Respiratory System
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D.A. is a 78 year old male who states he
cannot get rid of his “cold”
He has a productive cough
Sputum is white to grey
He has a 31 pack year smoking history
He uses Albuterol inhaler up to 6 times per
day
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What additional information do you need?
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Subjective information
Objective information
Psychosocial information
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Controlled by respiratory muscles of the
thorax
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Diaphragm
Intercostal muscles
Coordinated by respiratory centers of the
brain and carotid arteries
Respiratory centers respond to changes in:
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Blood levels of oxygen
Carbon dioxide
Blood pH
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Stiffening of connective tissue of lungs
Alteration in alveolar shape → increased
alveolar diameter
Decreased alveolar
surface area
Increased chest
wall stiffness
Stiffening of the
diaphragm
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Increased residual volume
Decreased vital capacity
Premature airway closure → air trapping in
lower airways
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Crackles—intermittent, nonmusical,
caused by fluid filled alveoli popping open
Wheezes—high pitched, occur when air
flow is blocked
Rhonchi—low pitched,
snoring, rattling, occur
when fluid partially
blocks large airways
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Pulmonary embolism?
GERD?
Obstruction?
ACEi cough?
Vocal cord
dysfunction?
Asthma
COPD
Chronic
bronchitis
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Symptom
Asthma
Wheezing
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Chest
tightness
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Chronic
productive
cough
Nocturnal
dyspnea
Smoking
history
Chronic
bronchitis
COPD
Heart Failure
Maybe
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Maybe
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Airway inflammation
Increased mucous secretion production
Increased airway
responsiveness/sensitivity
Reversible airflow obstruction (usually)
Eventually causes irreversible
damage and scarring
Often overlooked in the
older client
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Coughing
Wheezing
Shortness of breath
Chest tightness
Nocturnal dyspnea
between 0400-0600
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CHF nocturnal dyspnea
occurs 1-2 hours after
retiring
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Mild
Mild
Intermittent Persistent
Moderate
Persistent
Severe
Persistent
□ Sx ≤ 2 days □ Sx > 1
□ Symptoms
per week
times per
daily
week but <
once per day
□ Continuous
daily
symptoms
□ Sx ≤ 2
nights per
week
□ Frequent
nighttime
symptoms
□ Nighttime
sx > twice
per month
□ Nighttime
sx > one
night per
week
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Prevent symptoms that interfere with
quality of life
Prevent exacerbations of asthma
Minimize need for emergency department
visits
Maintain normal activity levels
Maintain (nearly) normal pulmonary
function
Minimize use of “rescue” medication
Minimize adverse effects of medication
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Intermittent asthma
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Step 1
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Preferred: short acting β-agonist (SABA) prn
Example: Albuterol
Persistent asthma with daily medication
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Step 2
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Preferred: low dose inhaled corticosteroids
(ICS)
Example: Beclomethasone
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Step 3
Preferred: Low dose ICS + LABA or medium
dose ICS
 Example LABA: Advair
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Step 4
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Preferred: Medium dose ICS + LABA
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Step 5
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Preferred: High dose ICS + LABA
And consider Omalizumab for patients who
have allergies
Step 6
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Preferred: High dose ICS + LABA + oral
corticosteroid
And consider Omalizumab for patients who
have allergies
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At each step…
Patient education
 Environmental control
 Step up if needed
 Step down if possible and
if asthma is well controlled
for at least 3 months
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Refer to video link in syllabus
Spacers are useful for
the elderly who have
difficulty with coordination
and timing (refer to link)
Encourage to rinse with
warm water and expectorate
(“swish and spit ”) to minimize
candidiasis, gum disease, tooth decay
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Provides misted form of medication
Easy to use at home
Machine requires regular cleaning
Breathe slowly, deeply
Hold each breath 1-2 seconds
before breathing out
Important to continue until
dose is complete
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Measures movement of air out of lungs
Helps patient anticipate asthmatic
episode
Patient finds best
peak flow number
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Every day for 2 weeks
On waking and
between 1200-1400
Before inhaled
β-agonist
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Β-blockers—can induce bronchospasm
NSAIDs—bronchospasm
Diuretics—hypokalemia
Antihistamines—prolonged QT interval
ACEi—cough
Antidepressants—symptoms of depression
can be worsened by corticosteroids
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COPD
Chronic
bronchitis
Emphysema
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Cough and sputum production on most
days
Minimum of 3 months for at least 2
successive years, or,
For 6 months during 1 year
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Acute inflammation of the
bronchi
Usually self-limiting
Viral
Similar to pneumonia: productive cough,
chills, lethargy, low grade fever
Negative chest xray
Treatment: rest, humidification, cough
suppressants, acetaminophen
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Permanent destruction of the alveoli
Collapse/narrowing of
bronchioles
Usually in older adults
with long smoking history
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COPD with chronic bronchitis
Increased mucous production
Normal to decreased lung capacity
Increased residual lung volume with air
trapping
Cyanosis and right heart failure
Body responds by decreasing ventilation
and increasing cardiac output
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COPD with severe emphysema
Pink complexion
Dyspnea
Increased residual lung capacity
Decreased elastic recoil
High tidal volume
Destruction of capillary bed
Body compensates for destruction of
pulmonary capillary bed by hyperventilation
Retractions
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Assessment, monitoring treatment of
disease
Reduce risk factors
Prevent disease progression
Assess, manage anxiety and depression
Mucolytic therapy (e.g., Mucomyst)
Rehabilitation
Manage exacerbations
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Bronchodilators
Inhaled corticosteroids
Antibiotics
Flu vaccine annually
Pneumococcal vaccine at age 65
Exercise training
Mucolytics and expectorants (e.g.,
Mucomyst, Guaifenesin)
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Continuous oxygen administration—low
flow
Postural drainage
Chest percussion
Controlled coughing
Tracheal suctioning
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Normal stimulus to breathe is rise in CO2
level
In COPD, stimulus to breathe is a decrease
in O2 level
Oxygen flow that is too high will minimize
or eliminate the stimulus to breathe in a
COPD patient
CO2
O2
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Elderly the most vulnerable
Drug resistant forms prevalent
Vulnerability enhanced by multiple risk
factors:
Living in an institution, homeless
 Exposure to drug-resistant form
 Previous infection
 Diabetes
 Use of immunosuppresive drugs (including
corticosteroids)
 Malnutrition
 Renal failure
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Isoniazid—prevent active disease once
infected
Rifampin
Side effects can be significant
Interrupting treatment can create drug
resistant form
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More common in the young-old
Initial symptoms are vague and mimic
other pulmonary illnesses
Chest xray initial diagnostic test
Older, debilitated patients may not be
surgical candidates
Chemotherapy
Radiation
Palliative care
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History nosocomial pneumonia
COPD
Recent hospitalization, insitutionalization
Smoking
Hyperglycemia
Use of immunosuppressants and/or
antibiotics and/or oxygen therapy
Recent antibiotic use
Eating dependency
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Cough
Fever
Sputum production
Prodromal headache, myalgia, lethargy
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Changes in behavior and mental status
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New onset tachycardia and tachypnea
Change in function
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Clotting disorders
Immobility
Dehydration
Recent surgery
Atrial fibrillation
Obesity
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Sudden onset
Tachypnea
Dyspnea
Chest pain
Hypoxia
Hypotension
Possible shock
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Flu vaccination every year
Pneumonia vaccination once if given after
the age of 65
Revaccinate in 5 years once only if first
vaccination given
before the age of 65
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What is your nursing
diagnosis for RB?
What is your desired
outcome?
What are appropriate
interventions pertinent
to your desired outcome?
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