Chapter 28
Obstructive Pulmonary Diseases
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Asthma
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2
Obstructive Pulmonary Diseases
⬤
Asthma
• 38% higher in blacks than whites
• Hispanics, especially from Puerto Rico have higher rates of asthma
and age-adjusted death rates than all other racial and ethnic groups
• Black females have the highest mortality rates from asthma
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3
Asthma Definition
⬤
Heterogeneous disease characterized by a combination of
bronchial hyperresponsiveness with reversible expiratory
airflow limitation
➢ Signs
and symptoms may vary
➢ Clinical course can be unpredictable
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4
Significance
⬤
⬤
⬤
⬤
Affects about 20.4 million adult Americans
1.7 million ED visits/year
Incidence increasing but mortality decreasing
Gender differences
➢ More
men affected before puberty; more women in adulthood
➢ Women more likely to be hospitalized
➢ Higher mortality in women
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5
Risk Factors for Asthma and
Triggers of Asthma Attacks
See Table 28-1
⬤ Related to patient (e.g., genetic factors)
⬤ Related to environment (e.g., pollen)
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6
Triggers of Asthma
Nose and Sinus Problems
⬤
History of allergic rhinitis common
➢ Treatment
⬤
improves symptoms
Acute and chronic sinusitis might make asthma worse
➢ Inflammation
of mucous membranes can precipitate an
asthma attack; need to treat
➢ Large polyps need to be removed
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7
Triggers of Asthma
Respiratory Tract Infections
⬤
Major precipitating factor of an acute asthma attack
➢ Acute
infection—reduced airway diameter and increased
airway hyperresponsiveness
➢ Viral-induced changes may exacerbate asthma
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8
Triggers of Asthma
Allergens
⬤
Role in development of asthma unclear
➢ Cockroaches
➢ Animal
dander
➢ Dust mites
➢ Fungi
➢ Pollen
➢ Molds
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9
Triggers of Asthma
Cigarette Smoke
⬤
Smokers with asthma have:
➢ Faster
decline in lung function
➢ Increased severity
➢ More visits to HCP
➢ Decreased response to treatment
⬤
CDC estimates 21% of patients with asthma smoke
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10
Triggers of Asthma
Air Pollutants
⬤
Can trigger asthma attacks—role unclear
➢ Wood
smoke
➢ Vehicle exhaust
➢ Concentrated pollution
• Heavily populated areas
• More industry
• Climate conditions
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11
Triggers of Asthma
Occupational Factors
⬤
Occupational asthma—most common job-related respiratory
disorder
➢ Exposure
to diverse irritating agents
• Include: wood dusts, laundry detergents, metal salts, chemicals,
paints, solvents, and plastics
➢ May
take months or years of exposure
➢ Arrive at work well, but experience a gradual decline
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12
Triggers of Asthma
Exercise
⬤
Exercise-induced asthma (EIA) or exercise-induced
bronchospasm (EIB) is induced or exacerbated during
physical exertion
➢ Airway
obstruction occurs with changes to mucosa from
hyperventilation, cooling or rewarming air, and capillary
leakage
➢ EIA: pronounced during activity
➢ EIB: occurs after vigorous exercise
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13
Triggers of Asthma
Drugs and Food Additives (1 of 2)
⬤
Asthma triad: nasal polyps, asthma, and sensitivity to
aspirin and NSAIDs
➢ Wheezing
develops in about 2 hours, also see rhinorrhea,
congestion, tearing, and angioedema
➢ Salicylic acid and NSAIDs—must avoid
• Found in many OTC drugs, foods, beverages, and flavorings
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14
Triggers of Asthma
Drugs and Food Additives (2 of 2)
⬤
⬤
⬤
β-Adrenergic blockers—bronchospasm
ACE inhibitors—cough
Sulfite-containing preservatives
➢ Eyedrops,
IV corticosteroids, inhaled bronchodilators
➢ Fruits, beer, wine, and salad bars (prevent oxidation)
⬤
Tartrazine (yellow dye no.5)
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15
Triggers of Asthma
Gastroesophageal Reflux Disease
⬤
GERD more common in persons with asthma
➢ Reflux
may trigger bronchoconstriction as well as cause
aspiration
➢ Asthma medications may worsen GERD symptoms (β2agonists relax lower esophageal sphincter)
➢ Treating GERD may reduce nocturnal asthma
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16
Risk Factors and Triggers
⬤
Genetics-inherited component is complex
➢ Atopy—genetic
predisposition to develop IgE-mediated
response to common allergens is a major risk factor
⬤
Immune response–hygiene hypothesis
➢ Baby’s
immune system must be conditioned to function
properly; exposure to microbes
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17
Triggers of Asthma
Emotional Stress
⬤
⬤
Asthma is not psychosomatic
Psychologic factors/stress can worsen symptoms
➢ Extreme
behavioral expressions leads to hyperventilation and
hypocapnia leads to airway narrowing (bronchoconstriction)
➢ Attacks can trigger panic, stress, and anxiety
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18
Case Study (1 of 26)
A.D., a 30-year-old woman, comes to the emergency
department with severe wheezing, dyspnea, and
anxiety.
⬤ She recently had a cold that did not resolve.
⬤ She is upset that her children had just brought home a
stray cat.
⬤ She does not know if she is allergic to the cat.
⬤
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19
Pathophysiology (1 of 5)
⬤
Main pathophysiologic process is inflammation
➢ Exposure
to allergens or irritants triggers the inflammatory
cascade involving a variety of inflammatory cells
➢ Inflammation leads to bronchoconstriction,
hyperresponsiveness, and edema of airways leads to limited
airflow
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20
Fig. 28-1 Pathophysiology of Asthma
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21
Pathophysiology (2 of 5)
⬤
Early-phase response—30 to 60 minutes after exposure to
allergen or irritant
➢ Mast
cells release inflammatory mediators when an allergen
cross-links IgE receptors
➢ Mediators include: leukotrienes, histamine, cytokines,
prostaglandins, and nitric oxide
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22
Fig. 28-2 Early Phase Response of Asthma
Triggered by Allergen
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23
Pathophysiology (3 of 5)
⬤
Inflammatory mediators effect:
➢ Blood
vessels—vasodilation and increased capillary
permeability (runny nose)
➢ Nerve cells (itching)
➢ Smooth muscle cells (bronchial spasms and narrowed airway)
➢ Goblet cells—mucus production
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24
Fig. 28-3 Factors Causing Obstruction
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25
Pathophysiology (4 of 5)
⬤
Late-phase response
➢ Airway
inflammation occurs within 4 to 6 hours after initial
attack due to influx and activation of more inflammatory cells
• Occurs in about 50% of patients
• Symptoms can be more severe than early phase and can last for
24 hours or longer
➢ Corticosteroids
are used to treat inflammation
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26
Case Study (2 of 26)
A.D. has been in the emergency department for 2
hours.
⬤ She is now breathing a little easier and wants to go
home.
⬤
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27
Pathophysiology (5 of 5)
⬤
Remodeling
➢ Structural
changes in bronchial wall from chronic inflammation
• Changes include: fibrosis, smooth muscle hypertrophy, mucus
hypersecretion, angiogenesis
• Progressive loss of lung function not fully reversible results in
persistent asthma
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28
Clinical Manifestations (1 of 5)
⬤
Characteristic manifestations: wheezing, cough, dyspnea,
and chest tightness
➢ Hyperinflation
and prolonged expiration due to air trapping in
narrowed airways
⬤
Acute attack—wheezing is most common
➢ Initially
expiration, then with progression, both inspiration and
expiration
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29
Clinical Manifestations (2 of 5)
⬤
Wheezing—unreliable to gauge severity of attack (must
move air to make the sound)
➢ Mild
attack—may have loud wheezing
➢ Severe attack—wheezing with forced expiration or no
wheezing at all
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30
Clinical Manifestations (3 of 5)
⬤
⬤
Decreased or absent breath sounds may occur with
exhaustion or inability to have enough muscle force for
breathing
“Silent chest”—ominous sign
➢ Severe
airway obstruction or impending respiratory failure;
may be life-threatening (See Safety Alert)
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31
Clinical Manifestations (4 of 5)
⬤
⬤
Hyperventilation—increased lung volume from trapped air
and limited airflow
Abnormal alveolar perfusion and ventilation
➢ Hypoxemic,
decreased PaCO2, increased pH
➢ Respiratory
alkalosis results in respiratory acidosis as patient
tires; sign of respiratory failure
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32
Clinical Manifestations (5 of 5)
⬤
Cough variant asthma
➢ Cough
is only symptom
➢ Bronchospasm is not severe enough to cause airflow
obstruction
➢ May be nonproductive or productive with thick, tenacious
secretions
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33
Case Study (3 of 26)
A.D. continues with wheezing.
⬤ Her anxiety increases.
⬤ What other signs of hypoxemia would you assess for?
⬤
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34
Asthma Classifications (1 of 2)
⬤
Classifications
Intermittent
➢ Mild persistent
➢ Moderate persistent
➢ Severe persistent
➢
⬤
Impairment criteria:
➢
➢
➢
➢
➢
⬤
Frequency of symptoms
Nighttime awakenings
SABA use for symptoms
Interference with normal activity
Lung function: FEV1,FVC
Risk of exacerbation
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35
Asthma Classifications (2 of 2)
➢ Severity
is used to guide treatment decisions initially, then
addresses level of control
➢ All patients should have an asthma action plan for acute
attacks and to prevent future attacks
➢ Patient education and adherence is emphasized
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36
Case Study (4 of 26)
A.D. is diagnosed with intermittent asthma.
⬤ It is probably exacerbated by an allergic response to the
cat.
⬤ What other assessment findings would you anticipate?
⬤
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37
Complications
⬤
Asthma attacks are variable and unpredictable
➢ Mild
to life-threatening
➢ Last few minutes to hours
➢ Between attacks, often asymptomatic
➢ Compromised pulmonary function to debilitation
➢ Complications may include: pneumonia, tension
pneumothorax, status asthmaticus or acute respiratory failure
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38
Status Asthmaticus (1 of 2)
⬤
Extreme acute asthma attack characterized by hypoxia,
hypercapnia, and acute respiratory failure; life-threatening
➢ Also
see: chest tightness, increased shortness of breath, and
sudden inability to speak
➢ Without treatment leads to hypotension, bradycardia, and
respiratory/cardiac arrest
➢ Bronchodilators and corticosteroids not effective
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39
Status Asthmaticus (2 of 2)
⬤
Emergency treatment:
➢ Intubation
and mechanical ventilation
➢ Hemodynamic monitoring
➢ Analgesia and sedation
➢ IV magnesium sulfate
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40
Case Study (5 of 26)
You perform a detailed assessment on A.D.
⬤ She reports that she is a beautician.
⬤ She smokes about ½ pack of cigarettes/day.
⬤
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41
Diagnostic Studies (1 of 2)
Detailed history and physical exam
⬤ Peak expiratory flow rate (PEFR)
⬤ Peak flow meter
⬤
➢ Predict
⬤
attack or monitor severity
Spirometry—lung volumes and capacities
➢ Stop
bronchodilators 6 to 12 hours prior
➢ Reversibility of obstruction following bronchodilator is
important for diagnosis
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42
Diagnostic Studies (2 of 2)
⬤
Fraction of exhaled nitric oxide (FENO)
➢ Increased
⬤
⬤
⬤
⬤
⬤
levels with eosinophilic-induced inflammation
Serum eosinophils and IgE—increased levels with atopy
Allergy testing
Oximetry; ABGs
Chest x-ray—rule out other disorders
Sputum culture and sensitivity
➢ Rule
out bacterial infection
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43
Interprofessional Care (1 of 5)
⬤
Goal of treatment is to achieve and maintain control; return
to best possible level of daily functioning
➢ Medication
guidelines based on steps
• Symptoms worse—step up medications
• Symptoms controlled—step down medications
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44
Fig. 28-4 Drug Therapy
Stepwise Approach
(
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45
Interprofessional Care (2 of 5)
⬤
Mild to moderate attacks—symptoms
➢ No
more than 2x/week
➢ Minimal interference in ADLs
➢ Alert, oriented, speaks in sentences
➢ May have some chest tightness and dyspnea
➢ Increased use of asthma meds
➢ O2 saturation > 90% on room air
➢ PEFR
> 50% predicted or personal best
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46
Interprofessional Care (3 of 5)
⬤
Mild to moderate attack—treatment
➢ *Inhaled
bronchodilators and oral corticosteroids
➢ Monitor VS
➢ Monitor as outpatient unless not responding to treatment or
another contributing factor
➢ Follow-up with HCP
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47
Interprofessional Care (4 of 5)
⬤
Severe attack—symptoms
➢ Alert
and oriented but focused on breathing
• Frightened; agitated if hypoxemic
➢ Tachycardia,
tachypnea (>30 breaths/min)
➢ Accessory muscle use; sits forward
➢ Wheezing
➢ PEFR < 50% predicted or personal best
➢ Recurring symptoms interfere with ADLs
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48
Interprofessional Care (5 of 5)
⬤
Severe attack—treatment
➢ ED
! hospital admission
➢ Supplemental O2 and oximetry
• PaO2 > 60 mmHg or SaO2 > 93%
➢ Monitor
PEFR, ABGs, VS
➢ Bronchodilators and oral corticosteroids
➢ Silent chest—immediately notify HCP
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49
Case Study (6 of 26)
A.D. has intermittent asthma.
⬤ Based on this diagnosis, she will be treated at Step
One.
⬤ She was treated in the E.D. with a nebulizer treatment.
⬤
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50
Audience Response Question (1 of 2)
A patient is admitted to the emergency department with a
severe exacerbation of asthma. Which finding is of most
concern to the nurse?
a. Unable to speak and sweating profusely
b. PaO2 of 80 mm Hg and PaCO2 of 50 mm Hg
c. Presence of inspiratory and expiratory wheezing
d. Peak expiratory flow rate at 60% of personal best
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51
Audience Response Question (2 of 2)
Answer: A
Unable to speak and sweating profusely
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52
Drug Therapy (1 of 14)
⬤
⬤
Quick relief or rescue medications—treat acute attacks
Bronchodilators:
➢ Short-acting
inhaled β2-adrenergic agonists (SABAs)—all
patients should have this
➢ Inhaled anticholinergics; often used with SABA
⬤
Antiinflammatory Drugs
➢ IV
corticosteroids
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53
Drug Therapy (2 of 14)
⬤
⬤
Long-term control medications—achieve and maintain control
Bronchodilators:
➢
Long-acting inhaled or oral β2-adrenergic agonists (LABAs)
Methylxanthines
➢ Anticholinergics
➢
⬤
Antiiflammatory Drugs
Oral or inhaled corticosteroids (ICS)
➢ Leukotriene modifiers
➢ Anti-IgE
➢
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54
Drug Therapy (3 of 14)
⬤
Short-acting β-Adrenergic agonists (SABAs)
➢ Example:
albuterol
➢ Stimulate β2 receptors in bronchioles to produce
bronchodilation
➢ Most effective for relieving acute bronchospasm with acute
attack
➢ Onset: minutes and duration: 4 to 8 hours
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55
Drug Therapy (4 of 14)
⬤
Short-acting β2-adrenergic agonists
➢ Prevent
release of inflammatory mediators from mast cells
• Take before exercise to prevent attack
➢ Too
frequent use results in tremors, anxiety, tachycardia,
palpitations, and nausea
➢ Not for long-term use
➢ See: Drug Alert
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56
Drug Therapy (5 of 14)
⬤
Long-acting β2-Adrenergic Agonist Drugs
➢ Examples:
Salmeterol (Serevent), formoterol (Foradil)
➢ Added to daily ICSs; combination ICS and LABA available
➢ Used once every 12 hours; decreases the need for SABAs
➢ Never used for acute attack
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57
Drug Therapy (6 of 14)
⬤
Methylxanthines
➢ Example:
theophylline
➢ Less effective long-term bronchodilator
• Used only as alternative
• Many drug interactions and side effects
➢ Action:
unknown
➢ Narrow margin of safety—monitor blood levels
• Toxicity: nausea, vomiting, seizures, insomnia
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58
Drug Therapy (7 of 14)
⬤
Anticholinergic drugs
➢ Promote
bronchodilation by preventing muscles around
bronchi from tightening
➢ Less effective than SABAs for asthma
• Used more with COPD
➢ Not
used in routine management; except for severe acute
asthma attacks
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59
Drug Therapy (8 of 14)
⬤
Three classes of antiinflammatory drugs
➢ Corticosteroids
➢ Leukotriene
modifiers
➢ Monoclonal antibodies
• Anti-IgE
• Anti-Interleukin 5
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60
Drug Therapy (9 of 14)
⬤
Corticosteroids—reduce bronchial hyperresponsiveness,
block late-phase response, and inhibit migrations of
inflammatory cells
➢ Most
effective long-term control drug
➢ Examples: beclomethasone, budesonide
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61
Drug Therapy (10 of 14)
➢ Oral
corticosteroids—use 1 to 2 weeks for maximum
effect for severe chronic asthma
➢ Inhaled corticosteroids (ICS)—effects in 24 hours; used
in long-term control on a fixed schedule
• Little systemic absorption except for high dose (easy
bruising, reduced bone density)
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62
Case Study (7 of 26)
1 month after discharge A.D. returns to the ED with an
acute exacerbation of her asthma.
⬤ IV corticosteroids are given in the ED.
⬤ An inhaled corticosteroid is prescribed for daily use.
⬤
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63
Drug Therapy (11 of 14)
⬤
Corticosteroids—local side effects
➢ Oropharyngeal
candidiasis, hoarseness, and a dry cough are
local side effects of inhaled drug
➢ Can be reduced using a spacer or by gargling after each use
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64
Drug Therapy (12 of 14)
⬤
Leukotriene modifying agents (LTMAs)
➢ Examples:
zafirlukast, montelukast, zileuton; administered
orally
➢ Interfere with synthesis or block the action of leukotrienes;
produce both bronchodilator and antiiflammatory effects
➢ Take for prophylaxis and maintenance; not for acute attacks
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65
Drug Therapy (13 of 14)
⬤
Anti-IgE (monoclonal antibody)
➢ Example:
omalizumab
➢ Reduced circulating IgE levels
➢ Prevents IgE from attaching to mast cells, preventing release
of chemical mediators
➢ Subcutaneous administration every 2 to 4 weeks for
moderate-severe asthma
➢ Risk of anaphylaxis
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66
Drug Therapy (14 of 14)
⬤
Anti-Interleukin 5 (monoclonal antibody)
➢ Examples:
mepolizumab and reslizumab
➢ Inhibits interleukin 5 (IL-5) to inhibit the production and
survival of eosinophils
➢ Used with severe asthma attacks despite current asthma
medications
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67
Nonprescription Combination Drugs
⬤
Bronchodilator (ephedrine) and expectorant (guaifenesin)
➢ OTC
⬤
—many side effects; should avoid
Epinephrine and ephedrine inhalers
➢ Stimulate
CV and CNS—potentially dangerous
➢ Ephedrine can be used to produce methamphetamine
➢ Reformulated with phenylephrine
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68
Inhalation Devices for Drug Delivery
➢ Many
asthma drugs are given by inhalation
➢ Faster action
➢ Fewer systemic side effects
➢ Devices used to inhale medications:
• Metered dose inhalers (MDI)
• Dry powdered inhaler (DPI)
• Nebulizers
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69
Inhalers (1 of 2)
⬤
MDI—small, hand-held, pressurized devices
➢ Deliver
dose with activation; 1 to 2 puffs
• Propellant —hydrofluoroalkane (HFA)
➢ Can
be used with spacer or holding chamber to:
• Reduce oropharyngeal medication deposition
• Increase delivery to lungs
• Reduce problems with hand-breath coordination
!
See Fig. 28-6
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70
Fig. 28-6 Spacer with MDI
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71
Inhalers (2 of 2)
Teach correct technique and care
➢ Taking several MDIs leads to confusion
➢
• Provide education
➢ Potential
for overuse
• Bronchodilator use of greater than 2 canisters/month should
prompt visit to HCP; may need antiiflammatory
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72
Fig. 28-7 Inhaler Use
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73
Case Study (8 of 26)
A.D. is being discharged from the ED after her
exacerbation.
⬤ She has had difficulty with administration of her MDI.
⬤ A DPI is ordered.
⬤
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74
Dry Powdered Inhaler (DPI)
⬤
DPI (dry powder inhaler)
➢ Powdered
medication; breath activated
➢ Advantages over MDIs:
• Less manual dexterity and inhalation coordination
• No spacer needed
➢ Disadvantages:
• Low FEV1—inadequate inspiration
• Not all common meds available as DPI
• Powder may clump
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75
Fig. 28-8 Example of a DPI
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76
Nebulizers
⬤
Machine converts drug solutions into a fine mist for
inhalation via face mask or mouthpiece; easy to use
➢ Requires
➢ Provide
air compressor or O2 generator
education for technique and care
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77
Patient Teaching Related to
Drug Therapy (1 of 2)
⬤
Correct administration of drugs
➢ Name,
purpose, dosage, method of administration, and when
to use
➢ Printed instructions
⬤
Response to drug therapy; keep diary/log
➢ Symptoms
⬤
⬤
improving or need help (HCP)
Side effects and actions if occur
How to clean and care for devices
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78
Patient Teaching Related to
Drug Therapy (2 of 2)
⬤
Identify factors that affect correct use
➢ Age,
dexterity, psychologic state, affordability, convenience,
administration time and preference
➢ Financial resource: www.needymeds.org
⬤
Importance of adhering to management plan
➢
Continue long-term therapy even when asymptomatic;
explain why
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79
Nursing Assessment (1 of 2)
⬤
Subjective data (consider degree of distress)
➢ Important
health information
• Past health history
• Medications
➢ Functional
•
•
•
•
health patterns
Health-perception–health management
Activity–exercise
Sleep–rest
Coping–stress
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80
Nursing Assessment (2 of 2)
⬤
Objective data
➢ General
➢ Integumentary
➢ Respiratory
➢ Cardiovascular
➢ Possible
diagnostic findings
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81
Nursing Diagnoses
⬤
Impaired breathing
Activity intolerance
Anxiety
Lack of knowledge
⬤
See eNursing Care Plan 28-1 on the Evolve website
⬤
⬤
⬤
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82
Planning
⬤
Overall goals
➢ Have
minimal symptoms during the day and night
➢ Maintain acceptable activity levels (including exercise)
➢ Maintain greater than 80% of personal best PEFR
➢ Few or no adverse effects of therapy
➢ Adequate knowledge to carry out plan
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83
Nursing Implementation (1 of 11)
⬤
Health promotion
➢ Teach
patient to identify and avoid known triggers and irritants
• Avoid allergens
• Use scarves or masks for cold air
• Avoid aspirin and NSAIDs; read OTC labels
➢ Prompt diagnosis and treatment of upper respiratory infections
and sinusitis
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84
Nursing Implementation (2 of 11)
⬤
Health promotion
➢ Weight
loss
➢ Fluid intake of 2 to 3 L every day
➢ Good nutrition
➢ Adequate rest
➢ Exercise; pretreatment plan if needed
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85
Nursing Implementation (3 of 11)
⬤
Acute care
➢ Goal:
maximize the patient’s ability to safely manage acute
asthma using an asthma action plan
➢ Plan is based on asthma symptoms and PEFR and when and
what change is needed to gain control
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86
Nursing Implementation (4 of 11)
➢ Asthma
action plan
➢ Green zone
➢ Doing well
• No symptoms
• Participate in usual activities
• Peak flow results
! Usually
greater than 80% of personal best
• Remain on medications
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87
Nursing Implementation (5 of 11)
➢ Asthma
action plan
➢ Yellow zone
•
•
•
•
Asthma is getting worse
Symptomatic
Able to do some activities but not all
PEFR
! 50%
to 79% of personal best
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88
Nursing Implementation (6 of 11)
⬤
Asthma action plan
➢ Red
•
•
•
•
zone
Medical alert!
Symptomatic and medications are not helping
Cannot do usual activities
PEFR
! 50%
or less of personal best
• Call doctor now; call ambulance or get to hospital
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89
Nursing Implementation (7 of 11)
⬤
Acute care
➢ Monitor
respiratory and cardiovascular systems
• Lung sounds
!
Wheezing may get louder as airflow increases
• Heart rate and rhythm, respiratory rate and work of breathing,
and BP
• Pulse oximetry, peak expiratory flow rates, and ABGs
• Give drugs as ordered
• Evaluate response to therapy; may take several days
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90
Nursing Implementation (8 of 11)
⬤
An important goal of nursing is to decrease patient’s anxiety
and sense of panic
➢ Position
comfortably (semi to high-Fowler’s)
➢ Use “talking down” to keep calm
• Coach to use pursed-lip breathing (Table 28-12)
➢ Stay
with patient
➢ After attack subsides, allow rest
• When appropriate, complete H and P if unable to obtain earlier
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91
Nursing Implementation (9 of 11)
⬤
Ambulatory care
➢ Patient/Caregiver
Teaching—drug therapy and monitoring for
control of symptoms
•
•
•
•
Review asthma action plan
Daily PEFR
Green, yellow, and red zone meaning and management
Step up/step down medications
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92
Case Study (9 of 26)
A.D.’s husband is with her in the ED and preparing to
take her home after discharge.
⬤ They both express concern about exacerbations and
knowing when to come in for help.
⬤
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93
Nursing Implementation (10 of 11)
⬤
⬤
⬤
Ambulatory care (continued)
Include caregiver with patient teaching
Other:
➢ Maintain
good nutrition
➢ Exercise within limits of tolerance
➢ Uninterrupted sleep is important
➢ Home monitoring (See Informatics in Practice)
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94
Nursing Implementation (11 of 11)
⬤
Consider socioeconomic status, access to health care, and
cultural beliefs
➢ Provide
⬤
educational resources in patient’s language
Relaxation therapies (See Chapter 6)
➢ For
example, yoga, meditation, breathing and relaxation
techniques
⬤
Asthma support groups
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95
Evaluation
⬤
Expected outcomes
➢ Maintain
patent airway with removal of secretions
➢ Have normal breath sounds an respiratory rate
➢ Report decreased anxiety with increased control of breathing
➢ Demonstrate correct use of medications
➢ Express confidence in ability to manage asthma
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96
Chronic Obstructive Pulmonary Disease (COPD)
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97
Obstructive Pulmonary Diseases
⬤
COPD
➢ See
Cultural and Ethnic Health Disparities
• Whites have highest incidence despite higher rates of smoking
among other ethnic groups
• Hispanics have lower death rates related to COPD than other
ethnic groups
➢ 16
➢
million in United States have COPD
Third leading cause of death; > 120,000/year
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98
COPD (1 of 3)
⬤
Gender differences
➢ More
common in men
➢ Men have poorer response to O2 therapy
➢ COPD
is increasing in women due to smoking and increased
susceptibility
➢ More women die from COPD
➢ Women have lower quality of life, more exacerbations and
increased dyspnea
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99
COPD (2 of 3)
⬤
Preventable, treatable, often progressive disease
characterized by persistent airflow limitation
➢ Chronic
inflammatory response in airways and lungs, primarily
caused by cigarette smoking and other noxious particles or
gases
➢ Exacerbations and other coexisting illness contribute to
severity of the disease
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100
COPD (3 of 3)
⬤
The definition of COPD no longer includes chronic
bronchitis and emphysema
➢ Chronic
bronchitis—the presence of cough and sputum
production for at least 3 months in each of 2 consecutive
years
➢ Emphysema—destruction of alveoli without fibrosis
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101
COPD
Risk Factors
⬤
Cigarette smoking
➢ Clinically
significant airway obstruction develops in 20% of
smokers
➢ COPD should be considered in any person who is over 40
with a smoking history of 10 or more pack-years
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102
COPD
Cigarette Smoking (1 of 2)
⬤
Effects on respiratory tract
➢ Hyperplasia
of cells
• Goblet cell—increased production of mucus
• Reduced airway diameter
➢ Lost
or decreased ciliary activity
➢ Abnormal distal dilation and destruction of alveolar walls
➢ Chronic, enhanced inflammation results in remodeling
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103
COPD
Cigarette Smoking (2 of 2)
⬤
⬤
Oxidative stress
Passive smoking (environmental tobacco smoke [ETS] or
secondhand smoke)
➢ Decreased
pulmonary function
➢ Increased respiratory symptoms
➢ Increased risk of lung and nasal sinus cancer
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104
COPD
Risk Factors (1 of 5)
Infection
⬤ Severe, recurring respiratory infections in childhood
⬤ HIV
⬤ Tuberculosis
⬤
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105
COPD
Risk Factors (2 of 5)
⬤
Asthma
➢ Considerable
pathologic and functional overlap between
asthma and COPD
➢ Older adults may have components of both diseases
• Asthma-COPD overlap syndrome
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106
COPD
Risk Factors (3 of 5)
⬤
Air pollution
➢ Urban
areas
➢ Coal and biomass fuels—cooking and indoor heating
➢ Mechanism unclear
⬤
Occupational dusts and chemicals
➢ Dusts,
vapors, irritants, or fumes
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107
COPD
Risk Factors (4 of 5)
⬤
Aging
➢ Unclear
if aging results in COPD or occurs due to cumulative
effects of exposures during life
➢ Normal aging changes similar to COPD
• Loss of elastic recoil, decreased compliance
• Changes in thoracic and rib cage
• Decreased functional alveoli and surface area for gas exchange
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108
COPD
Risk Factors (5 of 5)
⬤
Genetics
➢1
⬤
genetic factor identified
α1-Antitrypsin deficiency (AATD)
➢ Autosomal
recessive disorder; 3% of COPD
➢ ATT protects lungs from proteases during inflammation;
deficiency results in premature bullous emphysema;
accelerated by smoking
➢ See Genetics in Clinical Practice
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109
Case Study (10 of 26)
G.S., a 77-year-old man, comes to the hospital
reporting of shortness of breath, morning cough, and
swelling in his lower extremities.
⬤ He has difficulty breathing when he walks short
distances, such as to the bathroom.
⬤
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110
COPD
Pathophysiology (1 of 8)
➢ Characterized
by chronic inflammation of airways, lung
parenchyma, and pulmonary blood vessels
➢ Defining feature: airflow limitation not fully reversible
during forced exhalation due to:
• Loss of elastic recoil
• Airflow obstruction due to mucous hypersecretion, mucosal
edema, and bronchospasm
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111
COPD
Pathophysiology (2 of 8)
⬤
Disease progression marked by worsening:
➢ Abnormalities
in airflow limitation
➢ Air
trapping
➢ Gas exchange
⬤
Severe disease:
➢ Pulmonary
hypertension
➢ Systemic manifestations
⬤
Impaired or destroyed lung tissue exists alongside normal
tissue
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112
COPD
Fig. 28-10 Pathophysiology
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113
COPD
Pathophysiology (3 of 8)
⬤
Primary process is inflammation
➢ Inhalation
of noxious particles and gases results in
inflammation which results in damage to lung tissue and
impaired normal defense mechanisms and repair processes
➢ Predominate inflammatory cells are neutrophils,
macrophages, and lymphocytes
➢ Oxidants contribute to structural destruction
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114
COPD
Pathophysiology (4 of 8)
⬤
Main characteristic of COPD is the inability to expire air
➢ Main
site of airflow limitation is the smaller airways
• Peripheral airways are obstructed and trap air during expiration
results in increased residual volume which results in barrel
-shaped chest
• Patient becomes dyspneic and has limited exercise capacity as
they try to inhale against overinflated lungs
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115
COPD
Pathophysiology (5 of 8)
⬤
As air trapping increases, alveolar walls are destroyed
resulting in formation of bullae and blebs
➢ Bullae
and blebs have no surrounding capillary bed resulting
in ventilation-perfusion (V/Q) mismatch resulting in hypoxemia
and hypercapnia (especially with severe disease and in late
stages)
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116
COPD
Fig. 28-11 Pathophysiology
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117
COPD
Pathophysiology (6 of 8)
⬤
Excess mucus production and cough
➢ Increased
mucus-secreting goblet cells
➢ Enlarged submucosal glands
➢ Dysfunction of cilia
➢ Stimulation from inflammatory mediators
➢ Not
all patients with COPD have sputum production
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118
COPD
Pathophysiology (7 of 8)
⬤
COPD is a systemic disease as a result of chronic
inflammation
➢ Cardiovascular
diseases are common
➢ Other: osteoporosis, diabetes, metabolic syndrome
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119
COPD
Pathophysiology (8 of 8)
⬤
Pulmonary vascular changes
➢ Vasoconstriction
of small pulmonary arteries due to hypoxia
➢ Vascular smooth muscle of pulmonary arteries thicken with
advanced disease
➢ Pressure in pulmonary circulation increases
⬤
Results in pulmonary hypertension resulting in right
ventricular hypertrophy which results in right heart failure
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120
COPD Classification
⬤
Diagnosis of COPD
➢ FEV1/FVC
⬤
ratio of < 70%
Severity of obstruction—postbronchodilator FEV1 results
•
•
•
•
•
GOLD 1 Mild
GOLD 2 Moderate
GOLD 3 Severe
GOLD 4 Very severe
(Global initiative for Chronic Obstructive Lung Disease)
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121
Case Study (11 of 26)
G.S. states that he sleeps in a recliner to make it easier
to breathe.
⬤ He feels his shoes are tight at the end of the day.
⬤ He is placed on oxygen at 2 L/min via nasal cannula.
⬤
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122
Clinical Manifestations (1 of 5)
⬤
⬤
⬤
Develops slowly
Diagnosis is considered with:
➢ Chronic cough (intermittent—first symptom)
➢ Sputum production
➢ Dyspnea; occurs with exertion and progressive
➢ Exposure to risk factors
Distinguish from asthma—Table 28-4
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123
Clinical Manifestations (2 of 5)
⬤
Chest heaviness, can’t take a deep breath, gasping,
increased effort to breathe, and air hunger
➢ Symptoms
often ignored; patients change behaviors to avoid
dyspnea
⬤
Dyspnea usually prompts medical attention
➢ Occurs
with exertion in early stages
➢ Present at rest with advanced disease
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124
Clinical Manifestations (3 of 5)
⬤
Chest breather (versus abdominal)
➢ Use
of accessory and intercostal muscles
➢ Inefficient breathing
⬤
⬤
⬤
Wheezing and chest tightness
Fatigue
Weight loss and anorexia
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125
Clinical Manifestations (4 of 5)
Prolonged expiratory phase
⬤ Decreased breath sounds, wheezing
⬤ Barrel chest
⬤ Tripod position
⬤ Pursed-lip breathing
⬤ Peripheral edema (ankles)—right HF
⬤
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126
Clinical Manifestations (5 of 5)
➢ Hypoxemia
PaO2 < 60 mmHg; SaO2< 88 %
➢ Hypercapnia
PaCO2 > 45 mmHg
➢ Increased
production of red blood cells
➢ Hemoglobin concentrations may reach 20 g/dL (200 g/L) or
more
➢ Bluish-red color of skin—polycythemia and cyanosis
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127
Complications (1 of 6)
⬤
Pulmonary hypertension
➢ Pulmonary
vessel vasoconstriction due to alveolar hypoxia
➢ Increased pulmonary vascular resistance
➢ Polycythemia from chronic hypoxia results in increased
viscosity
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128
Complications (2 of 6)
⬤
Cor pulmonale (right-sided heart failure)
➢ Late
manifestation
➢ Pulmonary HTN results in increased right ventricle pressure
➢ Dyspnea most common
➢ Other: S3 and S4, murmurs, distended neck veins,
hepatomegaly, peripheral edema, weight gain
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129
Pathophysiology of Cor Pulmonale
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130
Complications (3 of 6)
⬤
Cor pulmonale (right-sided heart failure)
➢ Chest
x-ray: large pulmonary vessels
➢ Echocardiogram: Right side heart enlargement
➢ Increased BNP level
⬤
Treatment
➢ Long-term
O2 therapy
➢ Diuretics
➢ Anticoagulation
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131
Complications (4 of 6)
⬤
Acute exacerbations
➢ Worsening
of respiratory symptoms
• Increased dyspnea, increased sputum volume, increased
sputum purulence
• Malaise, insomnia, fatigue, depression, confusion, decreased
exercise tolerance, wheezing, fever
➢ Common
cause: bacterial or viral infections
➢ Increase in frequency with disease progression
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132
Complications (5 of 6)
⬤
⬤
Treatment as inpatient or outpatient depends on severity;
medical history, current symptoms, hemodynamic stability,
O2 requirements, work of breathing, ABG’s and coexisting
disease
Treatments:
➢ SABAs
and oral corticosteroids
• Other: anticholinergic, antibiotics, diuretics
➢ Oxygen
• Noninvasive preferred
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133
Complications (6 of 6)
⬤
Acute exacerbations
➢ Patient
education
• Manifestations of exacerbations
⬤
Acute respiratory failure
➢ May
occur if wait too long to see HCP with exacerbations
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134
Diagnostic Studies (1 of 2)
⬤
⬤
History and physical exam
Spirometry—confirms diagnosis
➢ FEV1/FVC
ratio <70%
⬤
Chest x-ray
Serum α1-antitrypsin levels
⬤
6-minute walk test
⬤
➢ Pulse
ox <88% at rest—qualify for supplemental O2
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135
Diagnostic Studies (2 of 2)
⬤
COPD assessment test (CAT)
➢ www.catestonline.org
⬤
Clinical COPD Questionnaire (CCQ)
➢ www.ccq.nl
⬤
⬤
⬤
ABGs
ECG, Echo, MUGA scan
Sputum culture and sensitivity
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136
Case Study (12 of 26)
G.S. is exhibiting symptoms of mild to moderate COPD.
⬤ He states he has smoked a pack of cigarettes/day for
30 years.
⬤ His history includes heart disease and GERD.
⬤
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137
Case Study (13 of 26)
⬤
G.S. shares that he has experienced “attacks” like this
in the past year, but this one was a bit worse.
⬤
He states that he and his wife had visited their daughter
and her 3 kids who were sick with colds.
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138
Case Study (14 of 26)
G.S.’s ABGs show a slight decrease in PaO2 and
increased PaCO2, and his chest x-ray shows flattening
of his diaphragm.
⬤ O2 saturation is 88%.
⬤
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139
Case Study (15 of 26)
⬤
His FEV1/FVC is 65%
⬤
He states he is having difficulty completing ADLs
without frequent rest periods.
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140
Interprofessional Care (1 of 24)
⬤
⬤
Most treated as outpatients
Hospitalized for complications
• Acute exacerbations
• Acute respiratory failure
⬤
⬤
⬤
Evaluate for exposure to environmental or occupational
irritants
Influenza virus vaccine—annually
Pneumococcal vaccine
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141
Interprofessional Care (2 of 24)
⬤
Smoking cessation
➢ Most
important reducing risk of developing COPD or the
progression
➢ Accelerated decline in pulmonary function slows to almost
nonsmoking levels
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142
Interprofessional Care (3 of 24)
⬤
Drug therapy
➢ Bronchodilators
• Relax smooth muscle in the airway
• Improve ventilation of the lungs
• Decreased dyspnea and increased FEV1
• Inhaled route is preferred
• Include: β2-Adrenergic agonists, anticholinergics,
methylxanthines
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143
Interprofessional Care (4 of 24)
⬤
Drug therapy
➢ Moderate
stage: FEV1 < 60%
• Inhaled long-acting anticholinergic (LABA)
• Inhaled corticosteroids (ICS)
➢ Severe
COPD and chronic bronchitis
• Rofumilast (Daliresp)—antiinflammatory drug
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144
Case Study (16 of 26)
G.S. is given a short-acting bronchodilator via nebulizer.
⬤ He will also be given a SABA inhaler and an ICS for
home use.
⬤ He is started on azithromycin (Zithromax).
⬤
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145
Interprofessional Care (5 of 24)
⬤
Surgical therapy
➢ Lung
volume reduction surgery (LVRS)
• Removes diseased tissue so healthy tissue works better
➢ Bronchoscopic
lung volume reduction surgery
• Place 1 way valve in airways to diseased lung leads to collapse
• Pneumothorax is common complication
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146
Interprofessional Care (6 of 24)
⬤
Surgical therapy
➢ Bullectomy
• Removal of one or more bullae to decrease work of breathing
➢ Lung
transplantation
• Single or double
Not all patients are surgical candidates
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147
Interprofessional Care (7 of 24)
⬤
COPD therapies
➢ Oxygen
therapy
➢ O2 therapy is used to treat hypoxemia
• Keep O2 saturation > 90% during rest, sleep, and exertion, or
PaO2 > 60 mm Hg
• Individualized
• Improves survival
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148
Interprofessional Care (8 of 24)
⬤
⬤
Methods of administration
O2 delivery systems are high- or low-flow
➢ Low-flow
is most common
➢ Low-flow is mixed with room air, and delivery is less precise
than high-flow
➢ High-flow fixed concentration
• Venturi mask
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149
Interprofessional Care (9 of 24)
⬤
Humidification and Nebulization
➢ Used
because O2 has a drying effect on the mucosa and
secretions
➢ Use sterile distilled water
➢ Supplied bubble-through humidifiers
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150
Interprofessional Care (10 of 24)
⬤
Complications of oxygen therapy
➢ Combustion—no
smoking or open flames
➢ CO2 narcosis—CO2 no longer stimulus to breathe
• Hypoxic drive; administer O2 carefully
➢ O2
toxicity—prolonged high O2
• Severe inflammation
➢ Infection—humidity
supports bacterial growth
• Pseudomonas aeruginosa
• Disposable equipment
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151
Interprofessional Care (11 of 24)
⬤
Oxygen therapy at home
➢ Short-term
O2 therapy—up to 30 days
• May need upon discharge from hospital
➢ Long-term
O2 Therapy (LTOT)
• Use O2 15 or more hours/day
• Need central source at home; portable system
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152
Fig. 28-13 Portable Liquid Oxygen System
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153
Interprofessional Care (12 of 24)
⬤
Long-term O2 therapy (LTOT) at home
➢ Respiratory
therapist comes to home to set up and provide
education
• Decreasing risk of infection
• Safety issues
➢ Patients
are encouraged to remain active and travel
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154
Interprofessional Care (13 of 24)
⬤
Respiratory care
➢ Breathing
retraining
• Pursed-lip breathing
!
Prolongs expiration to reduce bronchial collapse and air trapping
• Diaphragmatic breathing
!
Use of diaphragm instead of accessory muscles to achieve
maximum inhalation and slow respiratory rate
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155
Interprofessional Care (14 of 24)
⬤
Respiratory care
➢ Airway
clearance techniques
• Often used with other treatments (bronchodilator)
• Loosen mucus to clear with coughing
➢ Effective
coughing or huff coughing
• Conserves energy, reduces fatigue, and facilitate removal of
secretions
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156
Interprofessional Care (15 of 24)
⬤
⬤
Respiratory care
Chest physiotherapy (CPT) indicated for
➢ Excessive,
difficult-to-clear bronchial secretions
• Postural drainage, percussion, and vibration
➢ Complications
• Fractured ribs, bruising, hypoxemia, discomfort
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157
Interprofessional Care (16 of 24)
⬤
Postural drainage
➢ Position
patient so gravity assists in draining secretions from
lung segments to bronchi and trachea where they can be
coughed up
➢ Done 2 to 4 times/day (or every 4 hours)
➢ Contraindications:
• Traumatic brain injury, chest trauma, hemoptysis, heart disease,
PE, or unstable condition
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158
Interprofessional Care (17 of 24)
⬤
Percussion
•
•
•
Hands in a cuplike position to create an air pocket; not on
bare skin
Air-cushion impact facilitates movement of thick mucus
If it is performed correctly, a hollow sound should be heard
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159
Fig. 28-14 Cupped-Hand Position
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160
Interprofessional Care (18 of 24)
⬤
Vibration
•
•
•
Tense hand and arm muscles to creating vibration on
exhalation
Facilitates movement of secretions to larger airways
Commercial mechanical vibrators available
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161
Interprofessional Care (19 of 24)
⬤
Airway clearance devices
➢ Use
positive expiratory pressure (PEP) to mobilize secretions;
more tolerable than CPT
• Flutter
• Acapella
• TheraPEP
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162
Fig. 28-15
Acapella Airway Clearance Device
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163
Interprofessional Care (20 of 24)
⬤
High-frequency chest wall oscillation
•
•
•
•
Inflatable vest connected to high-frequency pulse generator
that vibrates the chest
Dislodges and mobilizes mucus, moves toward larger airways
Patient can use on their own
Portable
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164
Case Study (17 of 26)
G.S. is going to be discharged to home.
⬤ He is given an Acapella device to assist him with
expulsion of mucus.
⬤ His wife is present, and you begin to teach them about
home care.
⬤
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165
Interprofessional Care (21 of 24)
⬤
Nutritional therapy
➢ Malnutrition
in COPD patients is multifactorial
• Increased inflammatory mediators
• Increased metabolic rate
• Lack of appetite
➢ Advanced
stages—weight loss is a predicator of poor
prognosis
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166
Interprofessional Care (22 of 24)
⬤
Nutritional therapy
•
To decrease dyspnea and conserve energy
• Rest at least 30 minutes before eating
• Avoid exercise for 1 hour before and after eating
• Use bronchodilator before meals
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167
Interprofessional Care (23 of 24)
⬤
Nutritional therapy
•
Supplemental O2 may be helpful
•
High-calorie, high-protein, moderate carbohydrates, and
moderate fats diet is recommended
Eat 5 to 6 small meals to avoid bloating and early satiety
•
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168
Interprofessional Care (24 of 24)
⬤
Nutritional therapy
•
Avoid:
• Foods that require a great deal of chewing
• Exercises and treatments 1 hour before and after eating
• Gas-forming foods
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169
Gerontologic Considerations (1 of 2)
➢ Reduced
lean body mass and decreased respiratory
muscle strength, increased dyspnea, and lower exercise
tolerance leads to higher incidence of acute
exacerbations
➢ Smoking cessation important
➢ Often have other comorbidities
• Increased complications, stress, and drug interactions
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170
Gerontologic Considerations (2 of 2)
⬤
Adherence may be an issue
➢ Cognitive
impairment: memory
➢ Complex medication regimens
➢ Physical issues: arthritis, vision, side effects of meds (ICS)
⬤
Quality of life issues
➢ Psychologic
and emotional support
➢ Palliative care and hospice—later stages
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171
Nursing Assessment (1 of 3)
⬤
Subjective data
➢ Important
health information
• Past health history
• Medications
➢ Functional
health patterns
• Health-perception–health management
• Nutritional–metabolic
• Activity–exercise
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172
Nursing Assessment (2 of 3)
➢ Functional
•
•
•
•
health patterns
Elimination
Sleep–rest
Cognitive–perceptual
Coping–stress
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173
Nursing Assessment (3 of 3)
⬤
Objective data
➢ General
➢ Integumentary
➢ Respiratory
➢ Cardiovascular
➢ Gastrointestinal
➢ Musculoskeletal
➢ Possible
diagnostic findings
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174
Case Study (18 of 26)
G.S. appears fatigued and has difficulty answering the
many questions he is asked.
⬤ His wife expresses concern that he has not been
sleeping well.
⬤
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175
Nursing Diagnoses
Impaired breathing
⬤ Activity intolerance
⬤ Impaired nutritional status
⬤ Difficulty coping
⬤
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176
Planning
⬤
Goals
➢ Relief
from symptoms
➢ Ability to perform ADLs an improved exercise tolerance
➢ No complications related to COPD
➢ Knowledge and ability to implement a long-term treatment
plan
➢ Overall improved quality of life
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177
Case Study (19 of 26)
What areas could be addressed with G.S. in regard to
health promotion?
⬤ How can his wife and family help?
⬤
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178
Nursing Implementation (1 of 10)
⬤
Health promotion
•
•
•
•
Abstain from or stop smoking.
Early diagnosis and treatment of respiratory tract infections;
avoidance measures
Avoid or control exposure to occupational and environmental
pollutants and irritants.
Influenza and pneumococcal vaccines
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179
Nursing Implementation (2 of 10)
⬤
Health promotion
•
Awareness of family history of COPD and AAT deficiency
• Genetic counseling
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180
Nursing Implementation (3 of 10)
⬤
Acute care
➢ Hospitalization
required for acute exacerbations or
complications:
• Pneumonia, cor pulmonale, or acute respiratory failure
➢ Degree
and severity of underlying respiratory problem
should be assessed
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181
Case Study (20 of 26)
G.S. comes into the clinic in one week for follow-up.
⬤ He is breathing much easier and states that he is able
to perform ADLs with less distress.
⬤ He and his wife ask about how to prevent further
breathing difficulties.
⬤
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182
Nursing Implementation (4 of 10)
⬤
Ambulatory care
➢ Patient/caregiver
•
•
•
•
•
teaching
Pulmonary rehabilitation
Activity considerations
Sexual activity
Sleep
Psychosocial considerations
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183
Nursing Implementation (5 of 10)
⬤
Pulmonary rehabilitation (PR) is designed to reduce
symptoms and improve quality of life
➢ Includes
exercise training, smoking cessation, nutrition
counseling, and education
➢ Alternate: internet programs
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184
Nursing Implementation (6 of 10)
⬤
Activity considerations
➢ Exercise
training leads to energy conservation
• In upper extremities, it may improve muscle function and reduce
dyspnea
➢ Modify ADLs
to conserve energy
• Hair care, shaving, showering
• O2 during activities of hygiene
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185
Nursing Implementation (7 of 10)
⬤
Activity considerations
➢ Walk
15 to 20 minutes a day at least 3 times a week with
gradual increases
• Adequate rest should be allowed
➢ Exercise-induced
dyspnea should return to baseline within 5
minutes after exercise
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186
Nursing Implementation (8 of 10)
⬤
Psychosocial considerations
•
•
•
Healthy coping with lifestyle changes is a challenge
May feel denial, anger, frustration, loneliness, and guilt (if
smoking was the cause), depression, anxiety
Provide support and education
• Support groups
• Counselors, cognitive and behavioral therapy
• Medications
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187
Nursing Implementation (9 of 10)
⬤
Sexuality and sexual activity
•
•
•
•
•
Plan when breathing is best
Use slow, pursed lip breathing
Refrain after eating or drinking alcohol
Choose less stressful positions
Use O2 if prescribed
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188
Nursing Implementation (10 of 10)
⬤
Sleep
•
•
Adequate sleep is extremely important
O2 saturations may drop during sleep
Hypercapnia leads to frequent awakenings
➢ Interfering factors:
•
• Current tobacco use, depression, anxiety, meds, congestion,
coughing or wheezing, sleep apnea
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189
COPD
End-of-Life Considerations
Symptoms can be managed, but COPD cannot be
cured
⬤ End-of-life issues and advanced directives are
important topics for discussion
⬤ Palliative care, end-of-life, and hospice care are
important in advanced COPD
⬤
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190
Evaluation
⬤
Expected outcomes
➢ Maintain
patent airway by effective coughing
➢ Have an effective rate, rhythm, and depth of respirations
➢ Have clear breath sounds
➢ Return to pre-exacerbation baseline respiratory function
➢ PaCO2 and PaO2 return to levels normal for patient
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191
Audience Response Question (1 of 2)
The nurse reviews the arterial blood gases of a patient. Which
result would indicate the patient has later stage COPD?
a. pH 7.32, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3− 30 mEq/L
b. pH 7.30, PaCO2 45 mm Hg, PaO2 55 mm Hg, HCO3− 18 mEq/L
c. pH 7.40, PaCO2 40 mm Hg, PaO2 70 mm Hg, HCO3− 25 mEq/L
d. pH 7.52, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3− 35 mEq/L
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192
Audience Response Question (2 of 2)
Answer: A
pH 7.32, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3− 30
mEq/L
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193
Cystic Fibrosis
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194
Cystic Fibrosis (1 of 3)
⬤
Autosomal recessive, multisystem disease with altered
transport of sodium and chloride ions in and out of epithelial
cells of epithelial cells. Primarily affects:
➢ Lungs
➢ Pancreas
and biliary tract
➢ Reproductive tract
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195
Cystic Fibrosis (2 of 3)
➢Whites
have the highest incidence
• In United States 1 in 3000 white births
• One in 20 to 25 whites are carriers of the gene
➢Uncommon
among blacks ( 1 in 15,000),
Hispanics (1 in 9,200), and Asian Americans
(1 in 30,000)
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196
Cystic Fibrosis (3 of 3)
First signs and symptoms usually occur in children;
some patients are not diagnosed until adulthood
⬤ Median life span is more than 37.5 years
⬤ Blood-based DNA testing is available
⬤
➢ Prenatal
⬤
testing may also be done for known carriers
In United States, all newborns are screened at birth
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197
Etiology and Pathophysiology (1 of 12)
⬤
The CF gene is found on chromosome 7
➢ CFTR
gene provides the instructions for making the
protein that controls the channel that transports sodium
and chloride
➢ The mutation of the gene CFTR change the protein to
block the transport channels.
➢ The secretions from the affected organs are low in
sodium chloride and water.
• Many mutations of the gene have been identified
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198
Fig. 28-16
Etiology and Pathophysiology
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199
Etiology and Pathophysiology (2 of 12)
⬤
Obstruction of ducts of lungs, pancreas, and intestines is
caused by thick, sticky secretions
➢ Mucus
fills (plugs up) glands in these organs causing scarring
and ultimately organ failure
➢ Patients with CF have high concentrations of sodium and
chloride in their sweat
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200
Etiology and Pathophysiology (3 of 12)
⬤
⬤
Hallmark of CF is the effect on the airways
Upper respiratory tract manifestations include:
➢ Chronic
sinusitis
➢ Nasal polyposis
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201
Etiology and Pathophysiology (4 of 12)
⬤
In the lower respiratory tract, the disease affects the small
airways then progresses to the larger airways
➢ Mucus
becomes dehydrated and tenacious
➢ Cilia motility is decreased
➢ Thick secretions obstruct bronchioles, leading to scarring, air
trapping, and hyperinflation
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202
Etiology and Pathophysiology (5 of 12)
⬤
CF is characterized by persistent, chronic airway infection
➢ Most
common organisms cultured are
• *Pseudomonas aeruginosa
• Staphylococcus aureus
• Haemophilus influenzae
➢ Less
common but more serious
• Burkholderia cepacia
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203
Etiology and Pathophysiology (6 of 12)
⬤
Chronic infection results in
➢ Antibiotic
resistance
➢ Pulmonary inflammation, narrowed airways, and decreased
function
➢ Inflammatory mediators results in progression
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204
Etiology and Pathophysiology (7 of 12)
⬤
⬤
Initially: chronic bronchiolitis and bronchiectasis
Progression: pulmonary vascular remodeling occurs
because of local hypoxia and arteriolar vasoconstriction
➢ Leads
to pulmonary hypertension, enlarged arteries and cor
pulmonale in later phases
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205
Fig. 28-17
Pathologic changes in bronchiectasis
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206
Etiology and Pathophysiology (8 of 12)
⬤
⬤
Blebs and large cysts in lungs are severe manifestations of
destruction
Complications include:
➢ Hemoptysis
(which can be fatal)
➢ Pneumothorax
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207
Etiology and Pathophysiology (9 of 12)
⬤
Pancreatic insufficiency is caused by mucus plugs in
pancreatic ducts results in atrophy
➢ Exocrine
function of pancreas is altered or may be lost
completely
➢ Insufficient production of enzymes lipase, amylase, and
proteases do not allow for absorption of nutrients
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208
Etiology and Pathophysiology
(10 of 12)
⬤
Malabsorption of fat, protein, and fat-soluble vitamins
manifest as:
➢ Steatorrhea
• Frequent bulky, foul-smelling stools
➢ Failure
to grow and gain weight
• Low body mass index (BMI)
➢ Osteopenia
and osteoporosis
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209
Etiology and Pathophysiology
(11 of 12)
⬤
CF-related diabetes mellitus (CFRD) is related to
underdevelopment of islet cells in utero and later destruction
of islet cells
➢ See
type 1 and type 2 characteristics
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210
Etiology and Pathophysiology
(12 of 12)
⬤
Many also have GI problems
➢ GERD,
gallstones, and pancreatitis
➢ Liver enzymes elevated results in cirrhosis
➢ Portal hypertension
➢ DIOS (distal intestinal obstruction syndrome)
• Thick, dehydrated stool and mucus cause intermittent
obstruction at ileocecal valve
• RLQ pain, palpable mass, decreased appetite, nausea, vomiting
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211
Case Study (21 of 26)
K.W., a 28-year-old man with cystic fibrosis, visits a
clinic for his annual physical exam.
⬤ He is married and in good overall health.
⬤ He has a cough with scant wheezes auscultated.
⬤
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212
Clinical Manifestations (1 of 4)
⬤
Median age of diagnosis 6 to 8 months
➢ 2/3
⬤
diagnosed in first year of life
Early manifestations that suggest CF:
➢ Meconium
ileus in the newborn
➢ Acute or persistent respiratory symptoms
➢ Failure to thrive or malnutrition
➢ Steatorrhea
➢ Family history
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213
Clinical Manifestations (2 of 4)
⬤
Without treatment, patient develops:
➢ Large,
protuberant abdomen
➢ Emaciated appearance of extremities
➢ Bronchiectasis
➢ Delayed puberty
• Females: menstrual irregularities, amenorrhea, difficulty
conceiving; most are able to conceive
• Males: vas deferens doesn’t develop; with technology, able to
father a child
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214
Clinical Manifestations (3 of 4)
⬤
Atypical presentation in adults
➢ Diabetes
or infertility
➢ Commonly see: frequent cough
• Becomes persistent
• Produces sputum
!
!
!
Viscous and purulent
Yellow or greenish-colored
Most common bacteria—Pseudomonas
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215
Clinical Manifestations (4 of 4)
⬤
Recurrent respiratory problems may be indicative of CF
➢ Exacerbations
•
•
•
•
increase in frequency
Increased cough and sputum
Weight loss
Decreased respiratory function
Eventually results in respiratory failure
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216
Case Study (22 of 26)
K.W. states that he and his wife are thinking of starting
a family.
⬤ He asks what the chances are of transmission of cystic
fibrosis to his children.
⬤
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217
Complications
⬤
⬤
⬤
⬤
⬤
⬤
⬤
⬤
CFRD
Bone disease
Sinus disease
Liver disease
Pneumothorax
Hemoptysis (can be life-threatening if massive)
Digital clubbing
Late complications
Respiratory failure
➢ Cor pulmonale
➢
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218
Diagnostic Studies
⬤
⬤
Clinical presentation, family history, lab and genetic testing
Gold standard: *sweat chloride test with pilocarpine
iontophoresis method
➢ Pilocarpine
carried by electric current is used to stimulate
sweat production (in both arms)
➢ Sweat is collected and analyzed
➢ Sweat chloride values >60 mmol/L are considered positive for
CF
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219
Case Study (23 of 26)
His primary care provider refers K.W. to new CF care
center in his city.
⬤ K.W. asks what this center will provide for him.
⬤
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220
Interprofessional Care (1 of 9)
⬤
Cystic fibrosis foundation
➢ CF
care centers
• Improved length and quality of life
• Best care, treatment, and support
➢ Team
• Physician, nurse/nurse practitioner, respiratory therapist,
physical therapist, social worker, dietician
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221
Interprofessional Care (2 of 9)
⬤
⬤
Treatment focuses on relieving airway obstruction and
controlling infection
Treatment includes: aerosol and nebulization treatments of
medications to dilate the airways and liquefy mucus and to
facilitate clearance
➢ Inhaled
dornase alpha (Pulmozyme)
➢ Inhaled hypertonic saline (7%)
➢ Bronchodilators (e.g., β2-adrenergic agonists)
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222
Interprofessional Care (3 of 9)
⬤
Airway clearance techniques
➢ CPT
➢ High-frequency
chest wall oscillation systems
➢ Specialized expiratory techniques
•
•
•
•
PEP devices
Breathing exercises
Pursed-lip breathing
Huff coughing
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223
Interprofessional Care (4 of 9)
⬤
Lung infections
➢ Early
intervention with antibiotics
➢ Long courses of antibiotics are usual treatment (10 days to 3
weeks) or chronic suppression therapy
➢ Drugs are abnormally metabolized and quickly excreted—may
need prolonged high-dose therapy
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224
Interprofessional Care (5 of 9)
⬤
Antibiotic therapy
➢ If
resources available, IV therapy at home with two different
antibiotics with different mechanisms of action
⬤
⬤
⬤
Oxygen therapy—cor pulmonale or hypoxemia
Mild exacerbations—oral agents
Pseudomonas—aerosolized tobramycin
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225
Interprofessional Care (6 of 9)
⬤
Pneumothorax—chest tube drainage
If recurrent, pleural sclerosis, stripping or abrasion
➢ Massive hemoptysis -bronchial artery embolization
➢ Lung transplant
➢
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226
Interprofessional Care (7 of 9)
⬤
Pancreatic insufficiency management
➢ Replacement
of pancreatic enzymes and supplements
➢ Adequate fat, calorie, and vitamins (A, D, E, K)
➢ Caloric supplements
➢ Added dietary salt
➢ Insulin if hyperglycemia develops
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227
Interprofessional Care (8 of 9)
⬤
Partial or complete DIOS
➢ Medical
management
• Options: probiotics, mucolytics, stimulant laxatives, lactulose,
polyethylene glycol
➢ Surgery
if medical not successful
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228
Interprofessional Care (9 of 9)
⬤
CFTR genotyping for CFTR modulator therapy
➢ Ivacaftor
(Kalydeco) and Ivacaftor/lumacaftor are used to treat
patients who have a mutation in a specific CFTR gene
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229
Nursing Management (1 of 7)
Nursing assessment
⬤
Subjective data
➢
Important health information
• Past health history
• Medications
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230
Nursing Assessment (1 of 2)
⬤
Functional health patterns
➢ Health-perception–health
maintenance
➢ Nutrition–metabolic
➢ Elimination
➢ Activity–exercise
➢ Cognitive–perceptual
➢ Sexuality–reproductive
➢ Coping–stress
tolerance
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231
Nursing Assessment (2 of 2)
⬤
Objective data
➢ General
➢ Integumentary
➢ Eyes
➢ Respiratory
➢ Cardiovascular
➢ Gastrointestinal
➢ Possible
Diagnostic Findings
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232
Case Study (24 of 26)
What questions would you want to ask K.W. about his
health in the past year?
⬤ The past month?
⬤
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233
Case Study (25 of 26)
K.W. states that he has some difficulty with increased
cough and sputum in the morning.
⬤ He has difficulty coughing up sputum due to its
thickness.
⬤
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234
Nursing Management (2 of 7)
⬤
Nursing diagnoses
➢ Impaired
airway clearance
➢ Impaired respiratory system function
➢ Impaired nutritional status
➢ Difficulty coping
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235
Nursing Management (3 of 7)
Planning
⬤
Overall goals:
Adequate airway clearance
➢ Absence of respiratory infection
➢ Adequate nutritional support to maintain appropriate BMI
➢
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236
Nursing Management (4 of 7)
⬤
Goals (continued)
➢ Ability
to perform ADLs
➢ Recognition and treatment of complications related to CF
➢ Active participation in planning and implementing an
achievable treatment plan
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237
Nursing Management (5 of 7)
Nursing implementation
⬤
Acute care
➢
Relief of bronchoconstriction, airway obstruction, and airflow
limitations
• Aggressive CPT, antibiotics, O2 therapy, and corticosteroids
➢
Adequate nutrition
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238
Case Study (26 of 26)
K.W. states that he and his wife want to begin an
exercise program.
⬤ He asks what type of exercise might be best and if he
needs to consider anything special related to his CF.
⬤
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239
Interprofessional Care
⬤
Aerobic exercise can be effective in clearing airways
➢ Increased
nutritional demands of exercise
➢ Observe for dehydration
➢ Increase fluid intake and replace salt losses
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240
Nursing Management (6 of 7)
Nursing implementation
⬤
⬤
Help patient assume responsibility for care and life goals
Discuss altered sexuality
➢ Delayed
development
➢ Marriage and childbearing
➢ Genetic counseling
➢ Shortened life span
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241
Nursing Management (7 of 7)
⬤
Crises, life transitions, and resources
➢ Employment
➢ Motivation
➢ Coping
➢ Dependence
➢ Sharing
diagnosis with others
➢ Emotional needs; depression
➢ Financial needs
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242
Bronchiectasis
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243
Bronchiectasis (1 of 2)
⬤
Etiology and pathophysiology
➢ Permanent,
abnormal dilation of medium-sized bronchi due to
inflammatory changes
• Destruction of elastic and muscular structures of the bronchial
wall
• Cyclical process of inflammation results in damage which results
in remodeling
• Colonization of microorganisms (Pseudomonas) results in
weakening of walls and pockets of infection
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244
Bronchiectasis (2 of 2)
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245
Etiology and Pathophysiology (1 of 2)
⬤
Bronchial wall injury:
➢ Damages
mucociliary mechanism, results in accumulation of
mucus and bacteria
➢ Bacteria attracts neutrophils which increased inflammation
and edema
➢ Reduced mucus clearance and decreased expiratory flow
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246
Etiology and Pathophysiology (2 of 2)
⬤
Causes
➢ CF
in children
➢ Bacterial lung infections in adults
➢ Airway obstruction
➢ Systemic diseases
• Inflammatory bowel disease
• Rheumatoid arthritis
• Immune disorders
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247
Clinical Manifestations
⬤
Cough with persistent production of thick, tenacious,
purulent sputum
➢ Hemoptysis
⬤
Other: pleuritic chest pain, dyspnea, wheezing,
clubbing, weight loss, anemia, adventitious breath
sounds
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248
Diagnostic Studies
*CT scan
⬤ Chest x-rays
⬤ Spirometry
⬤ Sputum
⬤ CBC
⬤ AAT
⬤
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249
Interprofessional and
Nursing Management (1 of 3)
⬤
Treatment Goals:
➢ Treat
⬤
flare-ups and prevent decline in lung function
Antibiotics
➢ Patient
⬤
Bronchodilators
➢ SABA,
⬤
education to take as prescribed
LABA, anticholinergics
Corticosteroids
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250
Interprofessional and
Nursing Management (2 of 3)
⬤
Promote drainage and removal of mucus
➢ Airway
clearance techniques
• CPT
• Hydration of respiratory tract
⬤
Patient education
➢
Manifestations to report to HCP
• Increased sputum, increased dyspnea, fever, chills, chest pain,
hemoptysis (moderate to large amount)
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Interprofessional and
Nursing Management (3 of 3)
⬤
Acute care
➢ Hemoptysis
• Elevate HOB; side-lying position with bleeding side down
• Monitor VS and respiratory status
➢ Hydration—2
to 3 L/day unless contraindicated
➢ Rest
➢ Nutrition
➢ Surgical
resection or lung transplant
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