Respiratory problems Flashcards
Bronchodilators
- Beta 2 agonists
- Cholinergic antagonists (anticholinergics): ipratropium (Atrovent)
- Methylxanthines: theophylline (Theo-Dur)
Albuterol (Proventil)
short-acting beta 2 agonist (SABA) : rapid but short-term relief; causes bronchodilation by relaxing bronchiolar smooth muscles .
Inhaler
Albuterol : use
primary - fast acting rescue drug to be used either during an asthma attack or just before engaging in activity that usually triggers an attack
Albuterol: nursing interventions
- carry at all times;
- monitor HR: can cause tachycardia
- use 5 min before the other inhaled drug
Anti-Inflammatory Agents
- Corticosteroids
- NSAIDs
- Leukotriene antagonist
- Immunomodulator
Fluticasone (Flovent)
inhaled corticosteroid; disrupts all known production pathways of inflammatory mediators.
MDI or DPI inhalers
Flovent : use
The main purpose is to prevent an asthma attack caused by inflammation or allergies.
Flovent: nursing interventions
- Use daily , even if no symptoms are present
- Perform good mouth care and check mouth daily for lesions or drainage (drug reduced local immunity - risk for local infection - Candida albicans - yeast)
- not to use with onset of asthma symptoms ( drug has slow onset of action and does not relieve symptoms)
Prednisone ( Deltasone)
oral corticosteroid; not recommended unless asthma symptoms cannot be controlled with any other therapy; rescue drug .
Prednisone side effects:
- GI ulceration
- fat redistribution
- weight gain
- hyperglycemia
Prednisone: nursing interventions
- avoid anyone who has upper respiratory infection (drug reduces all protective inflammatory responses)
- avoid activities that lead to injury ( blood vessels become more fragile , leading to bruising and petenchie)
- take drug with food ( to reduce the risk for GI ulceration)
- do not suddenly stop taking the drug ( if vomiting - receive the drug parenterally) - drug suppresses adrenal production of corticosteroids.
Ipratropium (Atrovent)
cholinergic antagonist : both rescue and prevent asthma; used in place of SABA by patients who cannot tolerate side effects of beta 2 agonists: tachycardia, nausea, nervousness.
Mouth dryness - drink 4 L of fluid daily
Asthma and exercise
regular exercise (aerobic ) recommended: assist in maintaining cardiac health, enhancing skeletal muscle strength and promoting ventilation and perfusion.
Asthma and oxygen therapy
delivered by mask, NC, or endotracheal tube;
Heliox ( 50 % helium + 50 % of oxygen) can help improve oxygen delivery to the alveoli.
Status Asthmaticus
severe, life-threatening acute episode of airway obstruction that intensifies once it begins.
S/S: extremely labored breathing and wheezing - if not reversed - pneumothorax and cardiac or respiratory arrest !!!
TX: IV fluids, systemic bronchodilators, steroids ( decrease inflammation), epinephrine, oxygen.
Asthma S/s:
- Dyspnea (SOB)
- Chest tightness
3, Coughing - Wheezing
- Increased mucus production
- Use of accessory muscles (muscle retraction)
- Possible barrel chest
- Cyanosis of oral mucosa and nail beds
FVC
forced vital capacity : volume of air exhaled from full inhalation to full exhalation.
FEV1
forced expiratory volume in the first second
PEF
peak expiratory flow : fastest airflow rate reached at any time during exhalation
Asthma - inflammation
obstructs lumen (inside) ;can be caused by allergens attaching to antibodies which are
attached to mast cells and basophils (WBC)
-can also be cause by general inflammatory triggers not related to allergic responses.
Inflammation triggers:
cold air dry air fine airborne particles microorganisms aspirin (increase in leukotrienes)
Asthma - airway hyperresponsiveness
twitchy airways; obstructs airways ( outside) constricting bronchial muscles
Airway hyperresponsiveness triggers
exercise
upper respiratory illness
inflammation
unknown
Asthma labs:
- ABGs : decrease in PaO2
early : decrease in PaCO2 ( increase in RR)
later: increase in PaCO2 (poor gas exchange; CO2 retention) - Allergic asthma: increase in serum eosinophil count
increase in IgE levels (immunoglobulin E) - PFT: pulmonary function test
The Step System
- 1 – Mild Intermittent
- 2 – Mild Persistent
- 3 – Moderate Persistent
- 4 – Severe Persistent
- 5 – Severe Persistent Not Responsive to Previous Step
- 6 – Severe Persistent Not Responsive to Previous Step
Asthma : Goal
increase symptom-free periods, less hospital stays
Asthma: patient education
• Avoid environmental triggers
• Avoid trigger meds (ASA, NSAID’s, beta-blockers)
• Proper use and compliance with medications and metered dose inhalers (teach
patient to always carry the rescue drug inhaler with them)
• Monitor peak expiratory flow rates with a peak flow meter at least twice daily
• When to seek emergency care
Emphysema classic symptoms:
1 – loss of lung elasticity 2 – hyperinflation of the lungs • Air becomes trapped in the lungs • Loss of recoil in alveolar walls • Overstretched and enlarged alveoli - bullae • Use of accessory muscles for breathing
Emphysema: “air hunger”
need for oxygen ; Inhalation starts before exhalation is completed - uncoordinated patter of breathing
Proteases
enzymes that destroy and eliminate protein-based particulate matter and organisms inhaled during breathing;
if present in higher than normal levels: damage the alveoli and small airways by breaking down elastin ( alveolar sacs loose their elasticity).
Emphysema classification :
- An alveolar problem (loss of alveolar tissue)
- Classified as panlobular, centrilobular, or paraseptal depending on the pattern of destruction and dilation of the gas-exchanging units - acini
Chronic bronchitis
• Inflammation of the bronchi and bronchioles
• Affects only the airways and not the alveoli
The irritant triggers inflammation, with vasodilation, congestion, mucosal edema, and bronchospasm
Chronic bronchitis: causes
- increase in number of mucous glands
- increase in size of mucous glands
- thickened bronchial walls
- increased and excessive mucus production
- mucous plug formation
- PaO2 decreases - hypoxemia
- PaCO2 increases - respiratory acidosis
COPD and cigarette smoking
Most important risk factor !!!
8-pack-year history : obstructive lung changes;
20-pack-year history : early -stage COPD
Inhaled smoke triggers the release of excessive amounts of the proteases from cells in the lungs: break down elastin; impairing the action of cilia ( from clearing bronchi of mucus, cellular debris, and fluid).
COPD and AAT
Alpha 1-antitrypsin - Protease Inhibitor;
• Enzyme made by the liver to function in lungs - regulates proteases (which break down pollutants)
• Prevents proteases from breaking down lung structures
- depends on the inheritance of a pair of normal gene alleles for this protein .
COPD complications:
- Hypoxemia
- Acidosis
- Respiratory infection
- Cardiac failure (esp. cor pulmonale: right sided heart failure caused by pulmonary disease)
- Cardiac dysrhythmias
Obtain smoking history
- length of time the patient has smoked ;
- the number of packs smoked daily
to determine the pack - year smoking history
COPD: assessment
- Smoking history
- Description of breathing difficulties: wheezing, SOB, difficulty with breathing with speaking, cough/cough pattern, orthopnea
- Appearance: thin with loss of muscle mass in extremities
- Person usually sits in a forward-bending posture (tri-pod)
- L ABS ABG’s; sputum samples; Hgb and Hct
- Chest X-ray
- PFT
Orthopnea
breathlessness is worse when lying down ( many patients sleep in semi-sitting position
COPD: nursing diagnosis
- Impaired Gas Exchange
- Ineffective Breathing Problems
- Ineffective Airway Clearance
- Activity Intolerance
- Fatigue
- Imbalanced Nutrition
- Anxiety
- Sleep Deprivation
- Impaired Thought Processes
- Knowledge Deficit
- Sexual Dysfunction
- Ineffective Coping
COPD: interventions
• Airway maintenance and monitoring• Mucolytics to thin mucus secretions
• Expectorants
• Corticosteriods
• Couch enhancement
• Oxygen therapy (2-4L)
• Energy conservation (space out ADL’s/take breaks)
• Surgery: lung transplantation
• Homecare management: O2; pulmonary rehabilitation
programs
Expectorants:
mycolytics which thin secretions, making them easier to expectorate
Breathing techniques :
- diaphragmatic/abdominal breathing: use abd mucles to blow out as much air as can
- pursed-lip breathing: breath in through nose then purse lips when
breathing out as if whistling - planned/controlled coughing especially in morning and at mealtimes
Chest physiotherapy:
- postural drainage
- suctioning prn
- positioning and hydration
Pneumonia :
- Inflammatory process resulting in excess fluid in the lungs
- Inflammation can be in interstitial spaces, alveoli and bronchioles
- Triggered by infective/irritating organisms (many different kinds)
- Results in reduced oxygenation and tissue perfusion
- Can be nosocomial (HAP) or community (CAP)
HAP: risk factors
- Older adult
- Has chronic lung disease
- Altered LOC
- Poor nutritional status
- Immunocompromised
- Receiving mechanical ventilation
- Has NG, endotracheal or tracheostomy tube
CAP: risk factors
- Older adult
- Never received pneumonia vaccine or received more than 6 years ago
- Tobacco or alcohol use
- Has chronic health problem or other coexisting conditions
Pneumonia: S/s
- Flushed cheeks, bright eyes, anxious expression
- Chest or pleuritic pain or discomfort
- Hemoptysis; increased fatigue; cyanosis
- Headache; fever; chills; cough; sputum production
- Tachycardia; dyspnea; tachypnea
- Crackles - fluid
- Wheezing - inflammation and exudate in airways (narrowing)
- Tactile fremitus is increased over pneumonia consolidated areas; dulled percussion over these areas
Pneumonia: DX
- Diminished chest expansion and/or unequal on inspiration
- May be hypotensive with orthostatice changes
- Rapid weak pulse (dehydration)
- LABS: CBC (inc WBC); hypernatremia and inc BUN may be result of dehydration
- Chest x-rays (shows changes only until 2 or more days after manifestations are present): appears as area of increased density
- Thoracentesis if accompanying pleural effusion
Pneumonia: nursing diagnoses and intervention
- Similar and comparable to those symptoms of COPD
- Pts have potential for sepsis - eradication of the organism causing the infection
- Meds similar
- Antibiotics : Ampicillin/sulbactam (Unasyn); Azithromax (Zithromax); Levofloxacin (Levaquin); Vancomycin (Vancocin)
Pulmonary Tuberculosis (TB)
- Highly communicable; caused by Mycobacterium tuberculosis
* Airborne transmission
TB: assessment
• Has a slow onset and often symptoms not significantly recognizable until further advancement – can be several months • S/S: 1. persistent cough (mucopurulent with possible blood streaks) 2. fatigue 3. lethargy 4. nausea 5. anorexia; weight loss 6. irregular menses 7. low grade fever; night sweats
TB: labs
- Positive smear for acid-fast bacillus (AFB)
- Tuberculin test (mantoux test)
- Chest X-ray confirms diagnosis following a positive TB skin test
TB: nursing diagnosis
- Impaired gas exchange• Fatigue
- Imbalanced nutrition
- Social isolation
- Deficient knowledge
TB: interventions
• Drug therapy: Isoniazid (INH); Rifampin
• Additional drug therapy: Pyrazinamide; Ethambutol; (antiemetics for nausea
possibly caused by above TB drugs)
• Pt put on airborne precautions in hospital – room with ventilation of 6 exchanges of
fresh air per minute
• Health care workers must wear special mask/respirator
• Can be managed at home
Rifampin (RIF) : action
kills slower-growing organisms, even those that reside in macrophages and caseating granulomas
Rifampin : nursing interventions
- Expect the drug to stain the skin and urine and other secretions - reddish-orange tinge; + soft contact lenses will become permanently stained. ( harmless)
- Women using oral contraceptives - use additional protection while taking this drug + 1 month after.
- Avoid drinking alcoholic beverages while on this drug ( can cause liver damage).
- Risk for liver toxicity or failure : darkening of the urine, yellow skin or whites of the eyes; increase tendency to bruise or bleed.
- Ask patient about all other drugs in use ( interacts with many drugs).
Guaifenesin
expectorant - thin secretions
Bactericidal
Bacteria killing
Acetylcysteine ( Mucomyst)
mycolytic - destroys or dissolves mucus
Bacteriostatic
Inhibiting growth or multiplication of bacteria
Chronic bronchitis and hypoxia
Large amount of thick mucus ( impaired gas exchange )
Pneumonia, pulmonary embolus
altered alveolar capillary diffusion
Step 1 : Mild intermittent asthma
symptoms less the once/week ; night symptoms less than 2/month; no daily drugs; rescue drug - SABA inhaler : Albuterol
Step 2 : Mild persistent asthma
symptoms more than 1/week ( but not daily); night symptoms more than 2/month; daily ICS low dose: Flovent; rescue inhaler
Step 3 : Moderate persistent asthma
symptoms daily; night symptoms more than 1/week; low dose ICS + LABA : Salmeterol (Serevent) or ICS alone - medium dose range
Step 4: Severe persistent asthma
symptoms daily; night symptoms frequently; limited activity; ICS (medium) + LABA
Step 5: Severe persistent asthma not responsive to previous step
ICS ( high) + LABA
Step 6: Severe persistent asthma not responsive to previous step
ICS (high) + oral corticosteroids: Prednisone (Deltasone ) + LABA
