Module IIb

Patient with Chronic Respiratory Disorders

Obstructive Pulmonary Disease
.Category of chronic lung disease
.Chronic Obstructive Lung Disease (COPD)
.Asthma
.Cystic fibrosis
.Involves airway obstruction
.Affects over 35 million Americans
Asthma
.An intermittent, reversible obstructive airway disease
.increased responsiveness of trachea & bronchi to various stimuli
.narrowing of airways with inflammation & obstruction
.symptoms can be mild to severe even fatal
.exacerbation last minutes to hours
Asthma Triggers
.Allergens/irritants
.Exercise
.Respiratory Infections
.Nose & Sinus Problems
.Drug & Food Additives
.GERD
.Emotional Stress
Incidence/Prevalence
.20 million in US/ 6.3 million children
.More prevalent in boys until puberty, then increased in women
.common in urban settings
.more prevalent in African American
.gerontologic considerations
Pathophysiology of Asthma
.inflammation & edema of mucous membranes
.spasm & hypertrophy of smooth muscle of bronchi & bronchioles
.accumulation of tenacious secretions
.hyperinflation of alveoli
Diagnostic Evaluation of Asthma
.History
.allergy testing
.CXR
.WBC differential
.elevated immunoglobulin E (IgE)
.sputum
.ABG s, oximetry
.PFT s
.serial spirometric monitoring(PEFR)
.Nitric Oxide Levels
Clinical Manifestations of Asthma
.Frequency and severity of symptoms vary
.onset abrupt or insidious,lasting hours to days
.prolonged expiration
.wheezing
.cough
.dyspnea, tachypneic
.chest tightness
.anxious, uncomfortable, acute distress
.acute episode may cause s&s of hypoxemia
.complications
Step System Severity of Asthma
.Mild intermittent
.Mild persistent
.Moderate persistent
.Severe persistent
Pharmacologic Agents
.Beta adrenergic agonists
.epinephrine
.Proventil, Brethine, Alupent
.Methylxanthines
.Anticholinergics
.Atrovent & Spiriva
.Mast cell inhibitors
.Cromolyn Na
.Corticosteroids
.Leukotiene modifier
.Monoclonal antibody to IgE
Step Management of Asthma
.Mild intermittent asthma
.inhaled B2 adrenergic agents or cromolyn (Intal) before exposure to allerg
ens
.mild persistent asthma
.antiinflammatory agent(inhaled steroid or Intal)
.theophylline
.consider leukotriene modifiers
.moderate persistent asthma
.inhaled steroid &/or long-acting bronchodilator
.severe persistent
.inhaled or oral steroid & long-acting bronchodilator
Pharmacologic Management of Acute Asthma
.Depends on severity & response to therapy
.initial Rx: B2 adrenergic agonists via nebulizer or MDI
.corticosteroids: IV, PO, MDI
.Epinephrine sc
.Aminophylline IV or theophylline po
Non-pharmacologic TNI of Acute Asthma
.Monitor respiratory and cardiovascular systems
.Monitor response to therapy
.Administer O2
.decrease pt s sense of panic
.position to maximize chest expansion
.pursed lip breathing
Status Asthmaticus
.Continuing worsening of symptoms despite vigorous treatment
.Management
.corticosteroids IV, theophylline
.manage F/E balance; assure hydration
.O2(humidified low flow)
.prepare for possible intubation
.antibiotics
Patient Education for Asthma Management
.Goal: prevent acute attack
.avoid allergens
.knowledge of meds and use of MDI
.use Peak Expiratory Flow meter
.know when to seek medical attention
.healthy diet & plenty of fluids
.rest & exercise
.avoid exposure to infection
Chronic Obstructive Pulmonary Disease(COPD)
.Condition characterized by chronic obstruction to air flow
.periods of exacerbation
.emphysema, chronic bronchitis
Epidemiology
.4th leading cause of death
.Affects more than 10.7 million persons in US
.Incidence doubled in last 25 yrs
.COPD in women is increasing
.Mortality
.Costs
Etiology of COPD
.Cigarette smoking
.Infection
.Heredity
.Aging
.environmental exposure
Pathophysiology
.Inflammatory process
.Destruction of lung parenchyma
.Alpha-1 antitrypsin deficiency
.Pulmonary vascular changes

Clinical Manifestations
.Insidious onset
.Cough
.Dyspnea
.Wheezing chest tightness
.Weight loss, anorexia
.Fatigue
.Physical findings
.polycythemia
.ABG abnormalities
Staging COPD
.Stage 0 -at risk FEV1 nl
.Stage I -mild FEV1 <80% of predicted
.Stage II -moderate -FEV1 50-80%
.Stage III -severe -FEV1 30-50%
.Stage IV very severe COPD < 30% or<50% and chronic resp failure
Complications
.Cor pulmonale
.Exacerbations of COPD
.Acute Respiratory Failure
.GERD
.Depression/Anxiety
Diagnostic Studies
.History & Physical
.Chest X-rays
.CT of chest
.PFT s
.ABG s
.CBC
.Bronchoscopy
Nursing Diagnosis
.Impaired gas exchange
.Ineffective Breathing pattern
.Ineffective Airway Clearance
.Imbalanced Nutrition: less than body requirements
.Anxiety
.Activity Intolerance
Collaborative Management for COPD -Goals
.Prevent disease progression
.Relieve symptoms
.Improve exercise tolerance
.Prevent/ treat complications
.Promote participation in care
.Prevent/treat exacerbation
.Improve quality of life
.Reduce mortality risk
Collaborative Mangement of COPD
.Pharmacologic Agents
.Removal of bronchial secretions
.O2 therapy
.prevent & promptly treat infection
.physical therapy
.maintain proper environmental conditions
.provide psychological support
.patient education & rehabilitation
.Lung Volume Reduction Surgery
Evidenced Based Practice:Pursed Lip Breathing
.Several randomized controlled studies have demonstrated that teaching pursed li
p breathing in
COPD patient helps
.Improve SaO2 (Tiepet al, 1986)
.Reduce desperate, dyspnea, PaCO2, improved tidal volume and O2 sat (Bianch
i et al., 2004)
.Promote slower, deeper breathing pattern and decreased dyspnea during exer
cise
Nutritional Needs for COPD
.Maintain BMI 21 to 25kg/m2
.Protein: 1.2 to 1.9g/kg
.Nonprotein calories evenly divided between fats and CHO
.Calories
.to maintain wt.: 25-30kcal/kg/day
.to gain wt.: 45kcal/kg/day
Terminal Dyspnea
.Assess for response to dyspnea
.main goal for dying is comfort/relieve dyspnea
.barriers
.monitoring of vs
.declining LOC
.interventions: non-pharmacologic & pharmocologic
Ethical & Legal Support
.ANA position statement: Promotion of Comfort and Relief of Pain in Dying Patient
s
. The promotion of comfort and aggressive efforts to relieve pain and other s
ymptoms in dying
patients are obligations of the nurse. The increasing titration of medicatio
n to achieve
adequate symptom control, even at the expense of maintaining life or hasten
ing death
secondarily, is ethically justified.
Cystic Fibrosis
.Multisystem disorder primarily affecting the exocrine(mucous-producing) glands
.most common serious pulmonary & gastric disease in children
.inherited as an autosomal recessive trait
.occurs 1:1600 births;. d in Caucasians
.equal sex distribution
Pathophysiology of Cystic Fibrosis

lungs - obstructed bronchioles, progressive COPD, chronic infection

sm. Intestine - meconium ileus (newborn)
pancreas - malabsorption syndrome
reproductive decreased fertility, increased sterility
Clinical Manifestations of Cystic Fibrosis
.Pulmonary
.patchy atelectasis & hyperinflation of lung
.child cannot expectorate
.infection
.Gastro-intestinal
.meconium ileum may be early sign
.impaired digestion & absorption of nutrients
.steatorrhea
.complication: rectal prolapse
.DIOS/constipation
Diagnostic Evaluation of Cystic Fibrosis
.Dx may occur at birth or as late as early adulthood
.history
.pancreatic enzyme test
.fecal fat test
.sweat electrolyte test
.CXR
Management of Cystic Fibrosis
.Pulmonary Management
.chest PT
.meds: bronchodilators, mucolytics, expectorants, antibiotics
.transplant
.GI management
.meds: pancrelipase, multivitamins
 .diet: increased calories, increased protein, increased fluids, fat as tole
rated, give salty foods in
hot weather
.skin care
.manage rectal prolapse
TNI for Cystic Fibrosis
.Focus on:
.improving ventilation
.improving nutritional status
.support child & family
.patient & family education
.stress compliance with treatment
.encourage f/u care
.refer to CF foundation