, palpitations, tremors, and increased HR
B-agonist derivatives: Nursing implications (things to report)
-Insomnia, restlessness, palpitations, chest pain, or any change in symptoms
Inhalers: Pt education
-Teach time-intervals for inhalers
-Provide spacer if coordination of breathing is impaired
-Teach patient how to keep track of the number of doses in the inhaler
Anticholinergic mechanism of action
-Anticholinergics bind to the ACh receptors, preventing ACh from binding
-Prevents bronchoconstriction and airways dilate
About anticholinergics
-Include ipratropium bromide (Atrovent) and tiotropium (Spiriva)
-Slow and prolonged action
Anticholinergic adverse effects
-Dry mouth/throat, congestion, coughing, headache
-Heart palpitations, anxiety, GI distress
Bronchodilators: Xanthine derivatives
-The natural xanthines are the plant alkaloids caffeine, theobromine, and theophylline (Theolair, Uniphyl)
-Only theophylline is used as a bronchodilator
Synthetic xanthines
-Aminophylline (Phyllocontin)
-Oxtriphylline
Xanthine derivatives: Mechanism of action
-Increase levels of cAMP by inhibiting phosphodiesterase, the enzyme that breaks down cAMP
-The result is increased smooth muscle relaxation & bronchodilation
Xanthine derivatives: Drug effects (other effects)
-Increased contraction & HR resulting in increased CO and blood flow to the kidneys (diuretic effect)
-Stimulate CNS
Xanthine derivatives: Indications
-Dilation of airways in asthma, chronic bronchitis, and emphysema
-Mild to moderate acute asthma
-Combination drug in COPD management
Xanthine derivatives: Contraindications
-Uncontrolled cardiac dysrhythmias, seizure disorders
-Hyperthyroidism, peptic ulcers
Xanthine derivatives: Adverse effects
-N/V, nocturnal GERD, anorexia
-Sinus tachycardia, extrasystole, palpitations, ventricular dysrhythmias
-Transient increased urination
Xanthine derivatives: Interactions
-Several drugs increase serum levels of xanthine derivatives
-When used with sympathomimetics (e.g., caffeine) additive heart and CNS stimulation
-St. John’s wort (Hypericum perforatum) and cigarette smoking enhance the rate of metabolism
-Charcoal broiling and high-protein and low-carbohydrate foods may reduce serum levels of xanthines
Xanthine derivatives: Implications
-Report N/V, weakness, dizziness, palpitations, chest pain, & convulsions
Antileukotrienes
-AKA leukotriene receptor antagonists (LRTAs)
-“lukasts”; montelukast (Singulair) & zafirlukast (Accolate)
Antileukotrienes mechanism of action
-Leukotrienes cause inflammation, bronchoconstriction, and mucus production
-The result is coughing, wheezing, and SOB
-Antileukotriene drugs prevent leukotrienes from attaching to receptors on circulating immune cells and immune cells within the lungs
Antileukotrienes drug effects
-Prevent smooth muscle contraction of the bronchial airways, decrease mucus secretion
-Prevent vascular permeability, decrease inflammatory response in the lungs
Antileukotrienes indications
-Used for asthma if >=12
-NOT for acute asthmatic attacks
-Montelukast: Approved for use in children ages 2 and older and for treatment of allergic rhinitis
Antileukotrienes contraindications
Allergy to cellulose derivatives, titanium dioxide, povidone, or lactose
Antileukotrienes adverse effects: Zafirlukast
-Headache, nausea, diarrhea
-Liver dysfunction
Antileukotrienes: Nursing implications
-For chronic asthma, not acute
-Taken every night even if symptoms improve
-Therapeutic effect ~ 1 week
-High interaction rate
-Assess liver function before beginning therapy
Corticosteroids
-For chronic asthma, not acute asthmatic attacks
-PO or inhaled forms
-Inhaled forms reduce systemic effects
-May take several weeks before full effects are seen
Corticosteroids mechanism of action
-Stabilize membranes of leukocytes or WBCs that release broncho-constricting substances
-Increase responsiveness of bronchial smooth muscle to β-adrenergic stimulation
Inhaled corticosteroids
-Budesonide, triamcinolone acetonide “ides”
-Fluticasone furoate & propionate
-Mometasone furoate monohydrate “ates”
Inhaled corticosteroids indications
-Bronchospastic disorders that cannot be controlled by conventional bronchodilators
Inhaled corticosteroids contraindications
-Hypersensitive to glucocorticoids
-Positive for Candida organisms
-Systemic fungal infection
Inhaled corticosteroids adverse effects
-Pharyngeal irritation, oral fungal infection
-Coughing, dry mouth
-Systemic effects are rare because of the low doses used for inhalation therapy
Inhaled corticosteroids nursing implications
-Rinse mouth after to prevent fungal infections
-Bronchodilator used before the corticosteroid
-Encourage use of a spacer device to ensure successful inhalations
-Teach patients how to keep inhalers and nebulizer equipment clean after use
Care of the respiratory client: Diagnostics
-Pulmonary Function Tests, SpO2
-ABG’s, D-Dimer, sputum Cultures
-Chest X-Ray, CT Scan, MRI
Care of the respiratory client: Diagnostics cont’d
-D-Dimer is a by-product of blood clotting. D-dimer is released when a blood clot begins to break down.
-Fluoroscopy; continuous x ray image
-Bronchoscopy; scope to see interior of airway
-Thoracoscopy; look at the space inside the chest
-Pulmonary Angiogram; shows blood flow through lung
-Thoracentesis; remove fluid or air from around the lungs
-Biopsy; bronch, thoracentesis
Common upper airway complications
Rhinitis, sinusitis, pharyngitis, tonsillitis, laryngitis
Nursing care for common upper airway complications
-Fluid & Electrolyte balance
-Promote communication
-Medication management
Obstruction & trauma to upper airway
Obstructive Sleep Apnea, epistaxis, nasal Obstruction, laryngeal Obstruction
Nursing care of obstruction & trauma to upper airway
-Fear & Anxiety, sleep, communication
-Nutrition, body Image
Lower respiratory tract disorders
Atelectasis, pneumonia, tuberculosis, abscess
Lower respiratory tract disorders: Nursing care
-Rest
-Fluid balance, nutrition
-Knowledge
-Medication management
Lower respiratory tract disorders in pediatrics
-Respiratory Syncytial Virus (RSV)
-Respiratory Syncytial Virus (RSV)
-Acute viral infection causing bronchiolitis
-Most frequent cause of pediatric hospitalization for lower respiratory tract infection
RSV presentation
SOB, wheezing, tachypnea, nasal secretions, poor feeding, +/- fever
RSV nursing care
Symptom management, NP suction, I&O, IV fluids
Severe RSV may require…
PICU admission and intubation
Prevention of RSV
Monoclonal antibody (palivizumab)
Asthma diagnostic tests
-Pulmonary function tests (PFTs)
-Peak expiratory flow rate (PEFR)
-Lab tests (CBC + diff) and CXR
Status asthmaticus goals of therapy
Correct dehydration and acidosis + the obvious goals
Status asthmaticus treatment
-Humidified O2, SABA, +/- corticosteroids & anticholinergics
-IV Mg+ sulfate
-Admit to PICU
Pleural conditions
-Pleurisy
-Pleural Effusions
-Empyema
Pleural conditions: Nursing care
-Effective breathing pattern, gas exchange
-Tube & medication management
Respiratory failure
-Pulmonary Edema, Pulmonary Embolism; D-dimer
-Acute Respiratory Failure, ARDS
-Pulmonary HTN, Cor Pulmonale
Respiratory failure: Nursing care
-Medications, weight & fluid balance, nutrition
-Patient teaching, family centered care
-Fear & Anxiety
Chest trauma
-Blunt Trauma
-Sternal/Rib Fractures
-Penetrating Trauma
-Pneumothorax
-Cardiac Tamponade
-Hemothorax
Chest trauma: Nursing care
-Emergency…ABC
-Oxygen
-Lines & tubes
-Pain
-Fluid & electrolyte balance
-Medication management
-Family centered care
-Pt education
Chest tubes, drains and catheters
-1) Drainage of air:
-Pneumothorax
-Primary or secondary
-Spontaneous or traumatic
-2) Drainage of fluid:
-Malignant pleural effusion
-Parapneumonic effusions / Empyema
-Hemothorax
-3) Post operative for recovery
Insertion technique: Factors to consider
-Percutaneous:
-Simple
-Less painful & traumatic
-Quick
-No inspection of pleural space
-Required if located pleural space
-Surgical:
-More complex & painful
-Allows examination of pleural space
-Allows placement of large bore tubes
Large bore chest tubes
-Stiff
-Thick fluid (blood, pus)
-Large air leaks
-Pain
-Wound infections
Small bore tubes
-Pigtails
-Strait “pneumothorax”
-Tubes
-With or w/o image
-Guidance
-More comfortable
-Less traumatic
-Plugs easily, need for flushing
-Good for “lighter” fluids
Tunneled pleural catheters (Pleurx)
-Malignant effusions
-Long term use, intermittent home
-Low complication rates, soft/comfortable
