Chronic Pulmonary Diseases Asthma and COPD

transcript

Chronic Pulmonary DiseasesAsthma and COPD

JSBrinley, RN, MSN/Ed, CNE

Asthma – Definition• Chronic inflammatory disorder of airways

– Causes airway hyperresponsiveness leading to wheezing, breathlessness, chest tightness, and cough

– Risk factors• Genetics• Immune response• Allergens• Exercise• Air pollutants• Occupational factors• Respiratory infections• Nose an sinus problems• Drugs and food additives• GERD• Psychologic

Triggers of Asthma Allergens

May be seasonal or year round depending on exposure to allergen– House dust mites– Cockroaches– Furry animals– Fungi– Molds

Triggers of Asthma Exercise

• Induced or exacerbated after exercise– Pronounced with exposure to cold air

• Breathing through a scarf or mask may ↓ likelihood of symptoms

Triggers of Asthma Air Pollutants

• Can trigger asthma attacks– Cigarette or wood smoke– Vehicle exhaust– Elevated ozone levels– Sulfur dioxide

Triggers of Asthma Occupational Factors

• Most common form of occupational lung disease– Exposure to diverse agents

• Arrive at work well, but experience a gradual decline

Triggers of Asthma Respiratory Infection

• Major precipitating factor of an acute asthma attack– ↑ inflammation hyperresponsiveness of the

tracheobronchial system

Triggers of AsthmaNose and Sinus Problems

• Allergic rhinitis and nasal polyps– Large polyps are removed – Sinus problems are usually related to

inflammation of the mucous membranes

Triggers of AsthmaDrugs and Food Additives

• Asthma triad: Nasal polyps, asthma, and sensitivity to aspirin and NSAIDs– Wheezing develops in about 2 hours.– Sensitivity to salicylates

• Found in many foods, beverages, and flavorings

• β-Adrenergic blockers

Triggers of AsthmaDrugs and Food Additives

• Food allergies may cause asthma symptoms.– Avoidance diets – Rare in adults

Triggers of AsthmaGastroesophageal Reflux Disease

• Exact mechanism is unknown.– Reflux of acid could be aspirated into lungs,

causing bronchoconstriction.

Triggers of AsthmaEmotional Stress

• Psychologic factors can worsen the disease process.– Attacks can trigger panic and anxiety.– Extent of effect is unknown.

Pathophysiology

Fig. 29-1. Pathophysiology of asthma. IL, Interleukin.

Pathophysiology

• Primary response is chronic inflammation from exposure to allergens or irritants. – Leading to airway hyperresponsiveness and acute

airflow limitations

Pathophysiology

• Inflammatory mediators cause early-phase response.– Vascular congestion– Edema formation– Production of thick, tenacious mucus– Bronchial muscle spasm– Thickening of airway walls

Early Phase Response of Asthma Triggered by Allergen

Fig. 29-2. Allergic asthma is triggered when an allergen cross-links IgE receptors on mast cells, which are thenactivated to release histamine and other inflammatory mediators (early-phase response). A late-phase responsemay occur due to further inflammation.

Factors Causing Obstruction

Fig. 29-3. Factors causing obstruction (especially expiratory obstruction) in asthma. A, Cross section of abronchiole occluded by muscle spasm, swollen mucosa, and mucus in the lumen. B, Longitudinal section of abronchiole.

Pathophysiology

• Late-phase response– Occurs within 4 to 10 hours after initial attack– Occurs in only 30% to 50% of patients– Can be more severe than early phase and can last

for 24 hours or longer

Pathophysiology

• Late-phase response– If airway inflammation is not treated or does not

resolve, it may lead to irreversible lung damage.

Clinical Manifestations

• Unpredictable and variable– Recurrent episodes of wheezing, breathlessness,

cough, and tight chest– May be abrupt or gradual– Lasts minutes to hours

• Expiration may be prolonged. – Inspiration-expiration ratio of 1:2 to 1:3 or 1:4– Bronchospasm, edema, and mucus in bronchioles

narrow the airways.– Air takes longer to move out.

• Wheezing is unreliable to gauge severity. – Severe attacks may have no audible wheezing.– Usually begins upon exhalation

• Cough variant asthma– Cough is only symptom.– Bronchospasm is not severe enough to cause

airflow obstruction.

• Difficulty with air movement can create a feeling of suffocation.– Patient may feel increasingly anxious.

• An acute attack usually reveals signs of hypoxemia.– Restlessness– ↑ anxiety– Inappropriate behavior

• More signs of hypoxemia– ↑ pulse and blood pressure– Pulsus paradoxus (drop in systolic BP during

inspiratory cycle >10 mm Hg)

Classification of Asthma

• Mild intermittent• Mild persistent• Moderate persistent• Severe persistent

Complications

• Severe acute attack– Respiratory rate >30/min – Pulse >120/min– PEFR is 40% at best.– Usually seen in ED or hospitalized

Complications

• Life-threatening asthmaToo dyspneic to speakPerspiring profuselyDrowsy/confusedRequire hospital care and often admitted to ICU

Diagnostic Studies

• Detailed history and physical exam• Pulmonary function tests• Peak flow monitoring• Chest x-ray• ABGs

Diagnostic Studies

• Oximetry• Allergy testing• Blood levels of eosinophils• Sputum culture and sensitivity

Question

• A client is diagnosed with asthma is admitted to the emergency department with difficulty breathing. Which diagnostic test will be ordered to determine the status of the client?– A. Complete blood count.– B. Pulmonary function test.– C. Allergy skin testing.– D. Drug cortisol level.

Collaborative Care

• Education– Start at time of diagnosis.– Integrate through care.

Collaborative Care

• Desired therapeutic outcomes– Control or eliminate symptoms– Attain normal lung function– Restore normal activities– Reduce or eliminate exacerbations and side effects

of medications

Drug Therapy

Fig. 29-4. Drug therapy: stepwise approach for managing asthma.

Asthma Control Test

Fig. 29-5.

Collaborative Care

• Mild intermittent and mild persistent asthma– Avoid triggers of acute attacks.– Premedicate before exercising.

• Choice of drug therapy depends on symptom severity.

Collaborative Care

• Acute asthma episode– Respiratory distress– Treatment depends upon severity and response to

therapy.• Severity measured with flow rates

Collaborative Care

• Acute asthma episode– O2 therapy may be started and monitored with

pulse oximetry or ABGs in severe cases.

Collaborative Care

• Severe exacerbations– Most therapeutic measures are the same as for

acute episode.• ↑ in frequency and dose of bronchodilators

Collaborative Care

Severe exacerbations– IV corticosteroids are administered every 4 to 6

hours, then are given orally.– Continuous monitoring of patient is critical.– IV magnesium sulfate is given as a bronchodilator.

Collaborative Care

• Severe exacerbations– Supplemental O2 is given by mask or nasal cannula

for 90% O2 saturation.• Arterial catheter may be used to facilitate frequent ABG

monitoring.– IV fluids are given because of insensible loss of

fluids.

The nurse anticipates intubation and mechanical ventilation for the patient with a severe exacerbation of asthma (status asthmaticus) when:

1. The PaCO2 is 60 mm Hg.2. The PaO2 decreases to 70 mm Hg.3. Severe respiratory muscle fatigue occurs.4. The patient has extreme anxiety and fear of

suffocation.

Question

Drug Therapy

• Long-term control medications– Achieve and maintain control of persistent asthma

• Quick-relief medications– Treat symptoms of exacerbations

Drug Therapy

• Three types of antiinflammatory drugs– Corticosteroids– Leukotriene modifiers– Monoclonal antibody to IgE

Drug Therapy

• Corticosteroids (e.g., beclomethasone, budesonide)– Suppress inflammatory response– Inhaled form is used in long-term control.– Systemic form to control exacerbations and

manage persistent asthma

Drug Therapy

• Corticosteroids– Reduce bronchial hyperresponsiveness– Decrease mucous production– Are taken on a fixed schedule

Drug Therapy

• Corticosteroids– 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

Spacer

Fig. 29-6. Example of an AeroChamber spacer used with a metered-dose inhaler.

Drug Therapy

• Leukotriene modifiers or inhibitors (e.g., zafirlukast, montelukast, zileuton)– Block action of leukotrienes—potent

bronchoconstrictors

Drug Therapy

• Leukotriene modifiers or inhibitors – Have both bronchodilator and antiinflammatory

effects – Not indicated for acute attacks– Used for prophylactic and maintenance therapy

Drug Therapy

• Anti-IgE (e.g., Xolair)– ↓ circulating free IgE levels– Prevents IgE from attaching to mast cells,

preventing release of chemical mediators– Subcutaneous administration every 2 to 4 weeks

Drug Therapy

• Three types of bronchodilators– β2-Adrenergic agonists – Methylxanthines– Anticholinergics

Drug Therapy

• β-Adrenergic agonists (e.g., albuterol, metaproterenol)– Effective for relieving acute bronchospasm– Onset of action in minutes and duration of 4 to 8

Drug Therapy

• β-Adrenergic agonists – Prevent release of inflammatory mediators from

mast cells– Not for long-term use

Question

• The client is diagnosed with mild intermittent asthma. Which medication would the nurse discuss with the client?– A. Daily inhaled corticosteroids.– B. Use of a “rescue inhaler.”– C. Use of systemic steroids.– D. Leudotriene agonists.

Drug Therapy

• Methylxanthines (e.g., theophylline)– Less effective long-term bronchodilator– Alleviates early phase of attacks but has little

effect on bronchial hyperresponsiveness– Narrow margin of safety

Drug Therapy

• Anticholinergic drugs (e.g., ipratropium)– Block action of acetylcholine– Usually used in combination with a bronchodilator– Most common side effect is dry mouth.

Patient Teaching Related to Drug Therapy

• Correct administration of drugs is a major factor in success. – Inhalation of drugs is preferable to avoid systemic

side effects.• MDIs, DPIs, and nebulizers are devices used to inhale

medications.

Patient Teaching Related to Drug Therapy

• Correct administration of drugs – Using an MDI with a spacer is easier and improves

inhalation of the drug. – DPI (dry powder inhaler) requires less manual

dexterity and coordination.

Example of DPI

Fig. 29-8. Example of a dry powder inhaler (DPI).

Nursing ManagementNursing Assessment

• Health history – Especially of precipitating factors and medications

• ABGs• Lung function tests

• Physical examination– Use of accessory muscles– Diaphoresis– Cyanosis– Lung sounds

Nursing ManagementNursing Diagnoses

• Ineffective airway clearance• Anxiety• Deficient knowledge

Nursing ManagementPlanning

• Overall Goals– Maintain greater than 80% of personal best PEFR– Have minimal symptoms– Maintain acceptable activity levels

• Overall Goals– Few or no adverse effects– No recurrent exacerbations of asthma or

decreased incidence of asthma attacks– Adequate knowledge to participate in and carry

out management

Nursing ManagementHealth Promotion

• Teach patient to identify and avoid known triggers.– Use dust covers– Use scarves or masks for cold air– Avoid aspirin or NSAIDs

Nursing ManagementHealth Promotion

• Prompt diagnosis and treatment of upper respiratory infections and sinusitis may prevent exacerbation.

• Fluid intake of 2 to 3 L every day

Nursing ManagementNursing Implementation

• Acute intervention– Monitor respiratory and cardiovascular systems:

• Lung sounds• Respiratory rate• Pulse• BP

• An important goal of nursing is to ↓ the patient’s sense of panic. – Stay with patient.– Encourage slow breathing using pursed lips for

prolonged expiration.– Position comfortably.

• Ambulatory and home care– Must learn about medications and develop self-

management strategies– Patient and health care professional must monitor

responsiveness to medication.

• Ambulatory and home care – Patient must understand importance of continuing

medication when symptoms are not present.

Question

• The client is diagnosed with exercise-induced (EIA) is being discharged. Which information should the nurse include in the discharge teaching?– A. Take two (2) puffs on the rescue inhaler and wait five (%

minutes before exercising.– B. Warm-up exercises will increase the potential for

developing the asthma attacks.– C. Use the bronchodilator inhaler immediately prior to

beginning to exercise.– D. Increase dietary intake of food high in monosodium

glutamate (MSG).

• Important patient teaching– Seek medical attention for bronchospasm or when

severe side effects occur.– Maintain good nutrition.– Exercise within limits of tolerance.

• Important patient teaching– Measure peak flow at least daily.– Asthmatic individuals frequently do not perceive

changes in their breathing.

• Peak flow should be monitored daily and a written action plan should be followed according to results of daily PEFR.

• Peak flow results– Green Zone

• Usually 80% to 100% of personal best• Remain on medications.

Peak flow resultsYellow Zone

Usually 50% to 80% of personal bestIndicates cautionSomething is triggering asthma.

• Peak flow results– Red Zone

• 50% or less of personal best• Indicates serious problem• Definitive action must be taken with health care

provider.

Case Study

• 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.

Case Study

• She had taken a new job at a dry cleaners and laundromat.

• She has been having regurgitation of food after eating, which she related to the stress from her recent divorce.

Case Study

• She is upset that her children had just brought home a stray cat.

• She does not know if she was allergic to the cat.

Discussion Questions

1. What possible asthma triggers may she be experiencing?

2. Are there any possible triggers that she can avoid or manage?

3. What are her priorities of care?

4. What patient teaching topics should you cover with her?

COPD Description

• Airflow limitation not fully reversible– Generally progressive– Abnormal inflammatory response of lungs to

noxious particles or gases

COPDDescription

• Includes– Chronic bronchitis– Emphysema

COPDSignificance

• Fourth leading cause of death in the United States

• More women die than men• Death rates in Hispanics are lower than in any

other ethnic group

COPDEtiology

• Risk factors– Cigarette smoking– Occupational chemicals and dust– Air pollution

COPDEtiology

• Risk factors– Infection – Heredity– Aging

COPDCigarette Smoking

• Clinically significant airway obstruction develops in 15% of smokers.

• 80% to 90% of COPD deaths are related to tobacco smoking.

• Effects of nicotine– Stimulates sympathetic nervous system

• Increases HR• Causes peripheral vasoconstriction• Increases BP and cardiac workload

• Effects of nicotine– ↓ Amount of functional hemoglobin– ↑ Platelet aggregation– Compounds problems in CAD

• Effects on respiratory tract– Increased production of mucus– Hyperplasia of mucous glands– Lost or decreased ciliary activity

• Carbon monoxide– ↓ O2 carrying capacity

• ↑ Heart rate• Impaired psychomotor performance and judgment

• Passive smoking (second-hand smoke) – ↓ Pulmonary function– ↑ Risk of lung cancer– ↑ Respiratory symptoms

COPDOccupational & Environmental

• COPD can develop with intense or prolonged exposure to– Dusts, vapors, irritants, or fumes– High levels of air pollution– Fumes from indoor heating or cooking with fossil

COPDInfection

• Recurring infections impair normal defense mechanisms.

• Risk factor for COPD• Intensify pathologic destruction of lung tissue

COPDAging

• Some degree of emphysema is common because of physiologic changes of aging lung tissue.

Question

• The nurse is assessing the client with COPD. Which health promotion information is most important for the nurse to obtain?– A. Risk factors for complications.– B. Ability to administer inhaled medication.– C. Willingness to modify lifestyle.– D. Number of years the client has smoked.

COPDPathophysiology

• Defining features– Irreversible airflow limitations during forced

exhalation due to loss of elastic recoil– Airflow obstruction due to mucous

hypersecretion, mucosal edema, and bronchospasm

COPDPathophysiology

• Primary process is inflammation.– Inhalation of noxious particles– Mediators released cause damage to lung tissue.– Airways inflamed– Parenchyma destroyed

COPDPathophysiology

Fig. 29-7102

Fig. 29-9. Pathophysiology of COPD.

COPDPathophysiology

• Supporting structures of lungs are destroyed.– Air goes in easily, but remains in the lungs.– Bronchioles tend to collapse. – Causes barrel-chest look

COPDPathophysiology

• Pulmonary vascular changes – Blood vessels thicken.– Surface area for diffusion of O2 decreases.

COPDPathophysiology

• Common characteristics– Mucous hypersecretion– Dysfunction of cilia– Hyperinflation of lungs– Gas exchange abnormalities

Pulmonary Blebs and Bullae

Fig. 29-10. Pulmonary blebs and bullae.

COPDPathophysiology

• Commonly, emphysema and chronic bronchitis coexist.

• Distinguishing symptoms can be difficult with co-morbidities.

COPDClinical Manifestations

• Develops slowly• Diagnosis is considered with

– Cough– Sputum production– Dyspnea– Exposure to risk factors

• Dyspnea usually prompts medical attention.– Occurs with exertion in early stages– Present at rest with advanced disease

• Causes chest breathing– Use of accessory and intercostal muscles– Inefficient

• Characteristically underweight with adequate caloric intake

• Chronic fatigue

• Physical examination findings– Prolonged expiratory phase– Wheezes– Decreased breath sounds– ↑ Anterior-posterior diameter

• Bluish-red color of skin– Polycythemia and cyanosis

Question

• Which clinical manifestation should the nurse expect to assess in the client recently diagnosed with COPD?– A. Clubbing of the client’s fingers.– B. Infrequent respiratory infections.– C. Chronic sputum production– D. Nonproductive hacking cough.

COPDClassification

• Classified as– Mild– Moderate– Severe– Very severe

COPD Complications

• Cor pulmonale• Exacerbations of COPD• Acute respiratory failure• Peptic ulcer disease• Depression/anxiety

COPDCor Pulmonale

• Hypertrophy of right side of heart– Result of pulmonary hypertension– Late manifestation of chronic pulmonary heart

disease– Eventually causes right-sided heart failure

Pathophysiology of Cor Pulmonale

Fig. 29-12. Mechanisms involved in the pathophysiology of cor pulmonale secondary to chronic obstructivepulmonary disease.

COPDCor Pulmonale

• Dyspnea• Distended neck veins• Hepatomegaly with upper quadrant

tenderness• Peripheral edema• Weight gain

COPD Exacerbations

• Signaled by change in usual– Dyspnea– Cough– Sputum

COPDExacerbations

• Associated with poorer outcomes• Primary causes

– Infection– Air pollution

COPDAcute Respiratory Failure

• Caused by– Exacerbations– Cor pulmonale– Discontinuing bronchodilator or corticosteroid

medication

COPDAcute Respiratory Failure

• Caused by– Overuse of sedatives, benzodiazepines, and

opioids– Surgery or severe, painful illness involving chest or

abdomen

COPDDepression/Anxiety

• Approximately 50% of COPD patients experience depression.

• If patient become anxious because of dyspnea, teach pursed lip breathing.

COPDDiagnostic Studies

• Diagnosis confirmed by pulmonary function tests– Chest x-rays, spirometry, history, and physical

examination are also important in the diagnostic workup.

• Spirometry typical findings – Reduced FEV/FVC ratio– Increased residual volume

• ABG typical findings– Low PaO2

– ↑ PaCO2

– ↓ pH– ↑ Bicarbonate level found in late stages of COPD

COPD Diagnostic Studies

• 6-Minute walk test to determine O2

desaturation in the blood with exercise• ECG can show signs of right ventricular failure.

COPDCollaborative Care

• Primary goals of care– Prevent progression.– Relieve symptoms.– Prevent/treat complications.

• Primary goals of care– Promote patient participation.– Prevent/treat exacerbations.– Improve quality of life and reduce mortality risk.

• Irritants should be evaluated and avoided.• Exacerbations treated promptly

• Smoking cessation– Most effective intervention– Accelerated decline in pulmonary function slows

and usually improves.

• Drug therapy– Bronchodilators

• Relax smooth muscle in the airway• Improve ventilation of the lungs• ↓ Dyspnea and ↑ FEV1

• Inhaled route is preferred.

• Drug therapy– Commonly used bronchodilators

• β2-Adrenergic agonists• Anticholinergics• Methylxanthines

COPD Collaborative Care

• Drug therapy– Long-acting anticholinergic

Tiotropium (Spiriva)– Inhaled corticosteroid therapy

• Used for moderate to severe cases

• O2 therapy is used to– Reduce work of breathing– Maintain PaO2

– Reduce workload on the heart

• Long-term O2 therapy improves– Survival– Exercise capacity– Cognitive performance– Sleep in hypoxemic patients

• 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.

• Humidification – Used because O2 has a drying effect on the

mucosa– Supplied by nebulizers, vapotherm, and bubble-

through humidifiers

• Complications of oxygen therapy– Combustion – CO2 narcosis

– O2 toxicity– Absorption atelectasis– Infection

• Chronic O2 therapy at home improves– Prognosis– Mental acuity– Exercise intolerance

• Chronic O2 therapy at home reduces– Hematocrit– Pulmonary hypertension

• Chronic O2 therapy at home– Periodic reevaluations are necessary to determine

duration of use.

• Surgical therapy– Lung volume reduction surgery

• Remove diseased lung to enhance performance of remaining tissue

• Surgical therapy– Bullectomy

• Used for emphysema• Large bullae are resected to improve lung function.

• Surgical therapy– Lung transplantation

• Single lung—Most common because of donor shortages

• Prolongs life• Improves functional capacity• Enhances quality of life

• Respiratory and physical therapy– Breathing retraining– Effective coughing– Chest physiotherapy

• Percussion• Vibration• Postural drainage

• Respiratory and physical therapy– Airway clearance devices– High-frequency chest wall oscillation

• Breathing retraining– Decreases dyspnea, improves oxygenation, and

slows respiratory rate• Pursed lip breathing

• Pursed lip breathing– Prolongs exhalation and prevents bronchiolar

collapse and air trapping

• Effective coughing– Main goals

• Conserve energy.• Reduce fatigue.• Facilitate removal of secretions.

• Chest physiotherapy indicated for– Excessive, difficult-to-clear bronchial secretions– Retained secretions in artificial airway– Lobular atelectasis from mucous plug

• Postural drainage– Gravity assists in bronchial drainage.– Techniques are individualized according to

patient’s pulmonary condition and response to initial treatment.

– Commonly ordered 2 to 4 times per day

• Percussion– Hands in a cuplike position to create an air pocket– Air-cushion impact facilitates movement of thick

mucus.

Cupped-Hand Position

Fig. 29-16155

Fig. 29-15. Cupped-hand position for percussion. The hand should be cupped as though scooping up water.

• No percussion over– Kidneys – Sternum – Spinal cord– Bony prominences– Tender or painful area

• Vibration– Facilitates movement of secretions to larger

airways– Mild vibration tolerated better than percussion

• Flutter mucus clearance device– Produces vibration in lungs to loosen mucus for

expectoration – Hand-held device

• High-frequency chest wall oscillation– Inflatable vest that vibrates the chest– Works on all lobes– More effective than CPT

• Acapella– Vibrates lungs to shake free mucous plugs– Improves clearance of secretions– Faster and more tolerable than CPT

Acapella

Fig. 29-17. Acapella.

• Nutritional therapy – Weight loss and malnutrition are common.

• Pressure on diaphragm from a full stomach causes dyspnea.

• Difficulty breathing while eating leads to inadequate consumption.

• Nutritional therapy– To decrease dyspnea and conserve energy

• Rest at least 30 minutes before eating.• Use bronchodilator.• Prepare foods in advance.

• Nutritional therapy– Eat five to six small meals to avoid bloating and

early satiety.– Cold foods may cause less fullness than hot foods.

• Nutritional therapy– Avoid

• Foods that require a great deal of chewing• Exercises and treatments 1 hour before and after eating• Gas-forming foods

• Nutritional therapy– High-calorie, high-protein diet is recommended.– Fluids (intake of 3 L/day) should be taken between

meals.

• Obtain complete health history and conduct a complete physical assessment.– See Table 29-24 in textbook for COPD-specific

information.

Nursing ManagementNursing Diagnoses

• Ineffective airway clearance• Impaired gas exchange• Imbalanced nutrition: Less than body

requirements• Risk for infection• Insomnia

Question

• Which outcome is appropriate for the client problem “ineffective gas exchange” for the client recently diagnosed with COPD?– A. The client demonstrates the correct way to pursed-

lip breathe.– B. The client lists three (3) signs/symptoms to report

to the HCP.– C. The client will drink at least 2,500 mL of water daily.– D. The client will be able to ambulate 100 feet with

dyspnea.

• Goals– Prevention of disease progression– Ability to perform ADLs– Relief from symptoms– No complications related to COPD

• Goals– Knowledge and ability to implement long-term

regimen– Overall improved quality of life

• Health promotion – Abstain from or stop smoking.– Avoid or control exposure to occupational and

environmental pollutants and irritants.

• Health promotion – Early detection of small-airway disease– Early diagnosis and treatment of respiratory tract

infection

• Health promotion – Awareness of family history of COPD and AAT

deficiency

• Acute intervention – Required for pneumonia, cor pulmonale, or acute

respiratory failure– Degree and severity of underlying respiratory

problem should be assessed.

• Ambulatory and home care– Most important aspect is teaching.

• Pulmonary rehabilitation• Activity considerations• Sexual activity• Sleep• Psychosocial considerations

• Pulmonary rehabilitation– Increase exercise performance.– Reduce dyspnea.– Improve quality of life.

• Activity considerations – Exercise training leads to energy conservation.

• In upper extremities, it may improve muscle function and reduce dyspnea.

• Activity considerations– Modify ADLs to conserve energy.– Walk 15 to 20 minutes a day at least

3 times a week with gradual increases.• Adequate rest should be allowed.

• Activity considerations– Exercise-induced dyspnea should return to

baseline within 5 minutes after exercise.

• Sexual activity– Plan when breathing is best.– Use slow, pursed lip breathing.– Refrain after strenuous activity.– Do not assume dominant position or prolong

foreplay.

• Sleep– Can be difficult because of medications, postnasal

drip, or coughing• Nasal saline sprays, decongestants, or nasal steroid

inhalers can help.

• Psychosocial considerations– Healthy coping is difficult. – May feel guilt, depression, anxiety, social isolation,

denial, and dependence

Nursing ManagementEvaluation

• Expected outcomes– Normal breath sounds– Effective coughing– Return of PaO2 to normal range for patient– Improved mental status

• Expected outcomes– Maintenance of normal body weight– Normal serum protein levels– Feeling of being rested– Improvement in sleep pattern

• Expected outcomes– Awareness of need to seek medical attention– Behaviors minimizing risk of infection– No infection

When reviewing the arterial blood gases of a patient with COPD, the nurse identifies late stage COPD with which of the following results?

1. pH 7.26, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3 30 mEq/L2. pH 7.30, PaCO2 45 mm Hg, PaO2 55 mm Hg, HCO3 18 mEq/L3. pH 7.40, PaCO2 40 mm Hg, PaO2 70 mm Hg, HCO3 25 mEq/L4. pH 7.52, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3 35 mEq/L

Question

Case Study

• 77-Year-old man presents to the hospital complaining of shortness of breath, morning cough, and swelling in his lower extremities.

• He has difficulty breathing when he walks.

Case Study

• States sleeping in a recliner to make it easier to breathe

• Feels his shoes are tight at the end of the day

Case Study

• Has smoked one pack of cigarettes a day for the past 30 years

• His breathing is labored.

• Breath sounds faint with prolonged expiration

Case Study

• His arterial blood gases show ↓ PaO2 and ↑ PaCO2.

• Chest x-rays show hyperinflation of the lungs.

• 2+ peripheral edema bilateral lower extremities

1. He is diagnosed with COPD. What is the basis for this diagnosis?

2. Why does he have swelling of his feet and ankles?

3. What important teaching measures should you incorporate into his plan of care?

Chronic Pulmonary Diseases Asthma and COPD

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