Lower Respiratory

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Lower Respiratory
2011-08-16 16:57:57

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  1. General Nursing Care for Airway Clearance
    Incentive Spirometry

    Coughing and Deep Breathing (C & DB)

    Chest Physiotherapy (CPT)

    • Suctioning of Airway only as needed
    • *Nasopharyngeal
    • *Oropharyngeal
    • *Artificial airways if in place (Tracheostomy, Endotracheal Tube)
  2. Acute Bronchitis
    Inflammation of the bronchi

    Usually due to infection

    One of most common illnesses in primary care

    Etiology: viral, bacterial

    Most cases are viral

    Usually precipitated by upper respiratory infection
  3. Manifestations with Acute Bronchitis
    • Cough
    • Sputum production
    • Fever
    • Headache
    • Malaise
    • Shortness of breath on exertion
    • Rhonchi, wheezing
  4. Collaborative Care for Acute Bronchitis
    Supportive treatment: fluids, rest,

    antiinflammatory agents



    Teach for s/s of complications
  5. Asthma
    A clinical syndrome characterized by increased responsiveness of the tracheobronchial tree to a variety of stimuli.

    A disease of INFLAMMATION.
  6. Extrinsic asthma has an
    Allergic Cause

    examples: dust, pollen, animal dander
  7. Intrinsic or Idiopathic Asthma has a
    Non-allergic cause

    Examples: respiratory infection, exercise, cold air, cigarette smoke
  8. Parasympathetic Dominance (Pathophysiology of Asthma)
    Mucosal inflammation

    Constriction of bronchial smooth muscles

    Excess production of mucus
  9. Stages of Asthma
    Step 1 – Mild Intermittent

    Step 2 – Mild Persistent

    Step 3 - Moderate Persistent

    Step 4 – Severe Persistent

    Treatment based upon stages
  10. Diagnosis of Asthma
    Primarily on history and physical exam

    • History
    • Physical examination
    • Pulmonary function tests (more chronic)
    • Increase IgE levels and eosinophil levels
    • ABG/CBC
    • Pulse Oximetry
    • CXR
    • Allergy Skin Testing Sputum Culture if s/s infection is present
    • Sputum Specimen for Gram Stain & Culture
  11. Beta Agonist Medication for Asthma
    • activate the beta-2 receptor on the muscles surrounding the
    • airways→ relaxes the muscles surrounding the airways→ opens the airways

    (Albuterol, Xopenex, Terbutaline)

    P.O. & Inhaler

    Long acting – (Salmeterol)
  12. Xopenex
    newer drug, tried to reduce tachycardia so pts on this don’t complain as much of tachy and jitteriness
  13. Anticholinergics (meds for Asthma)
    relax and dilate the airways in the lungs; protect the airways from spasms

    Atrovent; Spiriva; Combivent

    Inhaler & Nebulizer

    Used for more chronic conditions
  14. Methylxanthines
    Slightly relax the airways in the lungs through bronchodilation

    • Increases the strength of the diaphragm by
    • stimulating the breathing control centers in the brain

    Aminophylline; Theophylline; Theodur; Slo-bid (side effects a lot jittery and HR goes up)

    IV, PO
  15. Antiinflammatory Agents
    • Many steroids, specifically glucocorticoids, reduce inflammation or swelling by binding to cortisol
    • receptors.

    Methylpredisolone; Solu-medrol; Prednisone; Flovent, Pulmacort

    Advair (combined drug – Flovent and Serevent)

    IV, PO, Inhaler
  16. Leukotriene Modifiers
    (leukotriene antagonists)

    work to block the effects of leukotrienes in our bodies by binding to receptors on smooth muscle and other tissue in the airways, as well as by preventing their release from mast cells

    Singulair; Accolate;

  17. Mucolytic Agents
    help loosen and clear the mucus from the airways by breaking up the sputum\

    Guiafenesin; Acetylcysteine

    PO, Nebulizer
  18. Using an Inhaler
    • Hold inhaler 2-3 cm from mouth; shake cannister;
    • spray one puff and inhale; hold for 10 sec.

    2 minutes in between each puff of the same type of inhaler.

    5 minutes in between use of inhaler of a different medication.

    Rinse mouth after use of steroid inhalers can get thrush
  19. Order of Use of Inhaler
    • BAS
    • Beta-agonist
    • Atropine-based
    • Steroid

    • BAC
    • Beta-agonist
    • Atropine-based
    • Cromolyn
  20. What does it mean when pt goes from wheezing to not wheezing ???
    if pt was wheezing and now they are not, its saying the pt could be getting worse, theres less movement and less air, pulse ox would drop, grasp neck, Louder can mean they are getting better meaning airway is getting bigger and more air is going through
  21. Asthma Nursing Management
    Assessment (esp. resp/cardiac status)

    Bedrest-High Fowler's or Recliner

    • C & DB time and place for both
    • Chest Physiotherapy

    Pursed Lip Breathing

    Balance Activity & Rest

    Fluids 3L/Day

    Diet-Sm. Frequent Meals
  22. What are some Other Asthma Nursing Management

    Relaxation Exercises

    Patient Education

    Preventive Measures
  23. What are some preventative measures for Asthma pts
    Stay indoors when weather too hot or cold or high degree of pollution

    Avoid OTC drugs containing ASA & Beta Blockers

    Prompt diagnosis and treatment of URI
  24. What are some Complications of Asthma
    Acute Respiratory Failure

    Status Asthmaticus (more than just a nebulizer)

    Ruptured Bleb---> pneumothorax
  25. COPD
    (Chronic Obstructive Pulmonary Disease): disease state characterized by the presence of airflow obstruction

    • Chronic Bronchitis
    • Emphysema
  26. Chronic Bronchitis
    presence of chronic productive cough for 3 months X 2 years

    45-65 yrs of age
  27. Emphysema
    – abnormal enlargement of airspaces accompanied by destruction of walls

    A condition of the lung characterized by abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls, and without obvious fibrosis.

    65-75 yrs of age
  28. COPD significance and etiology
    Related primarily to smoking-20 year lag before signs of disease are apparent

    • Etiology
    • Three major irritants
    • cigarette smoking
    • infection
    • inhaled irritants

    • Heredity (AAT found in emphysema)
    • Aging
  29. Chronic Bronchitis-Pathophysiology
    A syndrome of excessive mucus production in the bronchi accompanied by a recurrent daily cough that persists for at least 3 months of the year during at least 2 consecutive years.
  30. Pathophysiology-Chronic Bronchitis
    Hypertrophy & hyperplasia of bronchial glands

    Increased # goblet cells--->increased mucus

    Decreased cilia

    Chronic Inflammation---> airway narrowing

    Altered function of alveoli macrophages
  31. ATT in Normal individual
    ATT is secreted from the liver into the blood stream which transport it to the lungs
  32. ATT in Emphysema
    ATT's secretion from the liver is blocked
  33. Lungs with Emphysema is
    Hyper-inflated and the Diaphragm is flattened
  34. Cor Pulmonale
    right sided failure, bc pressure that builds up from chronic condition causing pressure in pulmonary circulation it has to pump harder as a result will develop right sided heart failure trying to get blood out. If you are suspecting this don’t increase fluids we don’t five extra fluid to pt with heart failure

    • Alveolar hypoxia-->pulmonary capillary
    • vasoconstriction-->increased pulmonary artery pressure (pulmonary hypertension)--> hypertrophy of right ventricle--> right-sided heart
    • failure
  35. Polycythemia
    compensation mechanism: body trys to do to deal with hypoxemia not really emphezemia

    physiologic compensation for hypoxemia.

    Increased RBC’s but not able to carry increased O2 as oxygen not available -->cyanosis.
  36. Polycythemia blood
    • Blood becomes very viscous, not enough o2 to attach to cells and as a result the blood gets thick and slughish resulting in heart attack and if not going to the brain stroke, if not goin to kidney will
    • continue to put out more eyrthropoetin
  37. Chronic Bronchitis Clinical Manifestations

    Cough-frequent, productive

    Frequent respiratory infections

    Dyspnea on exertion (DOE)

    Hypoxemia & Hypercapnia


    Robust appearance

    Finger clubbing

    Coarse rhonchi & wheezing

    blue pale overweight, bloated, barrel chest, rhonchi wheezing crackles
  38. Emphysema Clinical Manifestations

    Pink Puffers
    • have enough o2 to get out all that co2, thin bc
    • they are using all their energy to breathe, cough is minimal, combo usually emphysema and bronchitis



    Barrel chest

    Chest breather

    Thin and underweight

    Finger Clubbing

    Pursed-lip breathing

    Diminished breath sounds
  39. Pharmacotherapy for COPD
    Beta-adrenergic Agents

    Anticholinergic Agents



    Expect them to be agonist
  40. COPD collaborative care
    Smoking Cessation

    Influenza & Pneumococcal Vaccinations

    Avoid & Immediately Treat URIs

    Should quit smoking to help celia to grow back

    Flue and pneumonia
  41. Oxygen Treatment for COPD
    Oxygen-Low Flow, <2L/min- safety

    “O2 drive”

    O2 toxicity – inactivates surfactant and can lead to ARDS

    Less than 2 liters is safe don’t turn it up more than a liter per minute. Cant go from 1L to 5L
  42. What happens to a COPD pt concerning CO2 and O2
    Pt will walk around with co2 levels and their body will not respond to changes in co2. so their primary mechanism is o2. o2 will slow down RR. So if you turn up the o2 you can make the pt stop breathing
  43. a pt with COPD encourage how many Liters per day
    3 liters of fluid per day
  44. What kind of breathing exercises do you encourage for a pt with COPD
    Pursed-lip breathing (releases trapped air)

    Diaphragmatic breathing (abdomen protrudes on inhalation and contracts on exhalation)

    Effective coughing exercise
  45. is Chest Physiotherapy appropriate for a pt with COPD
    Yes , make sure pt has not had a meal before doing chest physiotherapy

    Eating takes a lot of oxygenation
  46. What are some Nutritional Considerations for a pt with COPD
    Sm. frequent meals; Fluids between meals

    High calorie/protein for emphysematic

    Low carbohydrate

    Low carb bc by product is co2 so if high carb high co2
  47. Why should a pt avoid foods that promote bloading
    Bloated pressure on diaphram and impact ability
  48. Collaborative Nutritional Care for pt with COPD
    Rest 30 minutes before eating

    Bronchodilator before eating

    • Frozen & microwave foods – conserve energy
    • in food preparation (be careful of sodium content-read labels)

    Sodium restriction may be necessary

    Avoid foods that cause bloating and gas (e.g. cabbage)

    5-6 small meals/day

    Liquid commercials diets

    Avoid food that requires significant chewing

    Avoid exercises for 1 hour after eating
  49. Activity Consideration for a pt with COPD
    exercise training of upper extremities may reduce dyspnea.

    Pt. may assume tripod position to conserve energy.

    Schedule periods of rest in between periods of activity.

    Walking 5-15 mins/day and slowly increase.
  50. What are complications that can occur for a pt with COPD

    Respiratory Failure

    Peptic Ulcer Disease and GERD

  51. The nurse caring for a client with COPD recognizes which of the following as an early sign of possible respiratory failure

    A. Restlessness

    B. Deep coma

    C. Hypotentsion and tachycardia

    D. Decreases urinary output
    A. Restlessness
  52. When teaching the use of a MDI containing flovent the nurse itstructs the clitnet to
    Rinse the mouth after using the inhaler
  53. Isabella is instructed to take her asthma meds in which order
    Albuterol atroven and cromolyn

    remember BAC
  54. What action will most help a client obtain max benefits after postural drainage ( position to drain pt)
    Encourage the client to cough deeply
  55. Which client should the charge nurse assign to a step down RN pulled to the intensive care unit for the day

    A. 72 yearo old with COPD who is ventilator dependent

    B. 68 yo pt on a ventilator with acute respiratory failure

    C. 56 yo NEW ADMISSION client with ketoacidosis and on an insulin

    D. 38 yo client on a ventilator with
    A. 72 yearo old with COPD who is ventilator dependent