PT 5 Flashcards
1
Q
What are the 3 processes involved in gas exchange
A
- Ventilation
- Perfusion
- Diffusion
2
Q
What is ventilation
A
Moving gases into and out of the lungs
3
Q
What is perfusion
A
Cardiovascular system sending oxygenated blood to tissue and returning de-oxygenated blood back to the lungs
4
Q
What is diffusion
A
Moving respiratory gases from one area to another by concentration gradient
5
Q
What is included in the upper respiratory tract
A
Nose, mouth, pharynx, epiglottis, larynx and trachea
6
Q
What is included in the lower respiratory tract
A
Bronchi, bronchioles, alveolar ducts and lung lobes
7
Q
What lung is more likely to have aspiration due to having a shorter bronchous
A
Right lung
8
Q
How many lobes are in the right and left
A
Right has three
Left has two
9
Q
Who is at risk of atelectasis
A
- Post op patients due to anesthesia and restrictive breathing
- Acute respiratory distress syndrome (no surfactant)
10
Q
What is PaO2
A
Partial pressure of oxygen in arterial blood (amount of oxygen dissolved in plasma)
11
Q
What is SaO2
A
Arterial oxygen saturation (amount of oxygen bound to hemoglobin)
12
Q
What is compliance of the lungs
A
How easily the lungs expand - when compliance is decreased, it makes it difficult for the lungs to inflate (like in COPD)
13
Q
What is elastic recoil
A
The tendency for the lungs to return back to their original size
14
Q
What is resistance
A
Any impediment to airflow during inspiration or expiration
15
Q
What are the two types of lower respiratory tract problems
A
- Restrictive: chest wall and diaphragm can’t fully expand
- Obstructive: Resistance of airflow due to airway obstruction or narrowing
16
Q
What are examples of extra-pulmonary restrictive disorders (outside of the lungs)
A
- Head injuries
- Spinal cord injuries
- Muscular dystrophy
- Chest wall trauma
17
Q
What are examples of intra-pulmonary restrictive disorders
A
- Pleural effusion
- Pleurisy
- Pneumothorax
- Acute respiratory distress syndrome (ARDS
- Atelectasis
- Interstitial lung diseases
- Pneumonia
18
Q
What are examples of obstructive pulmonary disorders
A
- Asthma
- Emphysema
- COPD
- Cystic fibrosis
19
Q
What are disorders of the upper respiratory system
A
- Epistaxis (nosebleeds)
- Allergic rhinitis (inflammation of the nasal mucosa due to an allergen)
- Acute viral rhinitis
- Influenza
20
Q
What can prolong a nosebleed (epistaxis)
A
Taking aspirin, NSAIDs, warfarin or other anticoagulant drugs
21
Q
How do you care for a nosebleed
A
- Have pt sit down, with head titled slightly forward
- Apply direct pressure by squeezing the nostrils together for 5-15 minutes
- Seek medical assistance if bleeding doesn’t stop in 15 minutes
22
Q
What can be used to treat posterior nosebleeds
A
Epistaxis balloons (inflates in the back of the nose to apply pressure, to help stop the bleed)
23
Q
What is pneumonia infecting
A
The lung parenchyma (gas exchange portion of the lungs)
24
Q
How do we get pneumonia
A
When pathogens reach the lungs and defense mechanisms become incompetent or are overwhelmed by the virulence or quantity of infectious agents
25
How can pathogens get into the lungs and cause pneumonia (examples - not an exhaustive list) 7
- Weak cough or epiglottal reflex may allow aspiration to get into the lungs
- Tracheal intubation, which bypasses normal filtration processes and interferes with the cough reflex and mucociliary escalator mechanism
- Mucociliary mechanism is impaired (self-cleaning mechanism of the airway)
- Air pollution
- Smoking
- Aging 65+
- Bed rest, prolonged immobility
26
What are three ways that organisms reach the lungs and cause pneumonia
1. Aspiration from nasopharynx or oropharynx (normal organisms that cause pneumonia live in our mouth and throat)
2. Inhalation of microbes present in air (mycoplasma pneumonia and fungal pneumonia)
3. Hematogenous spread from a primary infection elsewhere in the body (spread by bloodstream) (example strep or staph from endocarditis)
27
Describe the pathophysiology of pneumonia 4
1. Inflammatory response - bringing neutrophils to fight and kill off the pathogens, this causes edema, which then causes fluid to leak from the capillaries and tissues into the alveoli
2. This fluid leak, causes the alveoli to fill with fluid and debris (consolidation - when fluid fills a part of your lungs that is normally filled by air)
3. You also have an increase in mucus production, which leads to airway obstruction
4. Both consolidation and airway obstruction lead to a decrease in O2 transportation, resulting in hypoxia
28
What types of things can cause pneumonia 6
- Bacteria
- Viruses
- Mycoplasma
- Fungi
- Parasites
- Chemicals
29
What are the three ways to classify pneumonia
1. Community acquired pneumonia (CAP)
2. Hospital acquired pneumonia (HAP)
3. Ventilator associated pneumonia (VAP)
30
Why is it important to know what class of pneumonia it is
Once we know what is causing it, then we can treat it
31
What is community acquired pneumonia
Occurs in pts who have not been hospitalized or have lived in a long-term care facility within 14 days of the onset of symptoms
32
What are the most common organisms causing CAP
- Legionella pneumophila
- MRSA
- s. pneumoniae
33
What are the most common organisms causing HAP 4
- Acinetobacter species
- E. coli
- Klebsiella pneumoniae
- Pseudomons aeruginosa
34
If someone has pneumonia, what scoring system can we use to determine if the pt is high risk for death and should be hospitalized
CURB-65
35
What are the 8 factors of CURB
```
C: are they confused?
U: Is their BUN greater than 20?
R: Is their respiratory rate at or greater than 30?
B: Is their BP less than 90/60?
- Are they at 65 or older?
- Is their LDH above 230?
- Is their albumin less than 3.5?
- Is their platelet count less than 100?
(If yes, each counts for 1 point)
```
36
What are the points for pneumonia based on CURB
- 0-2 = outpatient
- 3-4 = In patient
- 5-8 = ICU
37
Once pneumonia is suspected, what should happen
The pt should go on empiric antibiotic therapy asap, even without knowing the causative agent - basically you're giving them an antibiotic based on the diagnosis of CAP, HAP, VAP, risk factors, early versus late onset, presentation, underlying medical conditions, hemodynamic stability, likely causative pathogen. The antibiotic can be adjusted once sputum cultures come back.
38
What is hospital acquired pneumonia (HAP)
pneumonia in a non-intubated pt that begins 48 hrs or longer after admission to the hospital, and was not present at the time of admission
39
What is ventilator associated pneumonia (VAP)
pneumonia that occurs 48hrs after endotracheal intubation
40
Are they always going to do a sputum culture for someone that is not high risk and going in as outpatient
No, probably not. They're most likely going to give you antibiotics and send you on your way. They'll probably get a sputum culture if you have HAP or VAP.
41
What is a major issue with pneumonia
Multi-drug resistant (MDR) organisms (staphylococcus aureus, gram-negative bacilli, MRSA)
42
What are risk factors for MDR pneumonia 4
- Advanced age
- Immunosuppresion
- History of abx use
- Prolonged mechanical ventilation
43
What is aspiration pneumonia
When something abnormal enters your trachea and lungs from your mouth or stomach
44
What are risk factors for aspiration pneumonia 3
- Decreased level of consciousness
- Difficulty swallowing
- NG tubes
45
What types of aspirated material can cause aspiration pneumonia 4
- Food
- Water
- Vomitus
- Secretions
46
What is the most common type of infection in aspiration pneumonia
Bacterial infection
47
What if aspiration pneumonia is caused by acidic gastric contents?
This causes chemical (noninfectious) pneumonitis, and may not need antibiotics.
48
What is necrotizing pneumonia
From a bacterial lung infection, usually from CAP, where the lung tissue turns into a thick, liquid mass.
49
What are the signs and symptoms of necrotizing pneumonia
- Immediate respiratory insufficiency and/or failure
- Leukopenia (Low WBCs)
- Bleeding into the airways
50
What is opportunistic pneumonia
Inflammation and infection of the lower respiratory tract in immunocompromised patients
51
What patients are at risk for opportunistic pneumonia 4
- Severe protein-calorie malnutrition
- Immunodeficiencies (HIV)
- Chemo/radiation pts.
- Long-term corticosteroid pts
52
What is pneumocytis jiroveci pneumonia (PJP)
pneumonia that is most common in people with HIV. It causes diffuse bilateral infiltrates and consolidation of the lungs, which can lead to acute respiratory failure and death. It can also spread to other organs like the liver, bone marrow, lymph nodes, spleen and thyroid.
53
What do we treat PJP with
Trimethoprim/sulfamethoxazole IV or orally
54
What causes cytomegalovirus (CMV)
Herpesvirus
55
Most CMV is asymptomatic or mild, however, it can cause severe disease in whom
People with an impaired immune response (ie transplant pts, chemo pts)
56
How can we treat CMV
Antiviral medications and high-dose immunoglobulin (antibodies)
57
What are complications of packing a nosebleed
They can be painful (give pain medicine) and they can put the pt at risk for infection from bacteria (might give antibiotics)
58
What are the most common clinical manifestations of pneumonia 7
1. Cough
2. Fever
3. Chills
4. Dyspnea
5. Tachypnea
6. Pleuritic chest pain
7. Green, yellow or rust colored sputum
59
What are some nonspecific manifestations of pneumonia 5
- Diaphoresis
- Anorexia
- Fatigue
- Myalgias (muscle aches and pain)
- Headache
(pneumonia symptoms are not just about respiratory)
60
Older adults and debilitated pts don't usually have the typical symptoms of pneumonia... What do they usually have 2
- Confusion or stupor
| - Hypothermia instead of a fever
61
What might viral pneumonia start as
Influenza, which then can lead to viral pneumonia
62
When examining someone with pneumonia, what might you find 5
- Fine or coarse crackles
If they have consolidation:
- Bronchial breath sounds
- Egophony (change in sound of voice)
- Increased fremitus (vibration of chest wall from vocalization)
- Dullness to percussion if pleural effusion is present
63
What are other complications from pneumonia 10
- Atelectasis (collapsed airless, aveoli)
- Pleurisy (inflammation of the pleura)
- Pleural effusion (fluid in the pleural space, usually the fluid is sterile and is absorbed in 1-2 weeks, might need thoracentesis)
- Bacteremia (bacterial infection in the blood)
- Pneumothorax (air collets in the pleural space, causing the lung to collapse)
- Meningitis
- Acute respiratory failure (can't exchange O2 and Co2 anymore - leading cause of death from severe pneumonia)
- Sepsis/septic shock (Bacteria from alveoli enter the bloodstream)
- Lung abscess (not common)
- Empyema (rare, accumulation of purulent exudate in the pleural cavity - requires abx and chest tube)
64
What usually gives us enough information to diagnosis pneumonia 3
- History
- Exam
- Chest x-ray
65
Do we always get a sputum culture and gram stain for pneumonia
Usually not for CAP. You also shouldn't delay treatment by waiting for these test, as this can increase morbidity and mortality.
66
With bacterial pneumonia, what diagnostic finding can be seen
Leukocytosis, where there is an increase in the WBC above 15,000. You also have bands (immature neutrophils)
67
When looking at ABGs with pneumonia, what might we find
- Hypoxemia when PaO2 is less than 80
- Hypercapnia when PaCO2 is greater than 45
- Acidosis when pH is less than 7.35
68
What is the normal range of PaO2
80-100
69
What is the normal range of SaO2
>95%
70
What is the normal range of PaCO2
35-45
71
What is the normal range of HCO3
22-26
72
What are some other diagnostic studies you might do for pneumonia (besides the main ones)
- Blood cultures for the seriously ill
- Thoracentesis and/or bronchoscopy with washings to obtain fluid samples when pts aren't responding to initial therapy
- Looking at biologic markers like C-reactive protein (CRP), kallistatin and procalcitonin
73
What can be given to prevent streptococcus pneumoniae
The pneumococcal vaccine
74
Who should get the pneumococcal vaccine
- Children younger than 2
- Adults 65 and older
- Or those between 2-65 who are high risk
75
When should the pt respond to abx tx for pneumonia. What will we see?
Within 48-72hrs. Decreased temp, improved breathing, reduced chest discomfort.
76
When would we repeat a chest x-ray after pneumonia tx
6-8 weeks
77
Besides given abx, what else can be given to help support a pt with pneumonia 4
- Oxygen for hypoxemia
- Analgesics for chest pain
- Antipyretics
- Tailor rest and activity
78
Are cough suppressants, mucolytics, bronchodilators, and corticosteroids prescribed as adjunctives for pneumonia
Yes - but there probably only useful if someone has an underlying chronic condition and needs them
79
If someone has pneumonia , do we want them to get more or less movement
More movement, to help mobilize those secretions
80
Is there a tx for viral pneumonia
Not really, usually care is supportive, and it should resolve in 3-4 days.
81
Once you classify pneumonia (CAP, HAP, VAP), what drug therapy do you use
Empiric therapy - where you are basing the drug therapy on the likely pathogen and risk factors for MDR
82
When should you see drug therapy improvement of pneumonia
3-5 days
83
Do you start with an IV or oral meds first for pneumonia
Usually start with IV meds, and then switch to oral as soon as the pt is stable.
84
How long is CAP tx? When is it stopped?
Lasts a minimum of 5 days. Pt should be afebrile (not feverish) for 48-72 hrs before tx can be stopped.
85
Why is hydration important for pneumonia
It helps thins and loosens secretions
86
Should people with pneumonia have big meals or small meals?
Small, frequent meals due to dyspnea. Want them high in calories.
87
What are some questions you may want to ask a pt when you suspect pneumonia 6
- Past health history
- Use of abx, corticosteroids, chemo or immunosuppressants
- Recent surgeries
- Recent intubation
- Tube feedings
- Pain (ie with breathing)
88
What is some objective data you may gather if you suspect pneumonia 13
- Fever
- Restlessness or lethargy
- Splinting affected area
- Tachypnea
- Asymmetric chest movements
- Use of accessory muscles
- Crackles
- Friction rub
- Dullness on percussion
- Increased tactile fremitus
- Sputum amount and color
- Tachycardia
- Changes in mental status
89
What can help reduce VAP
Adhering to all aspects of the ventilator bundle
90
How can we help prevent pneumonia in at risk pts 6
- Keep HOB elevated at or above 30 degrees
- Assist with eating, drinking and taking meds
- Assess for gag reflex before giving food or fluids
- Early mobilization
- IS
- Twice-daily oral hygiene with chlorhexidine swabs for post-op pts.
91
What would be a concerning finding when assessing a pt diagnosed with influenza:
a - sore throat, and headache
b - cough, with chest discomfort
c - crackles, with diminished breath sounds
d - fever of 102
C = indicates pneumonia (pneumonia is a complication of influenza)
92
What are complications of influenza 4
- Bronchitis
- Pneumonia
- Acute respiratory failure
- ARDS (acute respiratory distress syndrome)
93
What can cause nosebleeds 12
- Trauma
- Hypertension
- Low humidity
- Upper respiratory tract infections
- Allergies
- Sinusitis
- Foreign bodies
- chemical irritants (street drugs)
- Overuse of decongestant nasal sprays
- Facial or nasal surgery
- Anatomic malformation
- Tumors
94
Which is more difficult to treat, anterior or posterior nosebleeds
Posterior
95
Who often has posterior nosebleeds
Older adults with other problems like hypertension (hard to determine how much blood is lost because they are so close to the throat)
96
How can you treat an anterior nose bleeds
- Use a pledget (nasal tampon) with lidocaine
- Vasoconstrictive agents like epinephrine placed in the nose
- Keep packed for 48-72 hrs
97
TB most commonly infects the lungs, but what else can it infect
- Brain
- Kidneys
- Bones
98
What is the leading cause of death in patients with HIV/AIDs
TB
99
When is a strain of TB classified as multidrug-resistant TB
When it is resistant to the first-line antitubercular drugs (isoniazid and rifampin)
100
When is a strain of TB classified as extensively drug-resistant TB
When the strain is also resistant to the first-line drugs and any fluoroquinolones plus injectable antibiotics
101
What can cause TB to become resistant 3
- Incorrect prescribing
- Lack of case management
- Nonadherence
102
How is TB spread
Through airborne particles
103
How long can TB particles hang in the air
Minutes to hours
104
How do the TB particles get into the air
Through breathing, talking, singing, sneezing or coughing
105
Can you get TB by touching, sharing food utensils, kissing or other types of physical contact
No
106
Once you inhale TB, where do the particles go
Into your bronchioles and alveoli
107
Once TB is inhaled, what happens in the body
An inflammatory response occurs - calcified TB granuloma is created called a Ghon lesion or focus - this granuloma walls off the infection and prevents further spread - about 90% of the time TB does not develop due to this immune response
108
If you body is unable to fight off TB, when would we see it start to multiply
Months - years later
109
Even though TB is aerophilic (oxygen loving) and has an affinity for the lungs, what can it do
It can spread to other organs and grow as well
110
What are the 3 classifications of TB
- Primary infection
- Latent TB infection
- Active TB disease
111
What is primary infection of TB
When TB is inhaled and your immune response can't stop the spread.
112
What is a latent TB infection
They have TB, but it is not active.
- Asymptomatic
- Can't transmit TB, but can develop TB at some point.
- Immunosuppression, diabetes, poor nutrition, aging, pregnancy, stress and chronic disease can reactivate the TB
113
What is active TB disease
Could have primary TB or reactivation TB
- Primary TB: when active TB develops within the first 2 years of infection (HIV pts at greatest risk of this TB)
- Reactivation TB (post-primary): when TB develops after 2 years of the infection
114
When would you see symptoms of pulmonary TB (active)
Usually in 2-3 weeks
115
What are pulmonary TB symptoms 3
- Initial dry cough that becomes productive and frequent
- Constitutional symptoms (fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats)
- Dyspnea and hemoptysis (spitting of the blood) are late symptoms (not common)
116
TB can also present more acutely, what are some of those symptoms 5
- High fever
- Chills (flu like symptoms)
- Pleuritic pain
- Productive cough
- Crackles and/or adventitious breath sounds
117
What are extrapulmonary symptoms of TB
Depend on the organs infected
Examples:
- Renal TB can cause dysuria and hematuria
- Bone TB can cause severe pain
- Meningitis TB can cause headaches, vomiting, and lymphadenopathy
118
How are TB symptoms diff. for immunosuppressed and older adult pts
They are less likely to have a fever and show other signs of infection
119
What is the issue with HIV and TB symptoms
Symptoms of TB in HIV pts can look like other opportunistic infections (like PJP - pneumonia in immunocompromised pts). Need to carefully investigate the cause.
120
What may be the only symptom of TB in older adults
Change in cognitive function
121
Once pulmonary TB is treated, will there be any complications
No, there are not usually any complications if properly treated. There may be some scarring and residual cavitation within the lungs. Significant damage can occur in pts who are poorly treated or who do not respond to tx.
122
What is miliary TB
A complication of TB that has spread through the bloodstream to other organs
123
What are symptoms of miliary TB 5
- Fever
- Cough
- Lymphadenopathy (swelling of lymph nodes)
- Hematomegaly (enlarged liver)
- Splenomegaly (enlarged spleen)
124
What is pleural TB
A complication of TB where bacteria get into the pleural space, which triggers an inflammatory response and a pleural exudate of protein-rich fluid (called unilateral pleural effusion)
125
What are symptoms of pleural TB 4
- Chest pain
- Fever
- Cough
- Empyema (large number of TB organisms in the pleural space - less common)
126
What type of pneumonia can TB cause
Bacterial pneumonia
127
What can happen if TB gets into the spine
It can cause Pott's disease, which leads to the destruction of the intervertebral disc and adjacent vertebrae
128
What can happen if TB gets into the CNS
Bacterial meningitis
129
What can happen if TB gets into the abdomen
Peritonitis (inflammation of the peritoneum which lines the abdomen) (commonly seen in HIV positive patients)
130
Explain the TB skin test (mantoux test)
- Inject purified protein derivate (PDD) intradermally
- Assess for induration in 48-72 hrs
- Presence of induration (not redness) at the injection site indicates development of antibodies to TB exposure
131
What does induration look like
Palpable, raised, hardened area or swelling (no redness)
132
When would antibodies form after TB exposure
2-12 weeks
133
How big should the induration be if a low-risk individual has TB
15mm or bigger
134
How big should the induration be if a immunocompromised pt is positive for TB
5mm or bigger
135
What are the interferon-y gamma release assays (IGRAs)? What do they test for? What are the advantages and disadvantages?
The quantiferon-TB and T-SPOT.TB tests.
- They detect T-cells in response to mycobacterium tuberculosis
- They provide rapid results, require only one visit, no reader bias, no booster phenomenon not affected by bacilus calmette-guerin (BCG) vaccine
- Downside = expensive
136
What is the deal with this BCG vaccine?
Vaccine for TB given in other countries, where there is a high risk of TB. Can make the skin test look positive, but not the IGRAs.
137
Can you make a diagnosis of TB solely on a chest x-ray? Why or why not?
No you can't, because some pts may have a normal chest x-ray even though they have TB
138
What would a chest x-ray look like to suggest someone may have TB
- Upper lob infiltrates
- Cavity infiltrates
- Lymph node involvement
- Pleural and/or pericardial effusion
139
What is the gold standard for diagnosing TB
Sputum culture
140
Explain TB sputum culture tests. What's the downfall?
Have to give 3 consecutive sputum cultures, with 8-24 hr intervals. Results can take up to 6 weeks.
Downfall- you may have pts that are not compliant and do not come back for their consecutive tests.
141
Are most people hospitalized with TB
No, most people are treated on an outpatient basis
142
What should a pt do if they have a positive sputum smear test
They are considered infectious for the first 2 weeks after starting treatment. Basically they need to quarantine.
143
What should I really remember about TB
It's really difficult to get people to comply with tx, because the tx can be pretty brutal.
144
What is tx like for active TB
Aggressive.
Two phases:
- Initial lasting 8 weeks
- Continuation lasting 18 weeks
145
What are the 4 drugs used for active TB
- Isoniazid
- Rifampin
- Pyrazinamide
- Ethambutol
146
What do we worry about with the active TB drugs, especially isoniazid
They can cause hepatotoxicity and nonviral hepatitis
- Monitor liver function every 2-4 weeks
- Avoid alcohol
- Watch for signs of hepatitis at the start and during tx.
147
What if someone has a reaction to the 4 drugs for active TB treatment
There are alternatives like rifabutin and rifapentine.
148
What will help guide us when developing tx for MDR-TB
Using sensitivity testing
149
Describe directly observed therapy (DOT) for TB
Giving TB drugs directly to the pts and watching them swallow the pills.
- Preferred strategy for all TB patients, especially those at risk for non-compliance
- Nonadherence is a major factor in the emergence of MDR-TB
- Public health nurses administer at clinic sites
150
What do we give to treat latent TB and for how long (helps prevent latent from forming into active)
Isoniazid for 6-9 months
151
How long should HIV pts with latent TB take isoniazid for
9 months
152
What if a person is pretty much healthy and they have latent TB, what could the tx look like for them
If they don't do the standard, then they can do a 3 month regimen of isoniazid and rifapentine. Or 4 months of rifampin if allergic to isoniazid.
153
When doing our physical assessment for someone with suspected TB, what are we doing/look for
- Productive cough
- Night sweats
- Afternoon temp elevation
- Wt loss
- Pleuritic chest pain
- Crackles over apices of lungs
- Sputum collection
154
What do we do if someone has TB in the hospital 5
- Put them in a room by themselves with 6-12
- Negative pressure room (traps air inside to protect those outside)
- Wear high-efficiency particulate air (HEPA) masks
- Have pt wear mask outside of room to protect others
- Identify and screen close contacts.
155
What TB drug can turn your urine red-orange
Rifampin
156
What are some basic things you want to teach someone with TB 2
- Cover mouth when coughing
| - Wash hands
157
What type of disease is asthma
An obstructive pulmonary disease
158
What are risk factors for asthma 5
- Genetics
- Environment (pollen, pollutants)
- Being a male as a child (no risk as an adult)
- Obesity
- Smoking
159
What is interesting about allergens and asthma
They may not actually cause someone to have asthma, but they can trigger asthma symptoms
160
What are types of allergen triggers for asthma 5
- Cockroaches
- Furry animals
- Fungi
- Pollen
- Molds
161
When might exercise-induced asthma or bronchospasms trigger asthma
- After vigorous exercise
| - After exposure to cold air
162
What do we worry about with stagnant air and asthma
The stagnant air can lead to concentrated pollution in the atmosphere and trigger asthma
163
What is the most common job-related respiratory disorder
Asthma (working around chemicals for your job can trigger asthma)
164
What's the issue with asthma and respiratory infections
These infections can trigger acute asthma attacks
165
What are other common triggers of asthma 5
- Nose and sinus problems
- Medications
- Food additives and allergies
- GERD
- Emotional stress (cause hyperventilation and hypocapnia = narrow airway)
166
What medications can trigger asthma attacks and why 3
- Aspirin and NSAIDs (pts are sensitive to these drugs, so they can trigger an attack)
- Beta blockers can cause bronchospasm (blocks HR and lungs)
- ACE inhibitors can cause a dry, hacking couch which can make asthma symptoms worse
167
How can GERD trigger asthma
It can cause bronchoconstriction and aspiration. And asthma drugs may worsen GERD symptoms.
168
Basically, what is the pathophys of asthma
There's a trigger, which causes your immune system to respond, which then causes bronchoconstriction, hyperresponsiveness (hyperreactivity), edema of airways, congestion, thick mucus, bronchial muscle spasms, thickening of airway walls (these are usually what we see in early-phase).
169
When does the early-phase response occur with asthma
Within 30-60 minutes after exposure
170
When does the late-phase response occur
4-6hrs after initial attack
171
What's happening in late-phase asthma 4
- Can be more severe than early
- Can last for 24hrs or more
- Not treated or resolved, can lead to irreversible lung damage
- Structural changes in bronchial wall called remodeling occur
172
What are the clinical manifestations of asthma
- Wheezing
- Breathlessness
- Cough
- Tight chest
(may be abrupt or gradual)
(may last from minutes-hrs)
173
What is interesting about asthma symptoms
Expiration can be longer than inspiration since there is bronchospasm, edema and mucus, it takes longer to move the air out of the lungs
174
What is the only symptom of cough variant asthma
A cough because the bronchospasm is not severe enough to cause airflow obstruction
175
What are the 4 classifications of asthma
- Intermittent
- Mild persistent
- Moderate persistent
- Severe persistent
176
What are the severe exacerbations of asthma 6
- RR above 30
- Dyspnea at rest, feeling suffocated
- Pulse greater than 120
- PERF 40% at best (peak expiratory flow rate - measured by the peak flow meter to test lung function)
- Accessory muscles in neck with be bulging
- Can be combative and confused due to low sats
177
What the life-threatening exacerbations of asthma
- Too dyspneic to speak
- Perspiring profusely
- Drowsy/confused
- PERF below 25%
178
What can you use to help diagnosis asthma 7
- History and physical
- Spirometry
- Peak expiratory flow rate using a peak flow meter
- Chest x-ray (will look normal if pt is asymptomatic)
- Oximetry
- Allergy testing
- Elevated levels of eosinophils and IgE (these suggest that there may be a genetic risk factor for developing asthma)
179
What tool do HCP base drug therapy on for asthma pts
They use a step approach. If the patient is doing well, then they can step down the medication, if they are doing worse, then they can step up the medications
180
What are the two types of asthma drugs
- Short-term rescue/reliever medication
| - Long-term or controller medication
181
What is the "rescue" medication of asthma
B2-adrenergic agonist (SABA) = albuterol
182
What are the long term medications for asthma
Your inhaled corticosteroids (ICS) like fluticasone. Might also be used with long-acting bronchodilators (LABS)
183
How should someone take albuterol in a rescue situation
Take 2-4 puffs every 20 minutes. Repeat three times.
184
What am I checking for during an assessment for asthma 8
- Look at RR
- HR
- Are they using accessory muscles
- Do I hear wheezing (in an asthmatic, I am more concerned when I don't hear wheezing)
- Percussion of lungs
- PERF (difficult to get during an acute asthma attack)
- ABGs
- Pulse ox
185
What do the ABGs look like for asthmatics at first
At first, they are hyperventilating from the hypoxemia, so we will see a decrease in PaCO2 and an increase in pH
186
What PERF number shows an obstruction
Less than 200 L/min
187
What is one thing you don't want to hear in an asthmatic pt
A "silent chest"
188
What does a "silent chest" look like and indicate
There will be diminished breath sounds, no wheezing, pt will be struggling. This is a life-threatening situation - going into respiratory failure
189
When someone is having a severe asthma attack, what are we carefully monitoring 3
- HR
- RR and rhythm
- BP
190
How are we treating someone with severe and life-threatening asthma exacerbations
- IV magnesium sulfate (bronchodilator)
- 100% oxygen
- Hourly or continuous nebulized SABA
- IV corticosteroids
191
What medication is the fast acting drug for asthma
- albuterol (it's a short acting beta 2 agonists (SABA) bronchodilator)
192
What types of anti-inflammatory drugs may be prescribed for long-term asthma control
- Inhaled corticosteroids (ICSs)
- Leuikotriene modifiers
- Monoclonal antibody to IgE
193
What is an example of an ICS for asthma 5
- fluticasone
- beclomethasone
- budesonide (Pulmiocort)
- mometasone
- ciclesonide
194
What is an example of a leuikotriene modifier 3
- Montelukast (oral)
- zafirlukast
- zileuton
195
What is an example of a monoclonal antibody to IgE
omalizumab (Xolair)
196
What do corticosteroids do for asthma pts 5
- Suppress the inflammatory response
- Inhaled form is used in long-term control
- Systemic form is used to control exacerbations and manage persistent asthma (methylprednisolone, Solu-Medrol IV)
- Decrease bronchial hyperresponsiveness
- Decrease mucous production
197
What type of schedule should you take corticosteroids on
Fixed schedule
198
What are side effects of inhaled corticosteroids. What can help with these? 3
- Oropharyngeal candidiasis (yeast infection due to decrease in immune system)
- Hoarseness
- Dry cough
- Using a spacer or gargling after each use can help
199
What do Leukotriene modifiers do
- They block the action of leukotrienes (potent bronchoconstrictors)
- Have both bronchodilator and anti-inflammatory effects
200
What is one advantage of Leukotriene modifiers
They can be administered orally
201
What might we give in an addition to an ICS
Leukotriene modifiers (these do not take the place of ICSs, these are add-ons)
202
What does an anti-IgE do
- Decreases IgE levels
203
What are IgEs
They're antibodies that are released when your body overreacts to an allergen
204
How is anti-IgE given
Subcutaneous every 2-4 weeks in a HCPs office, due to the high risk of anaphylaxis
205
Describe our B-adrenergic agonists (SABAs) 4
- For short acting
- Not long-term use
- Onset of action in minutes and last from 4-8 hrs
- Prevent release of inflammatory mediators from mast cells
206
What are side effects of SABAs (when used often - this is why you shouldn't use often) 6
- Increased HR
- Anxiety (jittery)
- Tremors
- Palpitations
- Nausea
- Insomnia
(be careful giving these to cardiac pts, due to the things that this drug can elevate)
207
What are 2 examples of long-acting beta 2 - adrenergic agonist drugs (LABAs)
- Salmeterol (Serevent)
| - Formoterol (Foradil)
208
Describe LABAs 3
- Added to daily ICSs
- Decrease the need for SABAs
- Never use alone
209
What is the max amount that you should be using your SABA
No more than twice a week
210
What is a methylxanthine drug
Theophylline
211
What is the issue with Theophylline 3
- High interactions with other drugs
- Bad side effects (GI issues, tachycardia, dysrhythmias, seizures)
- Blood serum levels need to be regularly checked due to the safety risks
212
Describe anticholinergic drugs 4
- ipratropium (Atrovent)
- Prevent muscles in the bronchi from tightening by blocking acetylcholine
- Short-acting (not as effective as albuterol)
- More effective for COPD
213
What devices are used to inhale asthma medications
- Nebulizers
- DPIs (Dry Powder Inhalers)
- MDI (Metered Dose Inhalers)
214
What is the big thing to know about nonprescription combination drugs like epinephrine and ephedrine
They can be very dangerous due to their side effects. Caution pts from using these (can cause heart palpitations, dysrhythmias, tremors, insomnia, increased BP).
215
Why are MDIs and spacers beneficial
They reduce the amount of medicine delivered to your throat and increase the amount of med delivered to your lungs.
216
How should you use your inhaler 5
- Shake the inhaler
- Breathe out all the way
- Put the inhaler to your lips and breathe in slowly
- Hold breath for 10 seconds
- Wait one minute between breaths for quick-relief meds (not need to wait for the others)
217
What assessments are we going to do for someone with asthma 4
- History
- ABGs
- Lung function tests
- Physical (accessory muscles, diaphoresis, cyanosis, lung sounds)
218
What is the PEFR goal
Maintain 80% of personal best
219
What is an asthma's pts wheezes get louder
It can indicate that they are having a positive response to the tx
220
What can we do as nurses when a pt is having an acute asthma attack 3
- Stay with them
- Get them comfortable
- Use "talking down" (make eye contact with them and coach them in pursed lip breathing)
221
What is some good pt teaching for someone with asthma
- Know when to seek medical tx
- Use your peak flow meter daily
- Have a written plan
- Get good nutrition
- Get good sleep
- It's also hard to pts with asthma to notice that their breathing is changing (this is why you do your peak flows - as they will indicate if something is happening when they go down)
222
Describe the three peak flow zones
1. Green zone: 80-100% of personal best (keep doing everything the same)
2. Yellow zone: 50-80% of personal best (caution - something is triggering asthma - need medications - call HCP because something isn't working)
3. Red zone: less than 50% of best (serious problem - action must be taken with HCP)
223
What are our bronchodilator drugs 4
- SABA (albuterol)
- Anticholinergics (ipratropium)
- LABA (Serevent)
- Methylxanthines (theophylline)
224
What do bronchodilators do
Prevent bronchospasms by stopping the release of inflammatory mediators from mast cells
- No anti-inflammatory effects
225
What hurts both the bronchi and the alveoli, COPD or asthma
COPD (only the bronchi are affected in asthma)
226
What is the number one red flag and priority with someone having an acute asthma attack
The "silent chest"
227
If someone is having an acute asthma attack, are we going to see prolonged inhalation or prolonged exhalation
Prolonged exhalation
228
What ABGs are we going to see for someone in respiratory acidosis
- pH less than 7.35
- paCO2 over 45
- paO2 less than 80 (hypoxic)
229
What are the neuro signs of hypoxia 3
- Agitation
- Restlessness
- Drowsiness
(we will see mental status changes)
230
What if someone has status asthmaticus, where drugs aren't going to work for them
Intubate
231
Does stress cause asthma attacks
Yes, it can
232
How and how often do we clean albuterol MDIs vs corticosteroid MDIs
- Albuterol: Rinse with warm water 1-2 times per week (doesn't need to be cleaned after every use)
- Corticosteroids: Wash inhaler and mouth out after every use.
233
During an acute asthma attack, what drugs are we giving (think AIM)
A: albuterol
I: ipratropium
M: methylprednisolone (Solu Medrol)
234
Can you reverse COPD
No, it's a chronic, irreversible condition
235
What is COPD
Progressive disease, where there is an abnormal inflammatory response in the lungs, which is primarily caused by cigarette smoking and other noxious particles or gases
236
So what's the relationship between chronic bronchitis and emphysema
Both are no longer included in the definition of COPD
- Chronic bronchitis is now its own independent disease
- Emphysema is something that can happen in COPD pts, where the alveoli are destroyed
237
What is chronic bronchitis
Cough and sputum production for at least 3 months in 2 consecutive years
238
What are risk factors for COPD 7
- Smoking
- Chemicals and dust
- Pollution
- Severe recurring respiratory infections
- Asthma
- Aging
- a1-antitrypsin deficiency
239
What is a1-antitrypsin deficiency
Autosomal recessive disorder that can put you at a genetic risk for developing COPD
240
What is the purpose of a1-antitrypsin
It is a protein found in the lungs, that protects lung tissue from being attacked during inflammation related to smoking and infections
241
How might smoking lead to COPD 4
- The irritating smoke causes hyperplasia of cells, which increases mucus production, thus causing airways to become smaller
- Decrease or lost ciliary activity
- Abnormal distal dilation and destruction of alveoli
- Chronic, enhanced inflammation, which leads to destruction of collagen by increasing proteolytic enzymes
242
When should COPD be considered in a smoker
If they are over 40 and have a history of 10 or more pack-years
243
How do you calculate pack-years
Pack per day multiplied by the years that they've been smoking (ie half of pack a day for 30 years would be 15 pack years)
244
How many cigarettes are in a standard pack
20
245
What are the effects of nicotine 3
Stimulates the sympathetic nervous system, which leads to COPD
- Increase HR
- Cause peripheral vasoconstriction
- Increase BP and cardiac workload
246
What is interesting about pollution and COPD
Many people are developing COPD, even though they have never smoked, due to poor ventilation when cooking indoors using coal and other biomass fuels
247
What infections are risk factors for COPD
HIV and TB
248
How can aging put you at risk for COPD
Most older adults develop emphysema due to their lungs changing (lungs becoming less elastic, chest wall stiffens - basically you're showing signs of emphysema)
249
What is happening in COPD 3
- Loss of elastic recoil
- Airflow obstruction due to mucous hypersecretion, mucosal edema, and bronchospasm
- Inflammation from noxious particles and gas = damage to lung tissue, inflamed airways, parenchyma destroyed (type of lung tissue)
250
Do COPD have the same inflammatory cells reacting
No, they have different inflammatory cells reacting
251
Basically, what are the 4 pathophys changes caused by noxious particles and gases
- Inflammation of airways
- Peripheral airway remodeling
- Parenchymal destruction
- Pulmonary vascular changes (thick vessels, capillaries destroyed, arteries vasoconstrict)
252
What ends up happening in COPD 9
- Mucus hypersecretion
- Cilia dysfunction
- Airflow limitation
- Hyperinflation of lungs
- Alveolar destruction
- Loss of elastic recoil
- Gas exchange abnormalities
- Pulmonary hypertension
- Cor pulmonale
253
When structures in the lungs are destroyed from COPD, what do we see 3
- Air goes in easily, but remains in the lungs
- Bronchioles collapse
- Causes barrel-shaped chest
254
What would the alveoli look like in someone with COPD 2
- We would see bullae and blebs (large air spaces)
| - Fewer, larger alveoli
255
What can these pulmonary vascular changes result in
Pulmonary hypertension
256
What disease do we often see go with COPD
Cardiovascular disease
257
What clinical manifestations will we see with COPD 3
- Chronic cough or sputum production (usually in the morning)
- Dyspnea
- History of risk factors
258
How is dyspnea working with COPD
It comes on slowly, people may ignore it and state that they're just "out of shape," then it starts to get worse and interfere with their ADLs, then they start to have it even while at rest
259
Why does a COPD pt have chest breathing with COPD
The overinflated lungs have caused the diaphragm to flatten to accommodate the lungs. This forces the pt to become a chest breather, because they are relying more on intercostal and accessory muscles
260
What are some other clinical manifestations of COPD 5
- Chest breathing
- Wheezing and chest tightness
- Underweight and anorexic
- Chronic fatigue
- Paroxysmal coughing that is so severe that it may cause a pt to faint or fracture their ribs
261
What might we see if we examined someone with COPD 7
- Prolonged expiratory phase
- Wheezes
- Decreased breath sounds
- Increase in anterior-posterior diameter (barrel chest)
- Tripod position
- Pursed lip breathing
- Polycythemia (thickening of RBCs) and cyanosis
262
What does polycythemia and cyanosis look like? 6
- Hypoxemia (PaO2 less than 60 or SaO2 less than 88%)
- Hypercapnia (PaCO2 over 45)
- Increased production of red blood cells
- Bluish-red color of skin
- Hemoglobin concentrations my reach 20 g/dL
- Might see right-sided edema (indicates cor pulmonale
263
Why does polycythemia occur
Your body is trying to compensate by producing more RBCs when you are experiencing chronic hypoxemia
264
What could we use to determine the degree of COPD, and what would we find 2
- You could use a FEV1/FVC test . Less than 70% indicates COPD.
- You could also see an increased residual volume (they can take in air, but they can't get the air out)
265
Besides an FEV1/FVC test, what other diagnostic tests could you do to determine if someone has COPD 4
- Chest x-ray
- 6 minute walk test
- COPD Assessment Test (CAT)
- Clinical COPD Questionnaire (CCQ)
- ABGs
- Echocardiogram or multigated acquisition (MUGA) (cardiac blood pool) scan (look at heart function)
- Sputum for culture and sensitivity (for infection purposes)
266
What is a normal SaO2 reading for a pt with COPD
They usually live at or below 88%
267
What would you see on a chest x-ray that would indicate COPD
A flat diaphragm because of the hyperinflated lungs
268
Why would we get a culture and sensitivity for our COPDers
They tend to get chronic lung infections, like MRSA
269
What ABGs would we see for someone with late stage COPD 4
- Low PaO2
- Increased PaCo2
- Decreased pH
- Increased HCO3 (kidneys are trying to keep bicarbonate to help increase pH)
270
What are COPD complications 5
- Pulmonary hypertension which leads to cor pulmonale
- Exacerbations of COPD
- Acute respiratory failure
- Peptic ulcer disease
- Depression/anxiety
271
What is pulmonary hypertension
Constriction of the pulmonary vessels in response to alveolar hypoxia (Basically the blood vessels in the lungs are working super hard)
272
Do all COPD pts develop cor pulmonale
No
273
Is Cor pulmonale an early or late stage manifestation of COPD
Late stage
274
How does pulmonary hypertension lead to cor pulmonale
Now that the blood vessels are working super hard in the lungs due to the hypertension, this has caused pressure to increase on the right side of the heart, as it is working harder to push blood into the lungs. This increase in pressure leads to right sided heart failure.
275
What are signs and symptoms of cor pulmonale 5
- Dyspnea, possible lung crackles
(the below symptoms are all signs of right sided heart failure)
- Distended neck veins
- Hepatomegaly with right upper quadrant tenderness (enlarged liver with pain)
- Peripheral edema
- Weight gain
276
What diagnostic studies can you do to determine if someone has cor pulmonale 4
- Chest x-ray (large pulmonary vessels)
- Right sided cardiac catheterization (increased pressure)
- Echocardiogram (show right sided heart enlargement)
- BNP levels (shows heart failure)
277
How do we manage cor pulmonale
Continuous O2 and diuretics
278
What are COPD exacerbations
When someone with COPD is all of a sudden having pretty bad symptoms like increases in dyspnea, cough, sputum.
- Also look for other signs like malaise, insomnia, fatigue, depression, confusion, decreased exercise tolerance, increased wheezing or fever
279
When someone is having a COPD exacerbation, what should a nurse do 7
Determine the severity
- Are they using their accessory muscles
- Do we see cyanosis
- Do we see edema
- Is their BP unstable
- Are they alert
- Does their ABGs indicate respiratory acidosis
- Altered alertness
280
What are the primary causes of COPD exacerbations
- Bacterial and viral infections (increase in mucus production)
281
What treatments can we give for COPD exacerbations 4
- Short-acting bronchodilators
- Oral systemic corticosteroids (can be metered dose inhaler or nebulizer)
- Antibiotics
- Supplemental oxygen therapy
282
How can COPD cause acute respiratory failure 4
- Discontinuing bronchodilator or corticosteroid medication
- Overuse of sedatives, benzos and/or opioids (these can worsen your RR)
- Surgery or or severe, painful illness involving the chest or abdomen (just don't get enough air)
- Exacerbations (Typically COPD pts wait too longer to contact HCP when they have fever, increase cough, dyspnea or other exacerbation symptoms)
283
If a COPD pt becomes anxious, what can we teach them to do
Pursed lip breathing
284
How do we teach someone to do pursed lip breathing 4
- Inhale slowly and deeply through the nose
- Exhale slowly through pursed lips, as if whistling
- Do not puff out your cheeks
- Making breathing out 3 times a long as breathing in
285
What might we see being given for anxiety and depression for our COPD pts
buspirone (BuSpar) --- Never give benzos due to decrease in RR and habit forming
286
How will we tx a stable COPD pt 4. What will we evaluate and discuss with them?
- As outpatient (only hospitalized for exacerbations and respiratory failure)
- Evaluate for environmental or occupational irritants
- Discuss the flu and pneumococcal vaccines
- Discuss smoking cessation
287
What is the biggest thing you can do to lower your risk of developing and slowing down COPD
Smoking cessation
288
What drugs are we giving for someone with COPD
Bronchodilators
- B2 adrenergic agonists
- Anticholinergics
- Methylxanthines
289
How will bronchodilators help someone with COPD
- Relax smooth muscles in the airways
- Improve ventilation of the lungs
- Decrease dyspnea and increase FEV1
(usually inhaled)
290
Would we ever use a "step down" approach in medications with COPDers
No, because unlike asthma, COPD will continuously get worse, so they will "step up"
291
What short acting drugs will we probably give for COPD
Albuterol (SABA) or ipratropium (anticholinergic) (either together (combivent) or alone)
292
For moderate COPD, what medications are we probably using
LABA like salmeterol and formoterol
293
When would theophylline be used
When pts aren't responding with other treatments. We don't want to use this med often, because it can interact with other meds
294
What specific antibiotic may we give for someone with COPD. Why
Azithromycin, because it has anti-inflammatory effects and anti-mucus effects (they may take it orally everyday for this reason)
295
What is an oral drug that may be given for COPD. How does it work
Roflumilast (Phosphodiesterase inhibitor) (helps suppress the immune response and the production of O2 radicals)
296
What is different from COPD and asthma in terms of SABAs and LABAs
In asthma, a pt is always using SABAs and LABAs as dual therapy. However, in COPD, the pt can use LABAs only as a monotherapy
297
What is kind of the drug therapy pattern with COPDers
- Mild COPD/fewer symptoms = Short actings are used like albuterol and ipratropium (probably given as a combivent)
- Moderate COPD = using LABAs, like formoterol and salmeterol (SABA may or may not still be used for acute attacks)
- Severe COPD = ICS with a LABA combination like fluticasone/salmeterol or budesonide/formoterol
298
What are our oxygen goals for COPD pts
- Keeping SaO2 at least at 90% or above during all activities (sleep, rest, exertion) (you might also see a goal to keep above 88%)
- PaO2 at least above 60 mm Hg
299
What are the two methods of O2 delivery for COPDers
- Low-flow (most common), mixed with room air, less precise than high-flow
- High-flow using a venturi mask
300
To prevent the drying out and irritating effects of dry O2 delivery systems, what can be used to help
Can use nebulizers, vapotherm or bubble-through humidifiers (these attach to the O2 delivery device)
301
What are the complications from oxygen therapy 5
- Combustion
- CO2 narcosis (COPDer's bodys are use to having high amounts of CO2, so you could cause damage by giving them oxygen and throwing off that balance)
- O2 toxicity (high concentrations can cause an inflammatory response because of O2 free radical damage)
- Infection (humidifiers and nebulizers can have bacteria growth)
- Absorption atelectasis
302
What is the common bacteria that effects COPD pts due to humidifiers and nebulizers (it is also resistant)
Pseudomonas aeruginosa
303
What two things does chronic O2 therapy at home reduce
- Hematocrit
| - Pulmonary hypertension
304
What therapies can we do for COPDers 5
- Breathing retraining
- Effective coughing
- Chest physiotherapy (percussion, vibration, postural drainage)
- Airway clearance devices (ie the flutter, acapella)
- High-frequency chest wall oscillation (a vest that vibrates the chest)
305
What is the purpose of pursed lip breathing for COPDers 4 and what does it teach
- Prolongs exhalation
- Prevents bronchiolar collapse and air trapping
- Helps eliminate CO2
- Teaches pt to use "just enough" positive pressure
306
How do you use your peak flow meter (for asthma) 4
- Take a deep breath
- Blow on the mouth piece as hard and as fast as you can
- Record your number
- Repeat two mor times and write down your best number out of the three
307
Besides pursed lip breathing, what is another good breathing technique to teach for COPDers. What is good, what is bad
Diaphragmatic breathing
- Good because it teaches you to use your diaphragm instead of accessory muscles
- Helps achieve maximum inhalation and slows the RR
- Bad: may increase the workload of breathing and cause dyspnea
308
What is a different type of coughing technique you can teach your COPD pts
Huff coughing (forces secretions into your larger airways)
309
Talk more about postural drainage for COPDers 5
- Tx is individualized
- Usually ordered 2-4 times per day
- In position for 5 minutes with percussion and vibration being used
- Done 1 hr before meals and 3 hrs after meals
- Cannot be used on unstable pts (traumatic brain injury, chest trauma, hemoptysis, heart disease, pulmonary embolus)
310
Discuss a flutter mucus clearance device
- Provides positive expiratory pressure (PEP) tx
| - When pt blows on the device, it produces vibrations in the lungs to loosen up the mucus
311
When thinking about our COPD pts, what is our biggest goal of therapy
Clearing those secretions
312
What describes malnutrition in COPDers 3
It is multifactorial (caused by a lot of different things)
- Increased inflammatory mediators
- Increased metabolic rate (from ventilatory effort - using more energy to breathe)
- Lack of appetite
313
What is some pt teaching that we can provide to help decrease dyspnea and conserve energy when eating 6
- Rest at least 30 minutes before eating
- Avoid exercise for 1 hr before and after eating
- Use bronchodilator
- Use supplemental O2
- Eat high-calorie, high-protein diet
- Eat five-6 small meals a day to avoid bloating and early satiety
314
What are the 4 diff types of surgical interventions you can have for COPD
- Lung volume reduction surgery (LVRS)
- Bronchoscopic lung volume reduction surgery
- Bullectomy (to remove air pockets)
- Lung transplantation
315
What is happening in lung volume reduction surgery (LVRS)
- Removing diseased lung to enhance performance of the remaining healthy lung
- Results in decreased airway obstruction and increased room for remaining normal alveoli to expand
316
What is happening in a bronchoscopic lung volume reduction surgery
- One way valves are placed into the airways leading to the diseased parts of the lungs
- Collapses a certain segment of the lung
- Results in decreased airway obstruction and allows the remaining lung to function
317
What is happening in a bullectomy
Large bullaes (air sacs from destroyed alveoli) are removed
318
What drug, if possible, should not be given to COPDers. why
Nonselective beta blockers, because they can block lung receptors
319
What co-morbidities can make COPD complicated for our geriatrics
- Cardiovascular disease
- Serious infections
- Osteoporosis
- Psychologic problems (reduced lean body mass, decreased respiratory muscle strength, increased dyspnea, lower exercise tolerance)
- Impaired cognition
- Lung cancer
320
What is a good exercise regimen to teach COPDers
Walk 15-20 minutes a day at least 3 times a week with gradual increases
321
What can help COPDers with sleep
Nasal saline sprays, decongestants, nasal steroid inhalers
322
What do we need to worry about with decongestants
They can increase BP, so just be aware
323
What are serious topics of discussion for COPDers
Discussing palliative, end-of-life care, hospice and advanced directives
324
What is the most modifiable risk factor in the development of cardiovascular disease
Hypertension
325
Once you have high BP, what are you more at risk for 4
- MIs
- Heart failure
- Stroke
- Renal disease
326
What is elevated BP
120-129/80
327
What is the BP for stage 1 hypertension
130-139/80-89 (either)
328
What is the BP for stage 2 hypertension
140/90 (either)
329
What is the BP for hypertensive crisis
180/120 (either)
330
What two functions determine BP
Cardiac output multiplied by systemic vascular resistance
331
What is cardiac output
The amount of blood being pumped out of the heart per minute
332
What is systemic vascular resistance (SVR)
Force stopping blood from pumping (ie narrow arteries)
333
What is the pathway of blood in the heart
- deoxygenated blood flows from the right atrium to the right ventricle where it goes to the lungs to get oxygen
- Oxygenated blood flows from the lungs to the left atrium, to the left ventricle where it is pumped out through the aorta
334
What system kicks in when your BP drops
Your sympathetic nervous system, which tells your heart to speed out and increase contractility, causes vasoconstriction and renin release (renin increases your BP), which then increases CO and SVR
335
How do baroreceptors influence BP
They are sensitive to the stretching of of blood vessels. So when they are stimulated by an increase in BP, they send signals to the sympathetic vasomotor center to stop, which results in a decrease in HR, force of contraction and vasodilation. When they sense a fall in BP, they tell the SNS to get their butt in gear, which leads to constriction, increased HR and increased contractility of the heart.
336
How does hypertension affect baroreceptors
The baroreceptors become adjusted to elevated BP levels and recognize this level as their new "normal"
337
How does vascular endothelium cells play a role in controlling BP
These cells maintain dilation and constriction
338
What two things can damage endothelium cells
- Smoking
| - Diabetes
339
How can the kidneys impact BP 3
- Control of sodium
- RAAS system
- Prostaglandins
340
How does sodium control impact BP
The kidneys are responsible for excreting sodium. If they don't excrete enough sodium, then more sodium stays in the body. Water follows sodium, so you will have an increase in fluid. This increase in fluid causes the pressure in the body to increase, resulting in high BP
341
How does the RAAS system impact BP
The kidneys will secrete renin when there is a decrease in blood flow through the kidneys or a decrease in sodium concentration. Renin then converts agiotensinogen to angiotensin I, which is then converted to angiotensin II via ACE enzyme. This angiotensin II increases BP by vasoconstriction, which increases the SVR, and this results in an immediate increase in BP. Then over a period of hours or days, it increases BP indirectly by stimulating the adrenal cortex to secrete aldosterone.
342
How do prostaglandins impact BP
They cause vasodilation
343
What endocrine hormones come into play with BP 3
- Epinephrine and norepinephrine
- Aldosterone
- ADH
344
How does epinephrine and norepinephrine influence BP
Increases CO by increasing HR, myocardial contractility and vasoconstriction of peripheral arterioles
345
How does aldosterone influence BP
It tells your kidneys to keep sodium, which then causes your body to keep water, which then causes your BP to go up due to the increase in fluid volume
346
How does ADH influence BP
It tells your body to retain water, which will increase blood volume and cardiac output
347
What is primary hypertension
Hypertension without an identified cause, but there are multiple contributing factors (most common)
348
What are risk factors for primary hypertension (there's a bunch)
- Age (vessels lose their elasticity)
- Alcohol (releases renin which causes your vessels to constrict)
- Smoking (vasoconstrictor)
- DM (damages arteries)
- Elevated serum lipids
- Excess dietary sodium
- Gender (women are higher after menopause)
- Family History
- Obesity (heart has to work harder)
- Ethnicity
- Sedentary lifestyle
- Socioeconomic status (education level)
- Stress
349
What should be the max number of alcoholic drinks per day
No more than 3
350
What is the hallmark of primary hypertension
Persistently increased system vascular resistance (SVR)
351
What can lead to the development of primary hypertension 6
- Genetics
- Water and sodium retention
- Stress and increased SNS activity
- Altered RAAS
- Insulin resistance
- Endothelial dysfunction (heart cells)
352
What is the genetic link with sodium and primary hypertension
People can eat the same amount of sodium, but only some will get hypertension from it. This indicates a genetic link, where some people are more sensitive to sodium then others
353
How does insulin resistance lead to primary hypertension
High insulin levels can stimulate the SNS and cause vasodilation, vascular hypertrophy (thickening of muscle) and increase sodium reabsorption
354
What is secondary hypertension
Caused by something specific
355
How do you treat secondary hypertension
Remove/fix the cause
356
What are causes of secondary hypertension 8
- Coarctation of aorta (narrow aorta due to birth defect)
- Renal disease (where you're getting low blood volume to the kidneys, which then forces your kidneys to retain sodium, which leads to fluid retention)
- Endocrine disorders (hormone imbalances, pituitary, aldosterone, hyperthyroidsm makes your HR increase, hypothyroidism makes HR less efficient, cushings)
- Neurologic disorders (tumors)
- Cirrhosis (portal vein will get backflow)
- Pregnancy (ie having multiples, being older, etc)
- Sleep apnea (brain increases HR and BP during sleep apnea to try and save you when you stop breathing)
- Various drugs (ie meth - increase HRs, estrogen)
357
What is unique about the symptoms of hypertension in the beginning
It is known as the "silent killer" because there usually aren't any symptoms
358
What are symptoms of severe hypertension (hypertensive crisis) 7
- Fatigue
- Dizziness
- Palpitations
- Angina
- Dyspnea
- Nosebleeds
- Anxiety
359
What are complications of hypertension 5
When organs start to be impacted by hypertension, this includes:
- heart
- brain
- peripheral vascular disease (vessels)
- kidney
- eyes
360
What kinds of things can happen to your heart from hypertension 3
- Coronary artery disease (narrowing of arteries, hardening of arteries)
- Left ventricular hypertrophy (heart is working so hard)
- Heart failure (these lead to heart failure - heart can't take anymore)
361
What are symptoms of HF 2
- SOB, especially at night
| - Fatigue
362
How can hypertension damage the brain 2
- High BP can cause cerebral edema, which is intercranial pressure
- Stroke
363
How can your eyes be impacted by hypertension
We can see damage to the vessels from the increase in pressure
364
How should we measure BP 2
- Take two or more readings at separate occasions in a consistent manner (ie same time of the day, same sitting position)
- Measure BP on both arms for the first time to determine the diff., use the higher reading after that.
365
What diagnostic is usually ordered for hypertension evals. Why
Ambulatory blood pressure monitoring (ABPM)
- Helps determine a more accurate BP incase someone is having "white coat" hypertension (from being in the doctors office)
366
How does ABPM work
Automated system that measures BP at intervals over a 12-24hr period.
- Record activities and reading in diary
- Keep arm still by their side when monitor is trying to get a reading
367
Once BP is stable, how often will it be checked
Once every 3-6 months to see how they are responding to tx
368
What diagnostic assessments (besides ABPM) are we doing for hypertension (there's a lot)
- UA
- BUN/creatinine
- Creatinine clearance
- Electrolytes
- Glucose
- Lipids
- Uric acid levels (want baseline, because diuretic therapy will increase uric acid levels)
- CBC
- Thyroid function
- LFTs
- ECG
- Echo
- Ophthalmic exam
369
What pt teaching can we give to help modify lifestyle factors of hypertension 7
"Life's simple 7"
- Manage BP
- Control cholesterol
- Reduce blood sugar
- Get active
- Eat better
- Lose weight
- Stop smoking
370
A weight reduction by how many pounds may decrease SBP by approx. 5-20mm Hg
22lbs (10kg)
371
What does the DASH diet help you do
Lower BP and LDLs
372
What things are they eating on a DASH diet 9
- Fruits
- Veggies
- Fat-free/low-fat milk
- Whole grains
- Fish
- Poultry
- Beans
- Seeds
- Nuts
373
What is the max amount of sodium intake for the average adult
2300mg or less
374
What is the max amount of sodium intake for a high risk pt
1500mg or less
375
What is the recommended amount of moderate-intensity aerobic activity per week (if they don't do vigorous)
150 min/week
376
What is the recommended amount of vigorous-intensity aerobic activity per week (if they don't do moderate)
75min/week
377
How often should you do muscle-strengthening and flexibility and balance exercises
2 times a week
378
How many drinks put you at risk for hypertension
3 or more
379
What is the alcohol limit for men and women
Men should have no more than 2 drinks/day and women should have no more than 1 drink/day
380
When can pts notice changes in their cardiovascular health after they stop smoking
They can notice changes within 1 year
381
What do ACE inhibitors end in
Pril
382
What do ARBs end in
sartan
383
What do alpha blockers end in
osin or zosin
384
What do beta blockers end in
lol
385
What do calcium channel blockers end in
dipine
386
What do diuretics end in
ide
387
How do ACE inhibitors work
They prevent the conversion of angiotensin I to angiotensin II (angiotensin II causes vasoconstriction and sodium and water retention)
388
What is an ACE inhibitor drug
Lisinopril
389
What are some nursing considerations to remember about ACE inhibitors 4
- NSAIDs and aspirin may reduce effectiveness
- Can use with diuretics, except potassium sparing diuretics
- Can increase creatinine levels (because they can decrease blood flow to kidneys, which can lead to kidney damage)
- Pts may have a dry, hacking cough
390
What should you remember about lisinopril 3
- You can have angioedema (everything swells, notably the lips and tongue)
- Dry, cough
- Hyperkalemia
391
How do angiotensin II receptor blockers (ARBs) work
They block angiotensin II from binding to receptors in the walls of blood vessels
392
What is the most common ARB prescribed
losartan
393
What are some nursing considerations for ARBs 3
- Teach pts it may take 3-6 weeks to see full effects
- Will usually be given instead of ACE inhibitors when pts have a dry cough from ACE inhibitors
- Do not combine with ACE inhibitors due to adverse renal effects
394
How do alpha blockers work
They block alpha1 receptors on blood vessels, thereby preventing sympathetic catecholamines such as norepinephrine and epinephrine from binding. This causes decreased vasoconstriction and blood pressure. (Basically, they stop the fight or flight response from the SNS)
395
What is the more common alpha blocker
Prazosin
396
What are some nursing considerations for alpha blockers 2
- Teach pts to take at bedtime to reduce risks associated with orthostatic hypotension
- Teach pts to change positions slowly due to orthostatic hypotension
397
How do beta blockers work
Block beta 1 receptors in the heart, thereby preventing sympathetic catecholamines such as norepinephrine and epinephrine from binding. This causes a decrease in HR, stroke volume, CO and BP.
398
What is the diff between alpha and beta blockers
The receptors in beta blockers are actually located in the heart, whereas alpha receptors are located in blood vessels
399
What are 3 common beta blockers
- Atenolol
- Metoprolol
- Propranolol
400
What are nursing considerations for beta blockers 6
- Monitor BP and pulse regularly
- Use with caution in diabetics (can suppress tachycardia related to hyperglycemia and it can effect glucose metabolism)
- Drug of choice for pts with history of MI/HF
- Less effective in African American pts
- Esmolol IV only
- May cause bronchospasm in pts with asthma ( do not give)
401
What might be good to take with someone who is taking metoprolol
Their apical pulse
402
How do calcium channel blockers work
They block the calcium channels of vascular smooth muscle cells on the cardiac cells, which decreases smooth muscle contraction, vasoconstriction and blood pressure
403
What are the two main types of calcium channel blockers. What's the diff.
Dihydropyridines (more common, because they're more effects) and non-dihydropyridines. Dihydropyridines effect blood vessels, while non-dihydropyridines effect the heart
404
So what does calcium do when it enters these cells
It causes contraction and constriction, so if you block these channels, you could decrease contraction and constriction = lowers BP
405
What is the most common calcium channel blocker
Amlodipine
406
What are nursing considerations for calcium channel blockers
- Be aware they are more potent vasodilators, so be careful mixing with other vasodilators
- Clevidipine is for IV use only
- Only use IV nifedipine for emergencies
- Serious effects have occurred, like MIs and CVAs
407
How do diuretics work
They stop the reabsorption of sodium, which causes water to follow sodium out of the body, which decreases BP
408
What are the 3 main types of diuretics
- Loop diuretics
- Thiazide diuretics
- Potassium sparing diuretics
409
What is the most common loop diuretic. And what should you monitor
Furosemide. Monitor for orthostatic hypotension and electrolyte imbalances
410
What is the most common thiazide diuretic, and what should you monitor
Hydrochlorothiazide. Monitor for hypotension and hypokalemia. May need potassium supplements. Also, reducing sodium can help reduce the risk for hypokalemia.
411
What is the most common potassium sparing diuretic, and what should you watch for.
Spironolactone. Monitor for orthostatic hypotension, hyperkalemia. Do not give to someone with renal failure. Avoid potassium supplements.
412
What drugs do you want to avoid with potassium sparing diuretics
ACE inhibitors or ARBs, because they can cause hyperkalemia
413
What are the only 2 drugs that lower both SVR and SV
ACE inhibitors and ARBs (so they work on both decreasing how often the heart pumps (SV) and decrease resistance in the vessels (SVR))
414
What are the only 2 drugs that lower SVR only
Alpha blockers and calcium channel blockers
415
What is the only drug that lowers HR and SV
Beta blockers
416
What is the only drug that lowers SV only
Diuretics
417
What is a good way to remember the names of our ACE inhibitors suffix
Think of April (A for ACE and the suffix "pril" for our drugs)
Or you gambled away your "pril" necklace playing cards
418
What is a good way to remember the ARBs suffix
Both ARBs and the suffix "sartan" have AR in it
419
What is a good way to remember alpha blocker ssuffix
Alphas will be the first to get to the "osin"
420
What is a good way to remember calcium channel blockers suffix
Happy cows live in California, and California has a lot of "PINE" trees
421
What is a good way to remember diuretics suffix
You want to h"ide" from your pt when they have diuretics, because they will need to pee a lot
422
What is some good pt teaching in regards to hypertensive drugs 4
Encourage the pt to report all side effects such as
- Orthostatic hypotension
- Sexual dysfunction (common with these drugs)
- Dry mouth (diuretics)
- Frequent urination (diuretics)
423
What is dangerous about sexual dysfunction and hypertensive drugs
Sexual dysfunction may cause males to stop taking their meds, which can be very dangerous. Have them notify their HCP, who can help with switching to another med that may not cause this problem
424
How do you measure BP for orthostatic hypotension 3
- Take BP and pulse when pt is supine, sitting and standing
- Measure within 1-2 minutes of position changes
- Pt has orthostatic hypotension if their SBP drops 20 points, if their DBP drops 10 points or if their HR increases by 20 beats
425
How does aging affect your risk for developing hypertension 3
- You have altered drug absorption, metabolism and excretion
- Increased risk of orthostatic hypotension due to low volume, decreased renal/hepatic function and electrolyte imbalances (basically not taking in enough fluids)
- Postprandial drops in BP, where their BP drops about 1 hour after eating and then returns 3-4 hrs after eating (this can lead to orthostatic hypotension)
426
What BP indicates a hypertensive crisis
BP over 180/120 (can even be 240/140)
427
What are the two types of hypertensive crisis
- Hypertensive urgency (no evidence of target organ disease)
- Hypertensive emergency (target organ disease, usually requires hospitalization)
428
What can hypertensive emergencies lead too 7
- Encephalopathy (brain damage)
- Intracranial or subarachnoid hemorrhage
- HF
- MI
- Renal failure (not getting enough blood flow to the kidneys)
- Dissecting aortic aneurysm (the aorta is torn)
- Retinopathy
429
What if hypertensive emergencies go untreated
Most people will die within 1 year
430
What things can increase your risk of having a hypertensive emergency
- Not taking your meds as prescribed
| - Doing drugs like crack and cocaine
431
What are symptoms of hypertensive encephalopathy 6
- Severe headache
- nausea
- Vomiting
- Seizures
- Confusion
- Common
(these symptoms are caused by cerebral edema and disruption of cerebral function)
432
What are symptoms of an aortic dissection
Severe chest and back pain with reduced or absent pulses in extremities
433
When someone is having a hypertensive emergency, do we treat based on their BP
No, treat based on their MAP (mean arterial pressure)
434
If the pt is stable in their hypertensive emergency, how should we lower their BP. What happens if we do it too quickly
Slowly, over a 24hr period. If it's too quick, it can cause a decrease in perfusion to organs, and may cause a stroke, MI or renal failure.
435
Do hypertensive urgency cases need IV therapy
No, they are usually treated with oral hypertensives
436
How do you calculate the MAP
(SBP+2DBP)/3
437
What do most people need their MAP to be in order to have adequate perfusion. What is normal
At least 60. Usually anything between 70-100.
