Nursing Management of Clients
with Stressors of Respiratory
Function
Chronic Airflow Limitation (CAL)
Pneumonia
Tuberculosis
NUR133 Lecture #5
K. Burger, MSEd, MSN, RN, CNE
Chronic Airflow Limitation (CAL)
Term used for Chronic lung diseases:
- Emphysema
- Chronic Bronchitis
- Bronchial Asthma
COPD
Chronic Obstructive Pulmonary Disease
 Emphysema
 Chronic Bronchitis
Bronchospasm, dyspnea
Non-reversible and progressive
Continously symptomatic
Asthma
Reversible airflow obstruction d/t:
Inflammation
Airway hyperresponsiveness
Hyperresponsiveness leading to
bronchospasms
Asthma
- stimulus or allergen- chemical mediators
released. Within minutes:
Dyspnea
Wheezing
Cough
Mucus production
Inflammatory process
TRIGGER
Allergen binds to IgE
Release of inflammatory
chemicals
WBCs come to
the area
WBCs release Mediators which
produce more inflammation
Blood vessel dilation/ Capillary leak
Tissue swelling / Increased secretion
Asthma
 Common agents or stimuli:
-fog, smog, smoke
-odors, aerosols
-exercise
-cold air
 Allergens- dust mites, animal dander, pollen,
cockroaches, foods, medicines.
Asthma
 FOCUSED Respiratory assessment
1. Expiratory and Inspiratory wheezing
2. Dry or moist cough
3. Dyspnea, signs of hypoxemia, anxiety
4. increased HR, BP, RR
5. Diaphoresis, Pallor
6. Cyanosis
7. Nasal flaring
8. Use of accessory muscles
Asthma
 Diagnostic Assessment
 ABGs / PO2 low, PCO2 high, PH low
 SaO2 low
 Eosinophils / serum and sputum
 PFTs / FEV and PERF
 CXR
Asthma
STEP SYSTEM
MILD INTERMITTENT
MILD PERSISTENT
MODERATE PERSISTENT
SEVERE PERSISTENT
Complications of Asthma
- Respiratory infections
- Status Asthmaticus
- pneumothorax
- respiratory arrest
- cardiac arrest
Asthma
Nursing Diagnoses
1. Impaired Gas Exchange related to
alveolar
membrane changes, airflow
limitation, respiratory muscle fatigue,
excess production of mucus.
2. Ineffective Breathing pattern related to
airflow obstruction (narrowed airways),
and fatigue.
3. Ineffective Airway Clearance related to
excessive secretions, fatigue and
ineffective cough.
Asthma Interventions
 Client Education
A. Identify causes
B. Proper environmental changes
C. Stress management, rest, and sleep
D. Correct use of inhalers
E. Correct use of peak flow meter and step wise
approach to med management
F. What to do if an attack occurs
Asthma
– How to use a METERED DOSE inhaler
(without spacer) correctly:
1. Shake inhaler
2. Tilt head back, breathe out fully
3. Open mouth, mouthpiece 1-2” away
4. As you begin to breathe in deeply, press down
and release medicine.
5. Breathe in deeply and slowly for 3-5 sec.
6. Hold your breathe for 10 sec
7. Breathe out slowly
Asthma
Drug Therapy
 Bronchodilator
 Anti-inflammatory
 Beta agonists
short-acting
long-acting
 Anti-cholinergics
 Methylxanthines





Corticosteroids
Anti-leukotriene
Mast cell stabilizers
Monoclonal antibodies
Inhaled agents
Asthma
 Pharmacologic stepped approach to treating
asthma symptoms
 Step 1- mild intermittent- beta 2 agonist
 Step 2.- mild persistent – add cromolyn
 Step 3.- moderate persistent- add inhaled
corticosteroid , may add theophylline.
 Step 4.- Severe persistent- add po steroids
Chronic Obstructive Pulmonary Disease
EMPHYSEMA







Loss of lung elasticity
Hyperinflation of lungs / air trapping
Diaphragm flattening
Increased airflow resistance
Ineffective gas exchange
Retained CO2 (hypercapnia)
Chronic respiratory acidosis
Chronic Obstructive Pulmonary Disease
CHRONIC BRONCHITIS






Chronic inflammation of airways
Mucosol edema
Increased # of mucous glands
Bronchial wall thickening
Impaired airflow AND gas exchange
Hypoxemia, hypercapnia, respiratory acidosis
COPD
 FOCUSED assessment
1. Rapid, shallow respirations & dyspnea
2. Irregular breathing patterns
3. Moist cough
4. Limited diaphragmatic excursion
5. Decreased fremitus
6. Hyperresonant percussion
7. Crackles
8. Barrel chest
9. Cyanosis
10.Clubbing
11.Orthopneic posturing
COPD
 DIAGNOSTIC ASSESSMENT







ABGs
SaO2
CXR
PFT
Serum AAT
ECG
H&H, Electrolytes, WBC
Complications of COPD
 Respiratory infection
 Cor pulmonale
 Cardiac dysrhythmias
Nursing Diagnoses for COPD




Impaired gas exchange
Ineffective breathing pattern
Ineffective airway clearance
Activity intolerance
Interventions for COPD






Airway maintenance
Cough enhancement
Oxygen therapy
Energy conservation
Drug therapy
Surgical interventions
COPD Drug Therapy
 Bronchodilators
 Anti-Inflammatory drugs
 Inhalants AND systemic drugs
 PLUS Mucolytics
Pneumonia
 Community acquired pneumonia (CAP)
Versus
 Nosocomial pneumonia
 Higher incidence in:
Elderly, immunocompromised, CAL,
mechanically vented, chronically ill
 5th leading cause of death in US
Pneumonia
Assessment







Chest pain, dyspnea, tachypnea, SOB
Cough & hemoptysis
Crackles & wheezes
Tactile fremitus
Percussion
Fever and chills
Hypoxemia
Pneumonia
Nursing Diagnoses
 Impaired gas exchange
 Ineffective airway clearance
 Potential for sepsis
 Acute pain
Pneumonia
Interventions




C&DB q2h/ incentive spiro
O2 therapy / Positioning HOB elevated
Maintain hydration
Medications: bronchodilators, expectorants,
antibiotics
 Client teaching: completion of med rx,
influenza and pneumococcal vaccinnations
Tuberculosis
 Causative organism:
Mycobacterium tuberculosis
 Incidence increasing worldwide
 Highest prevalence: immunocompromised,
people living in crowded and or poor living
conditions
 Exposure versus infection versus active
Tuberculosis
Assessment







Persistent, productive cough
Hemoptysis
Fever and night sweats
Fatigue
Anorexia
Weight loss
Progressive and persistent S & S
Tuberculosis
Diagnostic Assessment
 Purified Protein Derivative PPD
Positive = 10mm induration or > general
5mm induration or > Hx HIV
 CXR
 Sputum for acid-fast bacillus AFB
 Sputum culture; BACTEC
 PCR assay
 NEW: Quantiferon TB Gold Test QFT-G
Tuberculosis
Nursing Diagnoses
 Impaired gas exchange
 Ineffective airway clearance
 Fatigue
 Deficient knowledge
 Ineffective therapeutic regimen maintenance
Tuberculosis
Interventions
 Combination drug therapy
Isoniazid (INH)
Rifampin (RIF)
 Plus
Pyrazinamide (PZA)
Ethambutol or Streptomycin
 RIFATAR = NEW med combo of INH, RIF, & PZA
 LONG TERM THERAPY!!!!!
6-12 months duration
 CLIENT EDUCATION!!!!!