Week 2 Material Flashcards
what is COPD?
- Encompasess emphysema and chronic bronchitis
- Irreversible
- Characterized by the loss of lung elasticity and hyperinflation of the lung tissue
emphysema
- causes destruction of the alveoli leading to a decreased surface area of gas exchange, carbon dioxide retention and respiratory acidosis
bronchitis
- An inflammation of the bronchi and bronchioles due to chronic exposure to irritants
risk factors for COPD
- Advanced age: older clients have decreased pulmonary reserve due to normal lung changes
- Cigarette smoking is the primary risk factor for COPD
- Alpha 1 - antitrypsin (AAT) deficiency
- Exposure to environmental factors - air pollution
health promotion and dz prevention for COPD
- Promote smoking cessation
- Avoid exposure to secondhand smoke
- Use protective equipment, such as a mask, and ensure proper ventilation while working in environments that contain carcinogens or particles in the air
- Influenza and pneumonia vaccinations are important for all clients who have COPD, but especially for older adults
assessment of clients with COPD
- Dyspnea upon exertion
- Productive cough that is most severe in AM
- Hypoxemia
- Crackles and wheezes
- Rapid and shallow respirations
- Use of accessory muscles
- Irregular breathing pattern
- Thin extremities and enlarged neck muscles
- Dependent edema secondary to RHF
- Clubbing of fingers and toes - late stages
- Pallor and cyanosis of nail beds and mucous membranes - late stages
- Decreased O2
- Barrel chest or increased chest diameter (w/emphysema)
- Hyperresonance on percussion ( w/ emphysema)
lab tests necessary for COPD
- Inc hematocrit due to low O2
- Use sputum cultures and WBC counts to diagnose acute respiratory infections
- ABGs
- Hypoxemia PaO2 < 80mmHg
- Hypercarbia PaCO2 >45 mmHg
- Serum electrolytes
what are the diagnostic procedures used for COPD?
- pulmonary function tests
- chest x ray
- pulse oximetry (will be less than normal, <95%)
- alpha 1 antitrypsin levels
pulmonary function test for COPD
- Forced expiratory volume (FEV) to Forced vital capacity (FVC) are used to classify COPD as mild to severe
- FEV to FVC ratio decreases over time
- Expected 100%
- Mild COPD <70%
- Moderate to severe COPD <50%
- FEV to FVC ratio decreases over time
chest x ray for COPD
- Reveals hyperinflation of alveoli and flattened diaphragm in the late stages of emphysema
- Not useful for diagnosis of early or mod dz
alpha 1 antitrypsin levels for COPD
- Used to assess for deficiency in AAT
- An enzyme produced by the liver that helps regulate other enzymes and help break down pollutants from attacking lung tissue
nursing care for COPD
- High Fowler’s position
- Encourage effective coughing or suction to remove secretions
- Encourage deep breathing and incentive spirometer
- Breathing tx and meds
- Administer O2
- Monitor skin breakdown (especially nose and mouth for O2 devices)
- Promote adequate nutrition
- Monitor weight
- Use breathing techniques to control dyspneic episodes
- Breathe from diaphragm, lie on back with knees bent, rest hand over abdomen
- Pursed lip breathing
- COPD can need up to 4L/min of O2
- Provide support
- Teach about home care services esp home O2
- Encourage verbalization of feelings
what is important to remember about promoting adequate nutrition for patients with COPD?
- Increased work of breathing = increase calories
- Proper nutrition prevents infection
- Encourage fluids to promote hydration
- Dyspnea dec energy available for eating
incentive spirometer use for COPD
- Monitor optimal lung expansion
- Show client how to use it
- Tight mouth seal
- Inhale and hold breath for 3-5 seconds
- Promotes lung expansion
list the classes of medications used to tx COPD
- bronchodilators
- anti-inflammatory agents
- mucolytic agents
name the types of bronchodilators used for COPD
- short acting beta2 agonist
- cholinergic antagonists/anticholinergic medications
- methylxanthines
short acting beta 2 agonists for COPD
- type of bronchodilator
- ie. albuterol: provides rapid release
- ADR: tremors and tachycardia
-
pt teaching:
- inc fluid intake
- report HA or blurred vision
anticholinergic medications for COPD
- type of bronchodilator
- ie. ipratropium
- blocks the parasympathetic NS
- allows for sympathetic NS effects of inc bronchodilation and dec pulmonary secretions
- long term: prevent bronchospasms
-
pt edu:
- observe for dry mouth: can use hard candies to help relieve
- inc fluid intake
- report HA and blurred vision
- monitor HR and for palpitations (toxicity)
methylxanthines for COPD
- type of bronchodilator
- ie. theophylline: relaxes smooth M of bronchi
- requires close monitoring of serum med levels b/c narrow therapeutic range
-
pt edu:
- inc fluid intake
- report HA and blurred vision
name the types of anti-inflammatory agents used for COPD
- corticosteroids–fluticasone and prednisone
- leukotriene antagonists–montelukast
- mast cell stabilizers–cromolyn
- monoclonal antibodies–omalizumab
what are ADRs to watch our for when administering corticosteroids?
- immunosuppression
- fluid retention
- hyperglycemia
- hypokalemia
- poor wound healing
nursing considerations for anti-inflammatory agents given for COPD tx
- Watch for a decrease in immunity function
- Monitor hyperglycemia
- Have pt report black, tarry stools
- Observe for fluid retention and weight gain
- Check throat and mouth for aphthous lesions (canker sores)
- Omalizumab can cause anaphylaxis
client education for anti-inflammatories given for COPD tx
- Encourage fluids
- Glucocorticoids taken with food
- Use medication to prevent and control bronchospasms
- Pt should avoid ppl with respiratory infections
- Mouth care
- Medication used prophylactically for COPD symptoms
- Do not discontinue suddenly
mucolytic agents given to tx COPD
- Help thin secretions to expel easier
- Nebulizer tx - acetylcysteine and dornase alfa
- Guaifenesin is an oral agent
- Combo of guaifenesin and dextromethorphan - oral to loosen secretions
therapeutic procedures to help tx COPD
- Chest physiotherapy uses percussion and vibration to mobilize secretions
- Foot of bed higher than head can facilitate optimal drainage via gravity
interdisciplinary care involved with COPD
- Consult respiratory for inhalers, breathing tx and suctioning
- Contact nutrition for weight changes
- Consult rehab if prolonged weakness and needs assistance with increasing activity
client education for those with COPD
- Can be debilitating - give contacts for services for food, home O2 etc
- Encourage high calorie foods
- Encourage rest periods when necessary
- Promote hand hygiene
- Reinforce importance of medications
- Promote smoking cessation if needed
- Encourage immunizations
- O2 as prescribed - it is flammable
- Support to family and client
list the possible complications of COPD
- respiratory infection
- right sided HF (Cor Pulmonale)
explain respiratory infection as a complication of COPD
- Result from increased mucus production and poor O2 levels
- Nursing actions
- O2 therapy and monitor
- Antibiotics
- Advise to avoid crowds and ppl with respiratory infections
- Pneumonia and flu immunization encouragement
explain R sided HF as a complication of COPD
- Air trapping, airway collapse, and stiff alveoli lead to increased pulmonary
- Blood flow through the lung tissue is difficult → increased workloads → enlargement and thickening of rt atrium and ventricle
- Manifestations
- Low oxygenation levels
- Cyanotic lips
- Enlarged and tender liver
- Distended neck veins
- Dependent edema
- Nursing actions
- Monitor respiratory status and O2 therapy
- Monitor HR and rhythm
- Meds as prescribed
- IV fluids and diuretics to maintain fluid balance
Patho of TB
- Infectious dz caused by mycobacterium tuberculosis
- Transmitted through aerosolization (airborne)
- Once in lungs, the body encases the TB bacillus with collagen and cells - can appear as ghon tubercle on xray
- Can lie dormant for years, not many people have active
- Primarily affects the lungs but can spread to any organ in the blood
- Risk of transmission decreases after 2-3 weeks of antituberculosis therapy
risk factors of TB
- Frequent and close contact with untreated individual
- Lower socioeconomic status and homelessness
- Immunocompromised status
- Poorly ventilated, crowded environments - long term care or prisons
- Advanced age
- Recent travel to areas of TB endemic
- Immigration
- Substance use
- Health care occupation with high risk activities
health promotion and dz prevention of TB
- Screen yearly if at high risk
- Family members of pt with TB should be screened
- Early detection and tx are vital
- TB should be considered for any client who has:
- Persistent cough, chest pain, weakness, weight loss, anorexia, hemoptysis, dyspnea, fever, night sweats or chills
- If exposed but not developed may have latent tb, needs to be treated
expected subjective findings with TB
- Persistent cough longer than 3 weeks
- Purulent sputum, possibly blood streaked
- Fatigue and lethargy
- Weight loss and anorexia
- Night sweats and low grade fever in afternoon
physical (objective) assessment findings with TB
- Older adults present atypical: altered mentation or unusual behavior, fever, anorexia, weight loss
lab tests done for TB
- positive intradermal TB test w/in 2-10 weeks of exposure
- QuantiFERON-TB Gold
- Mantoux Test
- Chest X-Ray
- Acid Fast Bacilli Smear and Culture
QuantiFERON TB Gold for TB
- Blood test that detects release of interferon gamma (IFN-g) in fresh heparinized whole blood from sensitized people
- Diagnostic for infection - active and latent
- Results within 24 hr
Mantoux Test for TB
- Read in 38-72 hr
- Intradermal injection of an extract of tubercle bacillus
- Induration of 10mm or greater in diameter indicated positive skin test
- Induration of 5mm is considered positive for immunocompromised pt
- Positive = developed an immune response to TB does not mean active
- Clients tx for TB previously will always be +
- Latent TB and Positive test → receive tx
- Pt with Bacillus Calmette- Guerin vaccine in last 10 years will have false-positive and need chest xray
- Clients starting immunosuppressive therapy should be tested for TB prior to starting tx
-
Client ed:
- Return to get test read
chest x ray for TB
- Prescribed to detect active lesions in the lungs
acid fast bacilli smear and culture for TB
- Positive indicates active infection
- Diagnosis confirmed by a positive culture
- Nursing actions
- 3 early morning sputum samples
- PPE
- Samples obtained in a negative airflow room
nursing care for TB
- Heated and humidified O2
- Prevent infection transmission
- N95 mask
- Negative airflow room
- Barrier protection when in contact
- Pt wear surgical mask for transportation
- teach pt to cough and expectorate sputum
- Administer medications
- Promote adequate nutrition
- Fluids
- Foods rich in protein, iron, vit C and B
- Provide emotional support
explain how medications are used to treat TB
- Due to resistance combo therapy is most commonly used
- Meds taken for 6-12 months - noncompliance is a contributing factor to resistant TB
- Current medication regimen includes: isoniazid, rifampin, pyrazinamide, ethambutol
- Client Ed: complete entire series of medication
Isoniazid (INH) to treat TB
- Bactericidal and inhibits growth of mycobacteria by preventing synthesis of mycolic acid in cell wall
- Nursing considerations
- Take on empty stomach
- Monitor hepatotoxicity
- Vit B6 used to prevent neurotoxicity
- Liver function testing prior and monthly
- Client Ed
- No alcohol
- Report manifestation of hepatotoxicity
Rifampin (RIF) to treat TB
- Bacteriostatic and bactericidal antibiotic that inhibits DNA - dependent RNA polymerase activity in susceptible cells
- Nursing considerations
- Hepatotoxicity
- Liver function testing
- Client Ed
- Secretions with become orage
- Report s/s hepatotoxicity
- This can interfere with oral contraceptives
Pyrazinamide (PZA) to treat TB
- Bacteriostatic and bactericidal
- MOA unknown
- Nursing considerations
- Hepatotoxicity
- Assess for gout hx - ADR of non gouty polyarthralgias
- Liver enzymes q2 weeks
- Client Ed
- Drink glass of water with each dose and increase fluids overall
- Report hepatotoxicity
- Avoid alcohol
Ethambutol (EMB) to treat TB
- Bacteriostatic
- Works by suppressing RNA synthesis, subsequently inhibiting protein synthesis
- Nursing Considerations
- Obtain baseline visual acuity tests and complete monthly
- Determine color discrimination ability
- Do not give to kids under 8
- Stop immediately if ocular toxicity occurs
- Client Ed:
- Report changes in vision
Streptomycin Sulfate to treat TB
- Aminoglycoside antibiotic
- Potentiates the efficacy of macrophages during phagocytosis
- Nursing considerations
- Only use for multidrug resistant TB b/c high level of toxicity
- Streptomycin can cause ototoxicity - monitor hearing fx and tolerance often
- Report significant changes in urine output and renal fx studies
- Client Ed
- Advise client to drink 2L + of fluid daily
- Notify provider if hearing declines
Interdisciplinary Care involved in caring for clients with TB
- Social services for obtaining medications
- Refer client to community clinic for follow ups and monitor
client education for those with TB
- TB is an at home tx
- Airborne precautions not needed in home b/c family has already been exposed
- Exposed family should be tested
- Educate on completing and complying with medication regimen
- Continue follow up care 1 full year after medication ends
- Sputum samples needed q 2-4 weeks to monitor effectiveness of therapy
- Encourage hand hygiene
- Cover mouth and nose when coughing or sneezing
- Contaminated tissues disposed of in plastic bag
- Wear mask in public or contact with crowds
list possible complications involved with TB and explain
- Miliary TB
- Organism invades bloodstream and can spread throughout body
- Headaches, neck stiffness, and drowsiness can be life threatening
- Pericarditis: dyspnea, swollen neck veins, pleuritic pain, hypotension due to an accumulation of fluid in pericardial sac that inhibits the heart’s ability to pump effectively
- Nursing actions: Tx is same for pulmonary TB
Patho and Manifestations of Asthma
- chronic inflammatory disorder of the airways
- Results in intermittent and reversible airflow obstruction of the bronchioles
- Obstruction occurs either by inflammation or airway hyperresponsiveness
- manifestations:
- Mucosal edema
- Bronchoconstriction
- Excessive mucus production
risk factors for asthma
- Older adults: have decreased pulmonary reserves due to physiologic aging process
- Family hx of asthma
- Smoking or 2nd hand smoke exposure
- Environmental allergies
- Exposure to chemical irritants or dust
- GERD
why are older adults at higher risk for asthma?
- More susceptible to infection
- Sensitivity of beta adrenergic receptors decreases with age
- As the beta receptors age and lose sensitivity, they are less able to respond to agonists, which relax smooth muscle and can result in bronchospasms
health promotion and dz prevention for asthma
- Promote smoking cessation
- If working in environment that contains carcinogens or air particles, advise client to use protective equipment (mask) and ensure proper ventilation
- Influenza and pneumonia vaccines: for older adults and clients with asthma
- Teach client how to recognize and avoid triggering agents:
- Teach client how to administer meds (nebulizers and inhalers)
- Teach client about infection prevention
- Encourage regular exercise to:
- Promotes ventilation and perfusion
- Maintains cardiac health
- Enhances skeletal muscle strength
- Clients may require pre-medication
- Instruct client to use hot water to eliminate dust mites in bed linens
what are likely triggering agents for asthma?
- Environmental factors (changing in temp (esp warm to cold) and humidity)
- Air pollutants
- Strong odors
- Seasonal (grass, tree, weeds) and perennial (mold, feathers, dust, roaches, animal dander) allergens
- Stress and emotional distress
- Meds: aspirin, NSAIDs, beta blockers, cholinergics
- Enzymes, esp those in laundry detergents
- Chemicals
- Sinusitis w/ postnasal drip
- Viral respiratory tract infection
diagnosis of asthma is based on 4 categories?
- Mild intermittent: symptoms less than 2x/week
- Mild persistent: symptoms arise more than 2x/week but not daily
- Moderate persistent: daily symptoms occur in conjunction with exacerbations 2x/week
- Severe persistent: symptoms occur continually, along with frequent exacerbations that limit physical activity and quality of life
expected (subjective) findings with asthma
- Dyspnea
- Chest tightness
- Anxiety or stress
physical (objective) assessment findings with asthma
- Coughing
- Wheezing
- Mucus production
- Use of accessory muscles
- Prolonged exhalation
- Poor oxygen saturation (low SaO2)
- Barrel chest or inc chest diameter
lab tests and their findings for asthma
- ABGs:
- Hypoxemia: dec PaO2 less than 80 mmHg
- Hypocarbia: dec PaCO2 less than 35 mmHg; early in attack
- Hypercarbia: inc in PaCO2 greater than 45 mmHg; later in attack
- Sputum cultures:
- Bacteria can indicate infection
what is the most accurate diagnostic procedure to diagnose asthma and its severity?
what are the findings seen with asthma?
- pulmonary function test
- For clients with asthma, we expect a decrease in FEV1 by 15-20% below the expected value.
- Diagnostic for asthma: increase in these values by 12% following admin of bronchodilators
which diagnostic procedure is used to diagnose changes in chest structure overtime assoc with asthma?
chest x ray
nursing care for asthma
- Position client in high-Fowler’s (maximize airflow)
- Administer O2 therapy
- Monitor cardiac rate and rhythm for changes during an acute attack (can be irregular, tachy, PVCs)
- Start IV access
- Maintain a calm and reassuring demeanor
- Provide rest periods for older adult clients who have dyspnea
- Design room and walkways with opportunities for rest
- Incorporate rest into ADLs
- Encourage prompt medical attn for infections and appropriate vaccines
- Administer meds
list the classes of medications used to tx asthma
- bronchodilators
- antiinflammatory agents
- combination agents
name the types of bronchodilators used to treat asthma
- short acting beta 2 agonists
- anticholinergic meds
- methylxanthines
- long acting beta 2 agonists
short acting beta 2 agonists used to treat asthma
- type of bronchodilator
- ie. albuterol
- Watch for tremors and tachycardia
- Provide rapid relief of acute symptoms and prevent exercise induced asthma
anticholinergic meds used to treat asthma
- type of bronchodilator
- Ie. ipratropium
- Nursing Considerations:
- Observe for dry mouth
- Client Education:
- Advise client to suck on hard candy to relieve dry mouth
- Inc fluid intake
- Report HA, blurred vision, palpitations (indicate toxicity)
- Monitor HR
- Block the parasympathetic NS
- Allows for sympathetic NS effects of inc bronchodilation and dec pulmonary secretions
- Long acting
- Used to prevent bronchospasms
- Nursing Considerations:
methylxanthines used to treat asthma
- type of bronchodilator
- Ie. Theophylline
- Nursing Considerations:
- Monitor serum levels for toxicity
- SEs: tachycardia, nausea, diarrhea
- Require close monitoring of serum medication levels due to narrow therapeutic range
- Use only when other tx are ineffective
- Nursing Considerations:
long acting beta 2 agonists
- Ie. Salmeterol
- Client Education:
- Advise client to use to prevent an asthma attack and NOT at the onset of attack
- Primarily used for asthma attack prevention
- Client Education:
types of anti-inflammatory agents used to treat asthma
- Corticosteroids: ie fluticasone and prednisone
- Client Edu: take with food
- Leukotriene antagonists: ie montelukast
- Mast cell stabilizers: ie cromolyn
- Monoclonal antibodies: ie omalizumab
- Nursing Considerations: Can cause anaphylaxis
anti-inflammatory agents used to tx asthma:
indication
nursing considerations
- used for prophylaxis, used to dec airway inflammation
- Nursing Considerations:
- Watch for dec immune function
- Monitor for hyperglycemia
- Report black, tarry stools
- Observe for fluid retention, weight gain (common)
- Monitor throat and mouth for aphthous lesions (canker sores)
client education for anti-inflammatory agents used to tx asthma
- Drink fluids and promote hydration
- Take to PREVENT asthma attack, NOT at onset of attack
- Avoid ppl with respiratory infections
- Use good mouth care
- Warn client not to d/c abruptly
combination agents used to treat asthma
- bronchodilator + anti-inflammatory
- Administer bronchodilator FIRST in order to inc absorption of anti-inflammatory agent
- Ipratropium and albuterol
- Fluticasone and salmeterol
interdisciplinary care involved with asthma
- Respiratory Services: consult for inhalers and breathing tx
- Nutrition: contacted for weight loss/gain related to meds
- Rehab Care: consulted if client has prolonged weakness and needs assistance with inc level of activity
list the possible complications associated with asthma
- respiratory failure
- status asthmaticus
explain respiratory failure as a complication of asthma
- persistent hypoxemia related to asthma can lead to respiratory failure
- Monitor oxygenation levels and acid base balance
- Prepare for intubation and mechanical ventilation
explain status asthmaticus as a complication of asthma
- life threatening episode of airway obstruction that is often unresponsive to common tx
- S/S: extreme wheezing, labored breathing, use of accessory Ms, distended neck veins, creates a risk for cardiac and/or respiratory arrest
- Prepare for emergency intubation
- Administer IV fluids, oxygen, bronchodilators, and epi
- Initiate steroid therapy