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 5000 ED visits each day; 217,000 ED visits each
year
 1000 hospital admissions every day; 500,000
hospitalizations each year
 10.5 million physician office visits each year
 Asthma increases odds of health care use in
obese people by 33%
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
 Estimated 20 million (8.4%) Americans affected
 Estimated 300 million people affected
worldwide
 More common in adult women than men
 Slightly more prevalent among AfricanAmericans than Caucasians
 Number of people with asthma continues to
grow
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 Estimated annual cost = $19.7 billion
 Estimated annual direct cost (hospitalizations)
= $14.7 billion
 $3,300 per person each year
 Medical expenses continue to increase
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 Condition that occurs intermittently
 Occurs in two ways:
 Inflammation
 Airway hyperresponsiveness leading to
bronchoconstriction
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 Intermittent and reversible airflow obstruction
affecting airways only, not alveoli
 Airway obstruction:


Inflammation
Airway hyper-responsiveness
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 Different types based on how attacks are
triggered
 Caused by specific allergens, general irritants,
microorganisms, aspirin
 Hyper-responsiveness caused by exercise, URI,
unknown reasons
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 Assessment
 History
 Physical assessment/clinical manifestations
Audible wheeze, increased respiratory rate
 Increased cough
 Use of accessory muscles
 “Barrel chest” from air trapping
 Long breathing cycle
 Cyanosis
 Hypoxemia

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 ABGs
 Arterial O2 may decrease in acute asthma attack
 Arterial CO2 may decrease early in attack and
increase later (indicating poor gas exchange)
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 Allergic asthma with elevated serum eosinophil
count , immunoglobulin E levels
 Sputum with eosinophils, mucous plugs, with
shed epithelial cells
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 Most accurate with use of spirometry
 Forced vital capacity (FVC)
 Forced expiratory volume in first second (FEV1)
 Peak expiratory flow rate (PEFR)
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 Teaching for self-management
 Use of peak flowmeter twice daily
 Personal drug therapy plan
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 Based on step category for severity and
treatment
 Preventive therapy (controller drugs)


Change airway responsiveness to prevent asthma attacks
Used every day, regardless of symptoms
 Rescue drugs
 Actually stop attack once it has started
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 Bronchodilators
 Short- and long-acting beta2 agonists
 Cholinergic antagonists
 Methylxanthines
 Anti-inflammatory agents
 Corticosteroids
 NSAIDs
 Leukotriene antagonists
 Immunomodulators
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 Exercise and activity to promote ventilation and
perfusion
 Oxygen therapy via mask, nasal cannula, ET
tube (acute asthma attack)
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 Severe, life-threatening, acute episode of airway
obstruction
 Intensifies once it begins, often does not
respond to common therapy
 Patient can develop pneumothorax and
cardiac/respiratory arrest
 Treatment—IV fluids, potent systemic
bronchodilator, steroids, epinephrine, oxygen
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 Includes:
 Emphysema
 Chronic bronchitis
 Characterized by bronchospasm and dyspnea
 Tissue damage not reversible; increases in
severity, eventually leads to respiratory failure
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 Loss of lung elasticity and hyperinflation of lung
 Dyspnea; need for increased respiratory rate
 Air trapping caused by loss of elastic recoil in
alveolar walls, overstretching and enlargement
of alveoli into bullae, collapse of small airways
(bronchioles)
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 Inflammation of bronchi and bronchioles caused by
chronic exposure to irritants, especially cigarette
smoke
 Inflammation, vasodilation, congestion, mucosal
edema, bronchospasm
 Affects only airways, not alveoli
 Production of large amounts of thick mucus
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.





Hypoxemia/tissue anoxia
Acidosis
Respiratory infections
Cardiac failure, especially cor pulmonale
Cardiac dysrhythmias
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



History
General appearance
Respiratory changes
Cardiac changes
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 ABG values for abnormal oxygenation,







ventilation, acid-base status
Sputum samples
CBC
Hemoglobin and hematocrit
Serum electrolytes
Serum AAT
Chest x-ray
Pulmonary function test
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 Improve oxygenation and reduce carbon dioxide




retention
Prevent weight loss
Minimize anxiety
Improve activity tolerance
Prevent respiratory infection
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





Beta-adrenergic agents
Cholinergic antagonists
Methylxanthines
Corticosteroids
NSAIDs
Mucolytics
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 Lung reduction surgery
 Preoperative care and testing
 Operative procedure by median sternotomy or
VATS
 Postoperative care and close monitoring for
complications
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 Needed during mealtime; can be reduced by
resting before meals
 4 to 6 small meals a day
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 Home care management
 Long-term use of oxygen
 Pulmonary rehabilitation program
 Teaching for self-management
 Drug therapy
 Manifestations of infection
 Breathing techniques
 Relaxation therapy
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 Genetic disease affecting many organs, lethally
impairing pulmonary function
 Error of chloride transport, producing thick
mucus with low water content
 Mucus plugs up glands, causing atrophy and
organ dysfunction
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 Adults: usually smaller, thinner than average





owing to malnutrition
Abdominal distention
GERD, rectal prolapse, foul-smelling stools,
steatorrhea
Vitamin deficiencies
Diabetes mellitus
Osteoporosis
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







Respiratory infections
Chest congestion
Limited exercise tolerance
Cough and sputum production
Use of accessory muscles
Decreased pulmonary function
Changes in chest x-ray result
Increased anteroposterior diameter
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 Nutritional management
 Weight maintenance
 Vitamin supplementation
 Diabetes management
 Pancreatic enzyme replacement
 Preventive/maintenance therapy
 Chest physiotherapy
 Positive expiratory pressure
 Active cycle breathing technique
 Exercise
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 Exacerbation therapy:
 Avoid mechanical ventilation
 Supplemental oxygen
 Heliox
 Airway clearance techniques
 Drug therapy
 Prevention
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 Lung and/or pancreatic transplantation
 Does not cure
 Extends life by 10 to 20 years
 Patient at continued risk for lethal pulmonary
infections
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 Occurs in absence of other lung disorders; cause
unknown
 Blood vessel constriction with increasing
vascular resistance in the lung
 Heart fails (cor pulmonale)
 Without treatment, death within 2 yr
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





Warfarin therapy
Calcium channel blockers
Endothelin-receptor antagonists
Natural and synthetic prostacyclin agents
Digoxin and diuretics
Oxygen therapy
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 Affects alveoli, blood vessels, surrounding
support lung tissue
 Restrictive disease; thickened lung tissue,
reduced gas exchange, “stiff” lungs
 Slow onset
 Dyspnea most common manifestation
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 Granulomatous disorder of unknown cause;
affects lungs most often
 Autoimmune response—normally protective Tlymphocytes increase and damage lung tissue
 Corticosteroids are main therapy
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



Common restrictive lung disease
Highly lethal
Extensive fibrosis and scarring
Corticosteroids, other immunosuppressants
mainstays of therapy
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 Caused by occupational or environmental
exposure—fumes, dust, vapors, gases,
bacterial/fungal antigens, allergens
 Worsened by cigarette smoke
 Prevention through special respirators and
adequate ventilation
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 Leading cause of cancer deaths worldwide
 Poor long-term survival due to late-stage




diagnosis
Bronchogenic carcinomas
Paraneoplastic syndromes
Staged to assess size/extent of disease
Etiology and genetic risk
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
 Health promotion and maintenance
 Assessment
 History
 Pulmonary manifestations
 Nonpulmonary manifestations
 Psychosocial assessment
 Diagnostic assessment
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



Chemotherapy
Targeted therapy
Radiation therapy
Photodynamic therapy
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



Lobectomy
Pneumonectomy
Segmentectomy
Wedge resection
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 Chamber 1: collects fluid draining from patient
 Chamber 2: water seal prevents air from re-
entering patient’s pleural space
 Chamber 3: suction control of system
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 Pain management
 Respiratory management
 Pneumonectomy care
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






Oxygen therapy
Drug therapy
Radiation therapy
Thoracentesis and pleurodesis
Dyspnea management
Pain management
Hospice care
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The patient is a 55-year-old woman with a long
history of COPD and 40 years of smoking
cigarettes. She is being admitted to the pulmonary
stepdown unit from the ED. The ED nurse tells
you that the patient is on oxygen at 2 L per nasal
cannula. She had a bronchodilator respiratory
treatment in the ED as well. She has bilateral
expiratory wheezes and crackles both anteriorly
and posteriorly. A saline lock was placed in her
right forearm for intermittent medications.
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Based on the patient’s diagnosis, which clinical
manifestations would you expect to see when assessing
this patient? (Select all that apply.)
A. Funnel chest appearance
B. Sitting in a forward posture
C. Shortness of breath
D. Bradycardia
E. Use of accessory muscles
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When the patient arrives to the unit, you
complete her assessment and find her to be in
acute respiratory distress. Her respirations are
labored and her respiratory rate is 34. She states
that she is severely short of breath. Her oxygen
saturation is 82% on O2 at 2 L via nasal cannula.
Based on these findings, what should you do
next?
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While the Rapid Response Team is at the bedside, the
patient’s health care provider arrives. The provider
writes several orders.
Which order is most important for you to implement
immediately?
A. Transfer to ICU
B. Increase O2 to 3 L per nasal cannula
C. ABGs 30 min after oxygen is increased
D. Methylprednisolone sodium succinate (Solu-Medrol)
40 mg IVP
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The patient is in the ICU for 3 days and then transferred
back to the pulmonary stepdown unit. She is still
slightly short of breath with exertion. Her O2 saturation
is 99% on oxygen at 2 L per nasal cannula. She denies
any shortness of breath during your assessment. The
provider plans to discharge the patient on home oxygen
in the morning.
What should you include in this patient’s discharge
teaching?
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59
Which risk factor is responsible for the majority
of deaths from lung cancer?
A. Cigarette smoking
B. Occupational radiation exposure
C. Chronic exposure to asbestos
D. Air pollution
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Which patient is at greatest risk for having pulmonary
hypertension (PH)?
A. 32-year-old female with a family history of PH
B. 42-year-old female with history of blood clots in the
pulmonary artery
C. 50-year-old male with history of right-sided heart
failure
D. Patient who is overweight
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A patient with a history of asthma is having shortness of
breath. The nurse discovers that the peak flowmeter
indicates a peak expiratory flow (PEF) reading that is in
the red zone. The nurse should immediately:
A.
B.
C.
D.
Repeat the PEF reading to verify the results.
Take the patient’s vital signs.
Administer the rescue drugs.
Notify the patient’s prescriber.
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