Upper Airway Diseases

D. Administer prescribed bronchodilator

A nurse is caring for an older adult with chronic obstructive pulmonary disease (COPD). Which action should the nurse take before placing the person into a position for postural drainage? A. Increase O2 flow rate B. Lightly clap the chest and back to help loosen secretions C. Coach to perform controlled coughing D. Administer prescribed bronchodilator

B. Environmental allergies.

A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? A. Gender. B. Environmental allergies. C. Alcohol use. D. Race.

D. Beta 2 agonist.

A nurse is caring for a client 2 hours after admission. The client has a sao2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer? A. Antibiotic. B. Beta blocker. C. Antiviral. D. Beta 2 agonist.

B. Nasal congestion

A nurse is caring for a client who has been taking phenylephrine drops for the past 10 days for sinusitis. The nurse should assess the client for which of the following adverse effects of this medication? A. Sedation B. Nasal congestion C. Productive cough D. Constipation

C. Increase oral intake of fluids

A nurse visits the home of an older person recovering from community-acquired pneumonia. Which actions should the nurse recommend to help the person remove pulmonary secretions? A. Take antibiotics until symptoms subside B. Schedule a repeat chest x-ray in a week C. Increase oral intake of fluids D. Remain on bedrest for 2 weeks

D. Increase daily exercise

An older person asks what can be done to prevent the development of respiratory infections during winter months. What recommendation should the nurse provide this person? A. Restrict intake of dairy products B. Limit cigarette smoking C. Increase intake of vitamin supplements D. Increase daily exercise

acidosis

Complications of COPD - Cor Pulmonale or Right sided Heart Failure Pathophysiology § Chronic _________ § ↓ L. Ventricle Function § Chronic hypoxia § ↑ Pulmonary flow Vascular obstruction → pulmonary HTN → Right heart failure

Ipratropium, tiotropium

Bronchodilators · Cholinergic Antagonist (anticholinergic): causes bronchodilation to both relieve and prevent asthma attacks § _____________________ § Side Effects: anticholinergic (blurred vision, urinary retention, dry mouth) § Caution: pregnancy, glaucoma, BPH § Nursing Actions: · If use as reliever drug, carry it at all times · Shake MDI well before using because drug separates easily · Increase daily fluid intake to combat dry mouth · Report blurred vision, eye pain, headache, nausea, palpitations, tremors, inability to sleep (symptoms of overdose that need intervention) · Suck on hard candy to relive dry mouth, increase fluid intake · Teach patient to use inhaled drug and MDI or DPI use. · Rinse mouth after using to decrease unpleasant taste

Mild intermittent asthma

Classifications of Asthma · ________________: symptoms occurs less than twice a week

Mild persistent asthma

Classifications of Asthma · ____________________: symptoms arise more than twice a week but not daily

C. Cough and pulmonary congestion

During an assessment, the nurse asks an older person about any recent trips to major cities. Which finding caused the nurse to ask this question? A. Elevated BP B. Hyperactive bowel sounds C. Cough and pulmonary congestion D. Weight gain of 2 pounds

· Depression · Liver injury (zileuton, zafirlukast)

Leukotriene Modifier · Montelukast: blocks leukotriene receptor to prevent asthma attacks and reduce inflammation, bronchoconstriction, airway edema, and mucus production § Side Effects: - - § Caution: pregnancy, liver dysfunction § Interactions: warfarin, theophylline, phenytoin § Nursing Actions for Montelukast: · Teach the patient to use the drug daily even when no symptoms are present because max effectiveness requires continued use for 48-72 hours and depends on regular use · Do not decrease the dose or stopping taking other asthma drugs unless instructed by doctor because this drug is for long-term use and does not replace other drugs, especially corticosteroids and rescue drugs · Administer 1 hour before or 2 hours after a meal · Monitor liver function tests · Monitor for suicidal ideation

bronchodilators, oral steroids, antibiotics (sputum volume and color change or fever)

Manage Exacerbations of COPD · The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution. · Usually benefit from _______________________________ · Noninvasive intermittent positive pressure ventilation improves blood gases and decreases need for ventilator. · With exacerbations, they will probably be admitted to hospital, get labs (ABGs, PFT), have IV antibiotics or corticosteroid)

Coughing (Constant!!), Wheezing (DURING ATTACK), Shortness of Breath (DURING ATTACK), Chest tightness (DURING ATTACK!), Worsening of Symptoms

Nursing Assessment of Signs and Symptoms of Asthma · Patient History: patterns of repeated dyspnea (SOB), chest tightness, coughing, wheezing, increased mucus production. Ask if symptoms occur with seasons, activities, at night, or continuously § Some have asthma symptoms for 4-8 weeks after URI § Patients with allergic (atopic) asthma can have other allergic problems § History of Episodes: onset, duration, precipitants, drug changes, drugs that work, self-care methods § Risk Factors: family history of asthma, smoking habits, older adults, allergies, chemical irritant exposure, GERD · Symptoms: ___________________ · During an acute episode: audible wheeze, initially is louder on exhalation, increased RR, coughing § using accessory muscles, retraction at sternum and suprasternal notch between ribs, mucous production, possible barrel chest § Prolonged expiration, unable to speak more than a few words between breaths § Severe attacks: hypoxia, hypoxemia (poor O2), Oral mucosa and nails cyanotic, changes in LOC, tachycardia, anxiety § With long-standing disease: barrel chest (air trapping causes round chest) · Asthma in Older Adults § Common symptoms: coughing (may be worse at night), wheezing (high-pitched on expiration), shortness of breath, chest tightness § *Nocturnal Dyspnea (feeling of being air starved or short of breath or experiencing labored breathing) occurring with asthma is most likely to occur at 4-6am, whereas nocturnal dyspnea occurring with heart failure typically occurs 1-2 hours after retiring. (try to pinpoint when the nocturnal dyspnea occurs) § These symptoms get worse with physical exercise, viral infection, inhaled allergens (fur, mold, pollen, smoke, dust mites, cockroach, mouse stool), stress or strong emotional expression (laughing/crying), changes in weather, irritations (smoke, wood smoke, ozone), or medications (aspirin, beta blockers, NSAIDS)

rescue inhaler less than 2 times per week

Possible Triggers for Asthma Symptoms · Dust mites · Animals · Tobacco Smoke · Strong odors and sprays · Pollens · Cold air · Exercise Asthma Management · Symptom management · Prevent symptoms that are impacting QOL · Prevent exacerbations · Normal activity levels · Nearly normal PFT's · Using __________________________ · Minimize side effects

§ Dyspnea § Barrel chest § Use of accessory muscles § Increased AP diameter § Decreased breath sounds with expiratory wheezes § May look pink and puffy § Tachypnea § Leans forward while sitting § Breathing through pursed lips § Clubbing of fingers and toes § Hyperresonance on percussion d/t air trapping.

Symptoms Of COPD · Emphysema:

A. "There are portable oxygen delivery systems that you can take with you."

A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? A. "There are portable oxygen delivery systems that you can take with you." B. "When you go out, you can remove the oxygen and then reapply it when you get home." C. "You probably will not be able to go out as much as you used to." D. "Home health services will come to you so you will not need to get out."

D. "I will take in a deep breath and hold it before exhaling."

A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will place the adapter on my finger to read my blood oxygen saturation level." B. "I will lie on my back with my knees bent." C. "I will rest my hand over my abdomen to create resistance." D. "I will take in a deep breath and hold it before exhaling."

A. Avoid eating gas-producing foods B. Cough to clear mucus right before eating D. Eat smaller meals more frequently G. Use your bronchodilator about 30 minutes before each meal

30-2 Which interventions are important for the nurse to teach a client with severe chronic obstructive pulmonary disease (COPD) to help ensure adequate nutrition? (Select all that apply.) A. Avoid eating gas-producing foods B. Cough to clear mucus right before eating C. Drink plenty of fluid with every meal D. Eat smaller meals more frequently E. Rest immediately following a meal F. Eat more raw fruits and vegetables G. Use your bronchodilator about 30 minutes before each meal

C. Take a deep breath in through your nose.

A nurse is planning to instruct a client on how to perform pursed‑lip breathing. Which of the following should the nurse include in the plan of care? A. Take quick breaths upon inhalation. B. Place your hand over your stomach. C. Take a deep breath in through your nose. D. Puff your checks upon exhalation.

C. No, albuterol is used to relieve the symptoms during an actual asthma attack and salmeterol is used to prevent an attack. Both are needed.

A client newly diagnosed with moderate asthma asks whether he can just take salmeterol instead of albuterol, because he has read that they are both beta agonists. What is the nurses best advice? A. Yes, both of these drugs have the same action, and you only need one. B. Yes, because they both need to be used daily whether you are having symptoms or not, just take a little more of the salmeterol and don't take any of the albuterol. C. No, albuterol is used to relieve the symptoms during an actual asthma attack and salmeterol is used to prevent an attack. Both are needed. D. No, albuterol is taken through the use of an aerosol inhaler and salmeterol is an oral drug (tablet) that is activated in the stomach. Both are needed.

B. Wheezing. C. Retraction of sternal muscles E. Tachycardia/PVCs

A nurse in the emergency department is caring for a client who is experiencing an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (SATA) A. Sao2 95%. B. Wheezing. C. Retraction of sternal muscles. D. Pink mucous membranes. E. Tachycardia/PVCs

A. Hypokalemia C. Fluid retention E. Black, tarry stools

A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply.) A. Hypokalemia B. Tachycardia C. Fluid retention D. Nausea E. Black, tarry stools

C. "I can have an increase in my heart rate while taking this medication."

A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates an understanding of the teaching? A. "This medication can increase my blood sugar levels." B. "This medication can decrease my immune response." C. "I can have an increase in my heart rate while taking this medication." D. "I can have mouth sores while taking this medication."

C. I will take my medication with meals.

A nurse is providing discharge teaching to a client who has a new prescription of Prednisone for asthma. Which of the following client statements indicates an understanding of the teaching? A. I will decrease my fluid intake while taking this medication. B. I will expect to have black tarry stools. C. I will take my medication with meals. D. I will monitor for weight loss while on this medication.

B. Administer the albuterol prior to using the beclomethasone inhaler

A nurse is providing instructions with a client who has a new prescription for albuterol and beclomethasone inhalers for the control of asthma. Which of the following information should the nurse include? A. Take the albuterol at the same time each day B. Administer the albuterol prior to using the beclomethasone inhaler C. Use beclomethasone if having an acute episode D. Avoid shaking the canister of beclomethasone before use

B. I take this medication to prevent asthma attacks.

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? A. This medication can decrease my immune response. B. I take this medication to prevent asthma attacks. C. I need to take this medication with food. D. This medication has a slow onset to treat my symptoms.

A. Asthma

A nurse is reviewing the health record of a client who asks about using propranolol to treat hypertension. The nurse should recognize that which of the following conditions is a contraindication to propranolol? A. Asthma B. Glaucoma C. Hypertension D. Tachycardia

B. Tremors are an adverse effect of this medication

A nurse is talking with an adolescent who has a new prescription for albuterol PO. Which of the following instructions should the nurse include? A. You can take this medication to abort an acute asthma attack B. Tremors are an adverse effect of this medication C. Prolonged use of this medication can cause hyperglycemia D. This medication can slow skeletal growth

B. "It can take as long as 3 weeks before the medication takes a maximum effect"

A nurse is teaching a client about the use of fluticasone to treat perennial rhinitis. Which of the following statements by the client indicates an understanding of the teaching? A. "I should use the spray every 4 hours while I am awake" B. "It can take as long as 3 weeks before the medication takes a maximum effect" C. "This medication can also be used to treat motion sickness" D. "I can use this medication when my nasal passages are blocked"

A. "Rinse your mouth after each use of this medication"

A nurse is teaching a client who has a new prescription for beclomethasone. Which of the following instructions should the nurse include? A. "Rinse your mouth after each use of this medication" B. "Limit fluid intake while taking this medication" C. "Increase your intake of vitamin B12 while taking this medication" D. "You can take the medication as needed"

C. Sedation

A nurse is teaching a client who has a new prescription for dextromethorphan to suppress a cough. The nurse should instruct the client to monitor for which of the following adverse effects of this medication? A. Diarrhea B. Anxiety C. Sedation D. Palpitations

A. Dry mouth D. Drowsiness E. Urinary hesitation

A nurse is teaching a client who has a new prescription for diphenhydramine for allergic rhinitis. The nurse should instruct the client to monitor for which of the following adverse reactions of this medication? (SELECT ALL THAT APPLY) A. Dry mouth B. Nonproductive cough C. Skin rash D. Drowsiness E. Urinary hesitation

A. Weight gain

A nurse is teaching a client who has a prescription for long-term use of oral prednisone for treatment of chronic asthma. The nurse should instruct the client to monitor for which of the following manifestations as an adverse effect of the medication? A. Weight gain B. Nervousness C. Bradycardia D. Constipation

B. "Expect this medication to smell like rotten eggs"

A nurse is teaching the family of a child who has cystic fibrosis and a new prescription for acetylcysteine. Which of the following information should the nurse include in the instructions? A. "Expect this medication to suppress your cough" B. "Expect this medication to smell like rotten eggs" C. "Expect this medication to cause euphoria" D. "Expect this medication to turn your urine orange"

B. Pulmonary function tests

An older person is concerned about a new onset of wheezing and chest tightness. Which diagnostic test should the nurse prepare teaching for this person? A. Sputum samples B. Pulmonary function tests C. CT scan of thorax D. Chest x-ray

C. Loss of muscle tone caused by change in lifestyle

An older person reports having more respiratory infections since retiring from a position as a mail carrier. What should the nurse explain as the potential reason for these infections? A. Respiratory system effort to rid the body of toxins B. Immune system adjustments to the change in environment C. Loss of muscle tone caused by change in lifestyle D. Increased exposure to pathogens in the home

C. Being at the apices and compare from side to side

An older person with COPD arrives for a routine wellness visit. Which approach should the nurse use when assessing this person's lung sounds? A. Identify the 8th rib and auscultate the anterior chest B. Start with the side with reduced respiratory excursion C. Being at the apices and compare from side to side D. Listen for tracheal sounds with the person in supine position

Suppression of adrenal gland function · Bone loss, osteoporosis · Hyperglycemia, glycosuria · Myopathy · PUD · Infection · Electrolyte/fluid imbalances · Increased appetite, weight gain · Insomnia, sleep disturbance

Anti-inflammatories Corticosteroids · Fluticasone, Beclomethasone, Budesonide § Side Effects: · Difficulty speaking, hoarseness, candidiasis § Nursing Actions: · Teach patient to use every day at same time even if no symptoms. Max effect require continued use for 48-72 hours and depends on regular use · Use good mouth care and check moth lesions/drainage because of risk of infection (thrush) · Teach use for MDI · Prednisone § Side Effects: - - - - - § Interactions: potassium-depleting diuretics, NSAIDS, hypoglycemics § Nursing Actions: · Teach patient about side effects because to reduce anxiety when they appear · Avoid anyone with URI, large crowds because the drug causes immunosuppression (wash hands frequently) · Teach patient to avoid activities that lead to injury because blood vessels are more fragile (bruising) · Teach patient to take the drug with food to reduce GI ulceration · Teach patient not to suddenly stop taking the drug suppresses adrenal production of steroids, which are essential for life · Monitor glucose, and electrolytes, and for black/tarry stools · Report muscle weakness WASH MOUTH AFTER USE!!!!!!!!!!!

Flunisolide, budesonide, fluticasone, mometasone, beclomethasone, ciclesonide

Anti-inflammatories · Corticosteroids: stops inflammation to prevent asthma attacks caused by inflammation or allergies (controller drug). They do have side effects like electrolyte and fluid imbalance (especially with renal/cardiac disease), hypokalemia ( with thiazide diuretics), worsening HTN, elevated blood sugar and BUN (in older people with diabetes) § EXAMPLES: ____________________________________ § Other side effects: HTN, HF (sodium retention), hypokalemia, alkalosis, worsening diabetes, cataracts, polyuria with dehydration (elevated glucose), thinning of skin, reduced muscle pass, myopathy, osteoporosis, hypoadrenalism, delirium, depression, altered LOC, joint effusions, articular pain (with withdrawal), osteoporosis, glaucoma, aggravation of PUD, cough, dystonia, loss of taste, oral thrust § For older adults, They can also negatively affect cognitive function, accelerate osteoporosis, cause oral thrush, increased intraocular pressure, and aggravate peptic and gastric ulcers § URGE OLDER ADULTS TO USE SPACERS WITH MDIs AND RINSE/SPIT AFTER USE OF INHALED CORTICOSTEROIDS

§ Sedation § Anticholinergic § GI discomfort § Acute Toxicity: excitation, hallucination, incoordination, seizures § Respiratory depression

Antihistamines: relive nasal itching, sneezing, rhinorrhea (not nasal congestion) · 1st gen H1 antagonist: Diphenhydramine, promethazine, dimenhydrinate · 2nd gen H1 antagonist: loratadine, cetirizine, fexofenadine, desloratadine · Side effects: - - - - - § IV: local tissue injury · Contraindications: pregnancy, older adults · Caution: asthma, cardiac disease, renal disease, urinary retention, glaucoma, HTN, BPH · Nursing Actions: § Take at night to minimize sedation, avoid hazardous activities, avoid alcohol/CNS depressants § Take sips of water, suck on candies, drink 2-3L/day § Take with meals for GI upset § Toxicity: activated charcoal

§ Mucosal edema (inflammation of airway lumens) § Bronchoconstriction § Excessive mucus production

Asthma is a chronic disease in which reversible airway obstruction occurs intermittently, reducing airflow. Airway obstruction occurs by inflammation and airway tissue sensitivity (hyperresponsiveness) with bronchoconstriction. Severe airway obstruction impairs gas exchange and can be fatal. !!!! 1. Inflammation obstructs the airway lumens, 2. Bronchoconstriction, 3. large amounts of mucus produced § Airway hyperresponsiveness and constriction of bronchial smooth muscle narrow the airways § Airway inflammation can trigger bronchiolar constriction, and many adults with asthma have both problems § When well controlled, it is often reversible and temporary. With poor control, chronic airway inflammation leads to damage, altered cell regulation, enlargement of bronchial cells (including mucus secreting cells), and smooth muscle changes. · Inflammation occurs in response to a trigger (allergens, irritants, cold air, dry air, fine air particles, microorganisms, aspirin, NSAIDs) § Drugs, like diphenhydramine, can block response of histamine to stop inflammation § Aspirin and NSAIDs trigger asthma by production of leukotriene § GERD can trigger asthma and often causes triggers at night. Acid stomach contents enter the airway and make tissue sensitivity worse § Inflamed airways are "twitchy" and overreact to irritants · Bronchospasm can occur when small amounts of pollutants or viruses stimulate nerves and cause constriction of bronchial muscle. · Manifestations: 1. 2. 3.

Indacaterol, arformoterol, salmeterol, formoterol

Bronchodilators · Long Acting Beta2 Agonists: slow but long-term relief. Prevents asthma attacks § _____________________________ § Side Effects · Tachycardia, increased myocardial O2 consumption (can cause angina in older people) · ECG changes (ventricular arrythmias) · Hypokalemia · Increased BP · Tremor · hypoxemia § Nursing Actions: · Teach patient not to use the drugs during acute attack cause it acts slow and won't relieve symptoms. It is used for daily control even if symptoms aren't present · Teach patient to use inhaled drug and MDI or DPI use.

Albuterol, levalbuterol, terbutaline § KEEP RESCUE INHALERS ON BEDSIDE TABLE because asthma attacks are common in the middle of the night (4am-6am)

Bronchodilators · Short Acting Beta2 Agonists: rapid but short-term relief. They are inhaled and useful during asthma attacks or to premedicate before activities that induce attacks § ____________________________ § Side Effects: · Myocardial ischemia (increased cardiac O2 consumption) · Ventricular arrythmias, cardiac arrythmias (r/t muscle weakness and hypokalemia) · Tachycardia, angina · Hypo/hypertension · Tremor · Tolerance? § Contraindications/Cautions: diabetes, hyperthyroidism, heart disease, HTN, angina § Interactions: beta blockers, MAOIs, TCAs § Nursing Actions: · Teach patient to use inhaled drug and MDI or DPI use. · Carry the drug at all times because it is a rescue drug · Monitor HR because excess use can cause tachycardia/tremors · Use this drug at least 5 minutes before other inhaled drugs (like anti-inflammatories) to allow bronchodilation effect to increase penetration of other drugs. · **Older adults who need rescue inhalers should be encouraged to obtain prescriptions for extra canisters and keep several inhalers in strategic places at home. Label them with bright colors to be seen easily if needed § KEEP RESCUE INHALERS ON BEDSIDE TABLE because asthma attacks are common in the middle of the night (4am-6am)

§ Most often, COPD occurs in people age 40 and over who... · Have a history of smoking · Have had long-term exposure to lung irritants such as air pollution, chemical fumes, or dust from the environment or workplace · Have a rare genetic condition called alpha-1 antitrypsin (AAT) deficiency · Have a combination of any of the above

COPD · Chronic Obstructive Pulmonary Disease interferes with airflow and gas exchange. These disorders include emphysema ad chronic bronchitis. § COPD refers to a group of diseases that cause airflow blockage and breathing-related problems including emphysema, chronic bronchitis, and in some cases asthma. (CDC, 2019) § COPD is the third leading cause of death, affects millions of Americans and causes long-term disability. · Who Does COPD Effect? - - - -

Emphysema

COPD Includes: Chronic Bronchitis, Emphysema, Asthma · _________________: Abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles that is accompanied by destruction of the airspace walls, without obvious fibrosis. § _________________: causes 2 major changes including loss of lung elasticity and hyperinflation of the lung. This results in destruction of alveoli. This results in dyspnea, reduced gas exchange, and the need for increased RR. It is classified as panlobular, centrilobular, or paraseptal § Smoking, chronic smoke exposure can cause increase in proteases, which can damage lungs. Alveoli lose elasticity, and small airways collapse/narrow § Increased air trapping in lungs due to loss of elastic recoil, overstretching/enlargement of alveoli into air filled bullae, and collapse of bronchioles § Patients need to use accessory muscles to inhale and exhale. Increased effort makes them "air hungry". Inhalation starts before exhalation is done, resulting in uncoordinated breathing pattern § Gas exchange is impacted -> increases RR -> ABGs may show no problems until advanced disease when CO2 is made faster than it can be eliminated -> CO2 retention, chronic respiratory acidosis, and low PaO2

Severe persistent asthma

Classifications of Asthma · Mild intermittent asthma: symptoms occurs less than twice a week · Mild persistent asthma: symptoms arise more than twice a week but not daily · Moderate persistent asthma: daily symptoms occur in conjunction with exacerbations twice a week · ___________________: symptoms occur continually, alone with frequent exacerbations that limit physical activity and quality of life

Moderate persistent asthma

Classifications of Asthma · ______________________: daily symptoms occur in conjunction with exacerbations twice a week

Status Asthmaticus

Complications of Asthma 1. Respiratory Failure § Monitor oxygenation levels and acid-base § Prepare for intubation and mechanical ventilation. 2. _______________________: severe, life-threatening acute episode of airway obstruction that intensifies once it begins and often does not respond to usually therapy. If not reversed, they can develop pneumothorax, cardiac arrest, or respiratory arrest. § Treatment: IV fluids, systemic bronchodilators, steroids, epinephrine, and O2 are given immediately. Sometimes magnesium is used § Prepare for emergency intubation. Sudden abstinence of wheezing indicates airway obstruction and requires a tracheostomy

· Oxygen Toxicity

Complications of COPD _____________________: § Early signs · ↓DECREASED Vital Capacity · Cough · Substernal Pain · N/V · Paresthesia · Nasal Stuffiness · Sore Throat · Malaise, tired § Late Signs · Pulmonary and peripheral Edema · Increase in Sputum · Lung changes: Lung Fibrosis § KEEP THE PEOPLE AT O2 @ 2-4L/min FOR BRONCHITIS (usually higher) § KEEP THE PEOPLE AT O2@ 2L/min FOR EMPHYSEMA

§ Bedrest § O2 therapy § ↓ fluids § Antibiotics § Bronchodilators § Diuretics § ↓ Na diet § Digitalis (if left sided failure occurs)

Complications of COPD · Cor pulmonale (right HF caused by pulmonary disease): COPD strains the heart and the right ventricle enlarged and thickens, resulting in abnormal rhythms § Cough, dyspnea, fatigue, peripheral edema, asities/congestion, high HR, JVD, polycythemia, increased blood volume, increased hematocrit § Hypoxemia, hypoxia, increasing dyspnea § Fatigue § Rhythm disturbances, palpitations § Enlarged liver § Warm, cyanotic hands and feet with bounding pulses § Cyanotic lips § Distended neck veins § Right ventricle hypertrophy § Visible pulsations below sternum § GI disturbances (nausea, anorexia) § Dependent edema § Metabolic and respiratory acidosis § Pulmonary hypertension · Treatment of Cor Pulmonale: (exactly like we treat heart failure) - - - -

Pneumothorax

Complications of COPD · Hypoxemia and Acidosis (Co2 retention) · Respiratory Infection (increased mucus and poor gas exchange) · Cardiac Dysrhythmias · Cardiac failure · _____________________: Decreased breath sounds and tracheal deviation from ruptured bleb (towards the good/unaffected side)

Respiratory Failure

Complications of COPD · ______________: Fails in one or both of it's gas exchange functions; oxygenation and carbon dioxide elimination. § Signs of Impending ________________: · Nasal flaring · Cyanosis · Dyspnea with excessive accessory muscle use · Increased, THEN Decreased respiratory effort (low RR, less chest rise/fall) · Decreased level of consciousness · Decreased breath sounds when previously there was air movement · Abdominal paradox and neck muscles use § CALL RAPID RESPONSE § Patients will be anxious, you remain calm

Cor pulmonale (right HF caused by pulmonary disease)

Complications of COPD · ____________________: COPD strains the heart and the right ventricle enlarged and thickens, resulting in abnormal rhythms § Cough, dyspnea, fatigue, peripheral edema, asities/congestion, high HR, JVD, polycythemia, increased blood volume, increased hematocrit § Hypoxemia, hypoxia, increasing dyspnea § Fatigue § Rhythm disturbances, palpitations § Enlarged liver § Warm, cyanotic hands and feet with bounding pulses § Cyanotic lips § Distended neck veins § Right ventricle hypertrophy § Visible pulsations below sternum § GI disturbances (nausea, anorexia) § Dependent edema § Metabolic and respiratory acidosis § Pulmonary hypertension

Phenylephrine, ephedrine, naphazoline, pseudoephedrine

Decongestants · EXAMPLES: ____________________ · Side effects: rebound congestion, CNS stimulation, Vasoconstriction · Taper dose when discontinuing and use for short-term therapy only · Use topical/nasal doses only for 3-5 days · Caution: HTN, cerebrovascular disease, dysrhythmias, CAD · Contraindicated: glaucoma

indicates what % of the total FVC was expelled during the first second of forced exhalation. normally 70 -75 %)

Definitions: · FVC = forced vital capacity; Maximum volume of air that can be forcibly expelled after inhaling as deeply as possible. · FEV1 (forced expiratory volume in 1 second) forced expiratory volume in one second; · FEV1/FVC ratio: ____________

1. Beta blockers (propranolol) can cause bronchospasm and decreased response to bronchodilators a. Commonly prescribed for HTN, heart disease, tremors 2. NSAIDS can cause bronchospasm and worsen asthma a. Commonly prescribed for arthritis 3. Non-potassium sparing diuretics can cause worse cardiac function and dysrhythmias and have added effects when taken with asthma medications that produce potassium loss 4. Antihistamines can cause QT prolongation and sedation 5. ACE inhibitors: can produce cough and worsen asthma symptoms 6. Antidepressants: can worsen underlying depression 7. Cholinergic Drugs can cause bronchospasm

Drug Therapy for Asthma · Control Therapy Drugs: reduce airway sensitivity to prevent attacks from occurring to maintain gas exchange. THESE ARE USED EVERYDAY REGARDLESS OF SYMPTOMS · Reliever drugs (rescue drugs) are used to stop an attack once it has started · Typically, corticosteroids are the most effective anti-inflammatory drugs at treating asthma (Tabloski) · Older adults may prefer nebulizers over MDIs due to moisture and easy of use. They are a very effective way to administer inhaled drugs to those with cognitive impairments. · Older adults using MDIs should use spacers · Certain medications should be avoided when treating older adults for asthma: 1. 2. 3. 4. 5. 6. 7.

Prevent disease progression

Goals of COPD Management · _____________________ · Relieve symptoms · Improve exercise tolerance · Improve health status · Prevent and treat exacerbations · Prevent and treat complications · Reduce mortality · Minimize side effects from treatment

planning and pacing activities for best tolerance and minimum discomfort. Have the patient divide their daily schedule into smaller parts to determine if the task can be performed differently/at different times § Tach planning activities with rest periods between activities § Develop a chart outlining activities and rest periods

Improving Endurance: Nursing Interventions for Chronic Obstructive Pulmonary Disease · COPD patients often have chronic fatigue. During exacerbations, they need help with ADLs, eating, bathing, grooming. · As problems resolve, encourage independence and self-care at their own pace. · No not rush through morning activities. Rushing increases dyspnea, fatigue, hypoxemia. · Assess response to activity by noting skin color changes, pulse rate, O2%, and WOB. Suggest use of O2 during periods of high energy use (bathing or walking) · Energy Conservation: ___________________________________________ · Avoid working with arms raised. Raising arms decreases exercise tolerance because accessory muscles are used to stabilize arms rather than help breathing. Adjust work heights to reduce fatigue and strain. · Keep arm motions smooth and flowing to prevent jerky motions that waste energy · Collaborate with occupational therapist to teach about use of adaptive tools: long-handled dustpans, sponges, dusters, reducing bending/reaching · Organize work spaces to most used objects are in reach · Don't talk while engaged in activities that require energy (walking) and avoid holding breath while walking

§ Hypoxemia: PaO2 less than 80mmHg § Hypocarbia: PaCO2 less than 35mmHg- in EARLY ATTACK § Hypercarbia: PaCO2 greater than 45mmHg- LATER IN ATTACK

Laboratory and Diagnostics for Asthma · ABGs: determine effectiveness of gas exchange. Arterial O2 level can decrease during asthma attacks. Arterial CO2 can be decreased initially due to high RR, but it rises as attack progresses indicating CO2 retention - - - · CBC: Elevated eosinophils § Elevated IgE · Sputum may contain eosinophils, mucus plugs ,and shed epithelial cells (Curschmann's spirals) · *Electrocardiogram: especially for older adults, these can help identify cardiac disease and risks of drugs that may be used to treat asthma and cardiac disease · Chest X-ray to rule out infection, lung tumors, abnormalities. Hyperinflation of the lungs would indicate emphysema · Pulmonary function Tests: measures airflow in asthma using spirometry § Baseline PFT are obtained. § Airway responsiveness is tested by measuring FEC and PEF before and after the patient inhales methacholine, which induces bronchospasm in susceptible adults § Forced Vital Capacity (FVC) : volume of air exhaled from full inhalation to full exhalation § Forced Expiratory Volume (FEV): volume of air blown out as hard/fast as possible § Peak expiratory flow (PEF): fasted airflow rate reached in exhalation § Asthma is diagnosed when: · FVC and PEF increase by 12% or more after treatment with bronchodilators · Airflow obstruction of FEV less than 80% of predicted and FEV/FVC ratio less than70% · Asthma: decreased FEV below 15-20% of normal value · Asthma: or peak expiratory rate flow (PERF) decreased below 15-20% of normal value § *** spirometry testing in older adults can have problems. They may have increased chest wall rigidity, weakness/paresthesia in extremities, cognitive impairment, poor hand-eye coordination that causes poor results · Collaborate with gerontological nurse, pulmonologist, allergist, RT to assist with testing to get accurate results § ***Elderly patients may be at greater risk for misdiagnosis and inappropriate treatment as a consequence of underutilization of, and low quality expectations about, pulmonary function testing in the elderly. Comorbidities, including cognitive impairment and apraxia, may influence the quality of spirometry and diffusion-capacity testing.

· FVC and PEF increase by 12% or more after treatment with bronchodilators · Airflow obstruction of FEV less than 80% of predicted and FEV/FVC ratio less than70% · Asthma: decreased FEV below 15-20% of normal value · Asthma: or peak expiratory rate flow (PERF) decreased below 15-20% of normal value

Laboratory and Diagnostics for Asthma · Careful History Taking: symptoms are worse based on their triggers; determine when triggers occur · ABGs: determine effectiveness of gas exchange. Arterial O2 level can decrease during asthma attacks. Arterial CO2 can be decreased initially due to high RR, but it rises as attack progresses indicating CO2 retention § Hypoxemia: PaO2 less than 80mmHg § Hypocarbia: PaCO2 less than 35mmHg- in EARLY ATTACK § Hypercarbia: PaCO2 greater than 45mmHg- LATER IN ATTACK · CBC: Elevated eosinophils § Elevated IgE · Sputum may contain eosinophils, mucus plugs ,and shed epithelial cells (Curschmann's spirals) · *Electrocardiogram: especially for older adults, these can help identify cardiac disease and risks of drugs that may be used to treat asthma and cardiac disease · Chest X-ray to rule out infection, lung tumors, abnormalities. Hyperinflation of the lungs would indicate emphysema · Pulmonary function Tests: measures airflow in asthma using spirometry § Baseline PFT are obtained. § Airway responsiveness is tested by measuring FEC and PEF before and after the patient inhales methacholine, which induces bronchospasm in susceptible adults § Forced Vital Capacity (FVC) : volume of air exhaled from full inhalation to full exhalation § Forced Expiratory Volume (FEV1): volume of air blown out as hard/fast as possible (forced expiratory volume in 1 second) § Peak expiratory flow (PEF): fasted airflow rate reached in exhalation FEV1/FVC ratio:indicates what % of the total FVC was expelled during the first second of forced exhalation. Normal: 70-75% § Asthma is diagnosed when: - - - - § *** spirometry testing in older adults can have problems. They may have increased chest wall rigidity, weakness/paresthesia in extremities, cognitive impairment, poor hand-eye coordination that causes poor results · Collaborate with gerontological nurse, pulmonologist, allergist, RT to assist with testing to get accurate results § ***Elderly patients may be at greater risk for misdiagnosis and inappropriate treatment as a consequence of underutilization of, and low quality expectations about, pulmonary function testing in the elderly. Comorbidities, including cognitive impairment and apraxia, may influence the quality of spirometry and diffusion-capacity testing.

uses severity of GOLD test and symptoms of COPD

Laboratory and Diagnostics for Chronic Obstructive Pulmonary Disease · COPD Assessment Test (CAT): _______________. It is an 8 item test where the patient rates their specific symptoms on a 0 (no symptoms) to 5 (worst symptoms) scale. The score is 0-40 § Low scores indicate less severe problems § Each GOLD class contains a designating ABCD for symptom severity and indicates risk for exacerbation: · A: low risk for exacerbation (even if GOLD score is 4) · D: high risk for exacerbation (and need for hospitalization) · GOLD Classification of COPD Severity: § GOLD 1: Mild: FEV greater than or equal to 80% of predicted § GOLD 2: moderate: FEV 50-79% of predicted § GOLD 3: severe: FEV 30-49% of predicted § GOLD 4: very severe: FEV less than 30% of predicted

declined in COPD to less than 70%

Laboratory and Diagnostics for Chronic Obstructive Pulmonary Disease · Pulse oximetry · ABGs: abnormal gas exchange, increased CO2, decreased O2, Respiratory Acidosis (possible metabolic acidosis as compensation by kidney to remove bicarb) § Hypoxemia: PaO2 less than 80mmHg § Hypercarbia: PaCO2 greater than 45mmHg · Sputum Samples: culture for infection (check WBC for increase) · Elevated RBCs, Hemoglobin/Hematocrit: secondary polycythemia (COPD causes compensatory increase in RBCs and iron in chronic hypoxia) which clots vessels and results in cyanosis · ATT: to assess for alpha1 antitrypsin deficiency · Serum Electrolytes: low phosphate, potassium calcium, magnesium reduce muscle strength · Chest X-Ray: emphysema causes hyperinflation and flat diaphragm · Pulmonary Function Tests: determines lung volumes, flow volumes, spirometry § Vital Capacity (VC) § Residual Volume (RV): increased (trapped air) § Forced Expiratory Volume (FEV) decline § Total Lung Capacity (TLC) § FEV/FVC ratio (normal 75-80%):______________________ · Peak Expiratory Flow Meters to determine effectiveness of drug therapy

Uncontrolled

Levels of Asthma Control _____________________: the presence of 3 or more characteristics from the partly controlled list is uncontrolled asthma § Daytime symptoms: symptoms more than 2x per week § Activity limitations: any § Nighttime symptoms: any § Reliver drug use: reliver used more than 2x per week § PEF or FEV: less than 80% of predicted or established personal best Treatment Actions:increase step until symptoms are controlled on a regular basis and then reduce step to the lowest step level that consistently controls symptoms

Partly controlled

Levels of Asthma Control ________________________: the presence of any one of these characteristics is partly controlled § Daytime symptoms: symptoms more than 2x per week § Activity limitations: any § Nighttime symptoms: any § Reliver drug use: reliver used more than 2x per week § PEF or FEV: less than 80% of predicted or established personal best Treatment Actions:increase step until symptoms are controlled on a regular basis and then reduce step to the lowest step level that consistently controls symptoms

Controlled

Levels of Asthma Control · _________________: all of the characteristics are present § Daytime symptoms: symptoms 2x per week or less § Activity limitations: none § Nighttime symptoms: none § Reliver drug use: relieve used 2x per week or less § PEF or FEV: normal § Treatment Actions: fain/maintain lowest step level that controls symptoms

FIVE

Metered Dose Inhaler · Know how to teach patient how to correctly use a metered-dose inhaler · Order of MDIs 1. Bronchodilator with RAPID action WAIT ONE MINUTE: 2. Bronchodilator NOT rapid action (*wait one minute between puffs) WAIT ______________ MINUTES: 3. Corticosteroids (RINSE MOUTH AFTER USE - to prevent oral candida) 4. ANTIBIOTICS for exacerbations of Bronchitis

· Supraventricular tachycardia, cardiac arrythmias · Nausea, vomiting, GI irritation, GERD · Headache, seizures, insomnia · Hyperglycemia · Hypokalemia · Toxicity (especially in older people): HR, liver disease, BB increase risk of toxicity

Methylxanthines: Theophylline § Theophylline: relaxes bronchial smooth muscle, bronchodilation. § Side Effects - - - - § Caution: heart disease, HTN, liver/kidney disease, diabetes, children, older adults § Interactions: Caffeine, phenobarbital, phenytoin, cimetidine, cipro § Nursing Actions: · Monitor blood levels to ensure therapeutic level: 8-12mcg/mL (ATI says 5-15?) · Toxicity: GI stress, restlessness, dysrhythmias, seizures

make a written plan of what to do if symptoms flare to provide confidence and control in knowing what to do (reduces anxiety)

Minimize Anxiety: Nursing Interventions for Chronic Obstructive Pulmonary Disease · Teach the patient how dyspnea causes anxiety, and anxiety causes dyspnea (especially with secretions) · Have a plan for dealing with anxiety: __________________________________ · Stress use of pursed-lip breathing and diaphragmatic breathing during periods of anxiety or panic. · Support: family, friends, support groups, professional counseling (can identify techniques to control dyspnea and anxiety) · Progressive relaxation, hypnosis therapy, biofeedback.

Always assess lung sounds with stethoscope directly on skin (NOT THROUGH CLOTHES), use a good stethoscope with a diaphragm and bell, and seek out a quiet environment.

Normal Changes of Aging in the Respiratory System · Decreased airway clearance, decreased cough and laryngeal reflexes, decline in mucociliary clearance · Decreased ciliary action can contribute to higher risk of aspiration and respiratory infection · Increased chest-wall stiffness with declining strength in chest muscles · Stiffness of the diaphragm · Increased AP diameter · Decreased response to hypercapnia · Arterial hypoxemia with reduced PO2 levels · Stiffening of elastin and the collagen connective tissue supporting the lungs · Decreased numbers of alveoli. Altered alveolar shape resulting in increased alveolar diameter · Loss of elastic recoil in lungs. Increased ventilation/perfusion mismatch · Decreased alveolar surface area available for gas exchange · The functional implications of these changes are a decreased elastic recoil of the lung that produces increased residual volume, decreased vital capacity, and premature airway closure in dependent portions of the lungs, which often traps air in the lower airways. · With aging, the amount of O2 carried by the blood is likely to be lower, and gas exchange will occur more slowly and less efficiently · **** Lung function in frail older adults is often difficult to assess with a stethoscope because so little air is moved with each inspiration and exhalation that lung sounds are very soft and distant. __________________________________________________________

Nocturnal Dyspnea (feeling of being air starved or short of breath or experiencing labored breathing) occurring with asthma is most likely to occur at 4-6am

Nursing Assessment of Signs and Symptoms of Asthma · Patient History: patterns of repeated dyspnea (SOB), chest tightness, coughing, wheezing, increased mucus production. Ask if symptoms occur with seasons, activities, at night, or continuously § Some have asthma symptoms for 4-8 weeks after URI § Patients with allergic (atopic) asthma can have other allergic problems § History of Episodes: onset, duration, precipitants, drug changes, drugs that work, self-care methods § Risk Factors: family history of asthma, smoking habits, older adults, allergies, chemical irritant exposure, GERD · Symptoms: Coughing, Wheezing, Shortness of Breath, Chest tightness, Worsening of Symptoms · During an acute episode: audible wheeze, initially is louder on exhalation, increased RR, coughing § using accessory muscles, retraction at sternum and suprasternal notch between ribs, mucous production, possible barrel chest § Prolonged expiration, unable to speak more than a few words between breaths § Severe attacks: hypoxia, hypoxemia (poor O2), Oral mucosa and nails cyanotic, changes in LOC, tachycardia, anxiety § With long-standing disease: barrel chest (air trapping causes round chest) · Asthma in Older Adults § Common symptoms: coughing (may be worse at night), wheezing (high-pitched on expiration), shortness of breath, chest tightness § *_________________________________________________, whereas nocturnal dyspnea occurring with heart failure typically occurs 1-2 hours after retiring. (try to pinpoint when the nocturnal dyspnea occurs) § These symptoms get worse with physical exercise, viral infection, inhaled allergens (fur, mold, pollen, smoke, dust mites, cockroach, mouse stool), stress or strong emotional expression (laughing/crying), changes in weather, irritations (smoke, wood smoke, ozone), or medications (aspirin, beta blockers, NSAIDS)

CENTRAL CYANOTIC, BLUE-TINGED, DUSKY APPEARANCE, DELAYED CAPILLARY REFILL, FINGER CLUBBING

Nursing Assessment of Signs and Symptoms of Chronic Obstructive Pulmonary Disease · Respiratory: earliest symptom is morning cough of clear sputum § DYSPNEA ON EXERTION, HYPOXEMIA, DECREASED O2SAT (OLDER ADULTS WITH DARK SKIN CAN BE LOWER) § Elevated TEMPERATURE, TACHYCARDIA, TACHYPNEA, DIAPHORESIS § Sputum production: amount, color, consistency, time of day, change from baseline § Respiratory muscle fatigue causes RAPID, SHALLOW RESPIRATION, ABNORMAL RESPIRATORY PATTERN (ABD wall is sucked in during inspiration), USE ACCESSORY MUSCLES IN ABD/NECK, CHEST RETRACTIONS · As respiratory muscles get fatigued, respiratory movement is jerky/uncoordinated · FORWARD-LEANING (TRIPOD) POSTURE, PURSED-LIP BREATHING § Acute exacerbation: RR of 40-50 requiring medical attention § Asymmetric chest expansion, diaphragm is flattened and below usual location § Fremitus (chest vibration) is decreased, increased sputum production § Chest sounds HYPERRESONANCE ON PERCUSSION (trapped air in emphysema) § Auscultation: WHEEZES/CRACKLES(RALES)/RHONCHI(GURGLES) IN DEPENDENT LUNG FIELDS on forced expiration, reduced breath sounds (note pitch, location, and point in RR cycle where the sound occurs) § Assess degree of dyspnea with Visual Analog Dyspnea Scale (VADS):straight line with verbal anchors at the mending and end. Tell patient to put a mark on the line to indicate their breathing difficulty. Document and use that to determine therapy effectiveness and pace activities § BARREL CHEST (AP diameter 1:1/normal is 1:1.5) with emphysema § ____________________________________ · Cardiac: RIGHT HF SYMPTOMS, SWELLING OF FEET/ANKLES, PALLOR/CYANOSIS, UNDERWEIGHT § ENLARGED OR TENDER LIVER · Psychosocial: smoking exposure, interests and hobbies, home conditions, crowded living conditions, economic status, anxiety, fear

calluses on elbows from leaning over tables to stretch torso and help breathing (tripod position) § Signs of an altered sensorium (restlessness or lethargy), which may be the first indicator of hypoxia

Nursing Assessment of Signs and Symptoms of Chronic Obstructive Pulmonary Disease (COPD) · History: older, men, family history, genetics (ATT deficiency), smoking, pack-years § Ask the patient to describe breathing problems, difficulty breathing while talking (taking breaths during sentences) § Ask about Coughs, wheezing, SOB, triggers to problems, presence of sputum § Ask about activity level and SOB now compared with a month ago and a year ago; SOB with eating, sleeping, orthopnea, ADLs, sexual activity § Compare weight to previous weights: weight loss is common with COPD · BASELINE ASSESSMENT of Respiratory and cardiac status is essential!!! · General Appearance: (underweight, overweight, bloated, dusky, pale) § THIN, LOSS OF MUSCLE MASS IN EXTREMITIES, NECK MUSCLES ENLARGED, § slow moving, slightly stooped, sitting with forward-bending posture with arms held forward (tripod/orthopneic position). § Dependent edema with right HF, JVD § CLUBBING of fingers § With severe dyspnea, bathing/hygiene can be neglected § ** older adults may have ____________________________________

D. Altered alveolar shape resulting in increased alveolar diameter

The nurse notes that an older person who has never smoked cigarettes has a barrel chest. What should the nurse consider as the reason for this person's anatomical change? A. Repeated infections caused by influenza and pneumonia B. Insufficient caloric intake and vitamin intake C. Excessive use of antibiotics for non-bacterial lung infections D. Altered alveolar shape resulting in increased alveolar diameter

OLDER ADULTS HOW TO AVOID ASTHMA ATTACKS AND HOW TO CORRECTLY USE PREVETIVE DRUG THERAPY

Nursing Focus on Older Adults: Chronic Respiratory Disorder · Provide rest periods between activities such as bathing, meals, and ambulation · Place the patient in upright position for meals to prevent aspiration · Encourage nutritional fluid intake after the meal to promote increased calorie intake · Schedule drugs around routine activities to increase adherence to drug therapy · Arrange chairs in strategic locations to allow the patient with dyspnea to stop and rest while walking · Urge the patient to notify the primary health care provider promptly for any symptoms of infection · Encourage the patient to get the pneumococcal vaccine and to have an annual flu shot · For patients with home O2, keep tubing coiled when walking to reduce risk of falls Considerations for Older Adults · Rarely, older adults will develop asthma. It can occur due to a continuing disorder. It is often under-diagnosed in older adults, which contributes to frailty. · With older adults, complete reversibility of airflow problems is more difficult (especially with persistent problems) due to irreversible damage to the airway, scarring, and stricture. · Normal changes of aging cause a decreased sensitivity to beta-adrenergic receptors. When stimulated, they relax smooth muscle and cause bronchodilation. But as they get less sensitive, they don't response as fast or as strong to agonists (epinephrine, dopamine) and beta-adrenergic drugs. THUS, TEACHING ____________________________________________ IS A NURSING PRIORITY!

rest for older adults with dyspnea. Design the room with opportunities for rest and incorporate rest into ADLs

Nursing Interventions for Asthma · Control and prevent episodes, improve airflow and gas exchange, and relive symptoms. It is best controlled when patient is active in the plan · DECREASE RISK OF EXPOSURE TO TRIGGERS · Symptom Management: improve QOL, prevent exacerbations, normal activity levels, nearly normal PFT's, using rescue inhaler less than 2x/week, minimize side effects · Priority nursing actions focus on patient education about using their personal action plan, including drug therapy, lifestyle management, and understanding disease and treatment. · Position in high fowlers and administer O2 therapy PRN · Monitor cardiac rate for rhythm changes due to acute attacks · Monitor RR and rhythm for changes in effort, symmetry, SaO2, and lung sounds · Initiate IV access - remain calm and reassuring. · Encourage Vaccines and taking/administering medications regularly as prescribed · Provide ________________________ · Pharmacological Treatment: § Inhaled corticosteroids- Rinse mouth after use § Short acting Beta 2 agonists (salbutamol or terbutaline) § Long acting Beta 2 agonists § Combination Drugs-Advair § Anticholinergic (Ipratropium) § Leukotriene inhibitor (singulair) § Theophylline (Methylxanthine) § Cromolyn solution

prednisone

Nursing Interventions for Asthma · Decrease risk of exposures · Control and prevent episodes, improve airflow and gas exchange, and relive symptoms. It is best controlled when patient is active in the plan · Priority nursing actions focus on patient education about using their personal action plan, including drug therapy, lifestyle management, and understanding disease and treatment. · Position in high fowlers and administer O2 therapy PRN · Monitor cardiac rate for rhythm changes during acute attacks · Monitor RR and rhythm for changes in effort, symmetry, SaO2, and lung sounds · Initiate IV access, remain calm and reassuring. · Provide rest for older adults with dyspnea. Design the room with opportunities for rest and incorporate rest into ADLs · Encourage prompt medical attention for infections. · Encourage appropriate vaccinations. · Administer medications as prescribed · Education of Asthmatic Client § Encourage to drink plenty of fluids to promote hydration. § Encourage client to take _____________________ with food. § Advise client to use anti-inflammatory medication to prevent asthma attacks. Leukotriene receptor antagonists such as montelukast (Singulair) help prevent asthma attacks. Leukotrienes are a group of naturally occurring chemicals in the body that promote inflammation in asthma and seasonal allergic rhinitis. § Use good mouth care § Do not stop the use of anti-inflammatory medications suddenly.

1. Set the peak flow meter at zero. Use a standing position without leaning or supporting yourself 2. Take as deep a breath as possible 3. Place mouthpiece in mouth; wrap lips tightly around 4. Blow breath out through mouthpiece as hard and fast as possible (if you cough/sneeze, reset meter and do it again) 5. Reset and perform the test 2 more times 6. The highest reading of the 3 is the current peak flow rate 7. Keep a record of these and examine for trends

Nursing Interventions for Asthma: Self-Management Education: o Teach the patient to assess asthma severity at least daily with a peak flow meter and to adjust drugs according to their personal asthma action plan to prevent or relive symptoms. § They should keep a symptom diary to learn triggers and early cues of asthma attacks § Using a Peak Flow Meter: 1. 2. 3. 4. 5. 6. 7.

after awakening and between noon and 2pm, before and after taking beta2 agonists, when symptoms occur, or when you have a respiratory infection

Nursing Interventions for Asthma: Self-Management Education: o Teach the patient to assess asthma severity at least daily with a peak flow meter and to adjust drugs according to their personal asthma action plan to prevent or relive symptoms. § They should keep a symptom diary to learn triggers and early cues of asthma attacks § Using a Peak Flow Meter: 1. Set the peak flow meter at zero. Use a standing position without leaning or supporting yourself 2. Take as deep a breath as possible 3. Place mouthpiece in mouth; wrap lips tightly around 4. Blow breath out through mouthpiece as hard and fast as possible (if you cough/sneeze, reset meter and do it again) 5. Reset and perform the test 2 more times 6. The highest reading of the 3 is the current peak flow rate 7. Keep a record of these and examine for trends § The patient 1st establishes a baseline personal best peak expiratory flow (PEF) by measuring it twice daily for 2-3 weeks when asthma is well controlled (Tabloski says every day for 2 weeks after diagnosis) § Keep using the peak flow meter __________________________________ § 2nd, the patient compares all other abnormal readings to this value. Some meters are color coded to help the patient use results. · Green are at least 80% or above personal best. This is ideal range for asthma control. No increase in drug therapy needed · Yellow is between 50-80% personal best. Patient needs to use the reliver drug. After a few minutes, do another PEF reading to determine if drug is working. · Frequent readings in the yellow zone or increasing use of reliver drugs indicates the need to reassess the asthma plan for need to change controller drugs · Red range is below 50% of personal best. Indicates serious respiratory obstruction. Immediately use reliver drug and seek emergency help § **Teach Older adults and family about peak flow meters and have a written plan and instructions to refer to (improves adherence and reduces confusion)

Gray/blue fingertips or lips · Difficulty breathing, walking, talking · Retractions of neck, chest, ribs · Nasal flaring · Failure of drugs to control symptoms Peak expiratory rate flow (PERF) declining after treatment or flow rate less than 50% of personal best

· Teach Asthma Management: § Get adequate rest, sleep, and exercise (improves cardiac health and perfusion) § Reduce stress/anxiety: relaxation methods, adopt coping mechanisms that worked in the past § Wash all bedding with hot water to destroy dust mites § Monitor peak expiratory flow rates with a flow meter 2x daily § Oxygen therapy may be needed during attacks. Ensure that no open flamers no other combustion hazards are in room when O2 is in use § Seek immediate emergency care for: - - - -

written plan and instructions to refer to (improves adherence and reduces confusion)

Nursing Interventions for Asthma: Self-Management Education: o Teach the patient to assess asthma severity at least daily with a peak flow meter and to adjust drugs according to their personal asthma action plan to prevent or relive symptoms. § They should keep a symptom diary to learn triggers and early cues of asthma attacks § Using a Peak Flow Meter: 1. Set the peak flow meter at zero. Use a standing position without leaning or supporting yourself 2. Take as deep a breath as possible 3. Place mouthpiece in mouth; wrap lips tightly around 4. Blow breath out through mouthpiece as hard and fast as possible (if you cough/sneeze, reset meter and do it again) 5. Reset and perform the test 2 more times 6. The highest reading of the 3 is the current peak flow rate 7. Keep a record of these and examine for trends § The patient 1st establishes a baseline personal best peak expiratory flow (PEF) by measuring it twice daily for 2-3 weeks when asthma is well controlled (Tabloski says every day for 2 weeks after diagnosis) § Keep using the peak flow meter after awakening and between noon and 2pm, before and after taking beta2 agonists, when symptoms occur, or when you have a respiratory infection § 2nd, the patient compares all other abnormal readings to this value. Some meters are color coded to help the patient use results. · Green are at least 80% or above personal best. This is ideal range for asthma control. No increase in drug therapy needed · Yellow is between 50-80% personal best. Patient needs to use the reliver drug. After a few minutes, do another PEF reading to determine if drug is working. · Frequent readings in the yellow zone or increasing use of reliver drugs indicates the need to reassess the asthma plan for need to change controller drugs · Red range is below 50% of personal best. Indicates serious respiratory obstruction. Immediately use reliver drug and seek emergency help § **Teach Older adults and family about peak flow meters and have a ________________________

decreased hospital visits

Nursing Interventions for Asthma: Self-Management Education: § Guided self-care to co-manage disease, increase symptom-free periods, and decrease severity of attacks. Good management = ______________ § Plan often includes: · prescribed daily controller drug schedule and drug directions · Patient-specific asthma control assessment questions · Directions for adjusting daily controlled drug schedule · When to call the doctor · Emergency actions to take when asthma doesn't respond to controller and reliver drugs

use the bronchodilator inhaler 30 minutes before exercise to prevent or reduce bronchospasm

Nursing Interventions for Asthma: Self-Management Education: · Teach Asthma Management: § Avoid asthma triggers: smoke, fire places, mold, dust, weather changes (warm/cold), avoid trigger drugs (aspirin, NSAIDs, beta blockers), avoid perfumes, stress, enzymes (laundry detergents, household cleaners) § Avoid food that has been prepared with MSG § Wear a mask and ensure ventilation when working around particles or carcinogens § Get flu and pneumonia vaccine § Regular exercise is recommended to maintain heart health § If you have exercise-induced asthma, _____________________________________ § Position in High-Fowlers to max ventilation § Be sure that you know the right technique and sequence when using metered dose inhalers. Count number of doses used to ensure you get refills PRN.

high fowlers at 60-70 degrees!

Nursing Interventions for COPD · Position client to maximize ventilation (__________________________). · Encourage coughing or suction to remove secretions. · Encourage Deep breathing and use of incentive spirometer. · Administer oxygen as prescribed. · Monitor skin breakdown nose and mouth from oxygen device. · Promote adequate nutrition, need for more calories, fluids for adequate hydration, high calorie foods encouraged. · Teach diaphragmatic or pursed lip breathing. · Remain calm with patient. · Continuously monitor for cardiac dysrhythmias. · Obtain IV access. Fluids are frequently given to help liquefy secretions, but monitor for fluid overload.

lie on back with knees bent (if this is not comfortable, sit in a chair). Place hands or book on the abdomen to create resistance. Begin breathing from ABD while keeping chest still. You can tell if you are breathing right if your hands and book rises and falls accordingly

Nursing Interventions for COPD: Improve Gas Exchange and Reduce CO2 Retention · Breathing Techniques: diaphragmatic breathing or ABD and pursed-lip breathing can manage dyspneic episodes. Use an inceptive spirometer § Diaphragmatic or Abdominal Breathing: ____________________________________ § Pursed-Lip Breathing: close mouth and breathe in through nose. Purse lips (like whistle) and breath out slowly through your mouth without puffing cheeks. Spend twice the amount of time it took you to breath in. Use ABD muscles to squeeze out every bit of air possible. Use this during any physical activity. Always inhale before beginning activity and exhale while performing it (never hold breath)

bronchodilators and corticosteroids

Nursing Interventions for COPD: Improve Gas Exchange and Reduce CO2 Retention · Drug Therapy: same drugs as for asthma (beta adrenergic drugs, anticholinergics, xanthines, corticosteroids) but the focus is on long-term therapy with long acting drugs § ** _____________________ are used in people with stage III and stage IV (severe and very severe) disease § **use bronchodilators before using corticosteroids § Bronchodilators: Arformoterol, indacaterol, tiotropium, olodaterol § Corticosteroids: Fluticasone § Expectorants: thin thick secretions, making them easier to cough up · Guaifenesin (often combined with dextromorphan) · Nebulizer treatments with saline or mucolytic · Side effects: GI upset, drowsiness, dizziness, allergic reaction (rash) · Caution: asthma, breastfeeding · Take with a full glass of water § Mucolytics: thin thick secretions, making them easier to cough up · Acetylcysteine, hypertonic saline · Side effects: bronchospasm, drowsiness, dizziness, hypotension, tachycardia, hepatotoxicity · Caution: asthma, liver/renal disease, seizures, hypothyroidism · Change positions slow · Monitor LFT · It smells like rotten eggs § Non-opioid Antitussives: dextromethorphan · Side effects: nausea, dizziness, sedation, low abuse potential · Do not take with alcohol § Many treatments for COPD come in DPIs that need to be loaded. This can be difficult for older adults

Pulmonary Rehabilitation

Nursing Interventions for COPD: Improve Gas Exchange and Reduce CO2 Retention · Exercise Conditioning: improve function, endurance, exercise tolerance, and quality of life using: Breathing, relaxation, smoking cessation, energy conservation, exercise, group support § ________________________: education and exercise training to prevent muscle deconditioning (good for older adults). § Walking indoors until symptoms limit walking, then stopping, then walking until 20 minutes of walking has been obtained. Gradually increase the time spent walking (5 min) and walk at least 2-3 times weekly § Teach patients with severe symptoms to modify exercise using a walker with wheels or O2 while exercising § Exercise 2-3 times weekly for improvement § Rest as needed · Suctioning: only when needed (not routinely). Nasotracheal suctioning is used for patients with a weak cough, weak muscles, and inability to expectorate effectively § Assess for dyspnea, tachycardia, and dysrhythmias during suctioning; assess for improved breath sounds afterwards · Hydration: maintains thick, tenacious, sticky secretions making them easier to remove by coughing. Drink 2-3L/day. Use humidifiers if you live in a dry climate

Controlled Coughing

Nursing Interventions for COPD: Improve Gas Exchange and Reduce CO2 Retention · Monitor/assess for changes in respiratory status to provide prompt interventions every 2 hours (even if COPD is not why they are hospitalized) § Apply O2, assess response to therapy, prevent complications § If condition worsens, more aggressive therapy is needed. Noninvasive ventilation can be useful for stable, very severe CPOD and hypercapnia. Intubation and mechanical ventilation for respiratory failure · Positioning: Upright position with HOB elevated to alleviate dyspnea and increase chest expansion (keeps diaphragm in right location). Help the patient who can tolerate sitting in a chair to get out of bed for 1 hour periods 2-3 times per day § Chest percussion: lightly clapping chest and back to loosen secretions · Effective Coughing: increases airflow in larger airways § ______________________: cough on arising in the morning to eliminate nighttime mucus. Cough before meals to make eating more pleasant. Cough before bed to clear lungs for better sleep. § Sit in a chair or side of the bed with feet on floor. Turn shoulders in and bend the head slightly downward, hugging pillow against stomach. Take a few breaths (in through nose out through pursed lips), then take a deeper breath and bend forward while coughing 2-3 times from same breath. On return to sitting, take another breath

is 88-92%, thus they benefit from O2 either all day or just at night

Nursing Interventions for COPD: Improve Gas Exchange and Reduce CO2 Retention · Oxygen Therapy: all hypoxic patients, even those with COPD and hypercarbia, should get O2 therapy at rates to reduce hypoxemia and bring SPO2 levels between 88-92% § NORMAL O2 LEVEL FOR CHRONIC BRONCHITIS ________________________________ § NORMAL O2 LEVEL FOR EMPHYSEMA PATIENTS can be normal or low. If they have Co2 retention and we put a non-rebreather mask on them, that can falsely increase pulse oximetry reading (it only reads O2). Usually 2L is about all they can handle (higher Co2 = decreased respiratory drive) § Monitor skin breakdown nose and mouth from oxygen device. § Home O2 therapy can improve exercise tolerance and ability to perform on cognitive and physical tests. It improves cardiac function and prevents development of cor polmonale § NO SMOKING NEAR O2 THERAPY: If an older person says they are turning off the O2, then smoking, discuss complete removal of O2 equipment from the home. Everything in the home becomes "oxygen enriched" and is more easily ignited. § CPAP can be used at night to wean patients from mechanical ventilation and improve exertional dyspnea because it keeps narrowed airways open. It also helps prevent CO2 retention and respiratory depression because positive pressure keeps airway open § Intermittent positive pressure breathing (IPPB) is used for frail, debilitated older adults for short-term ventilatory support and delivery of inhalation drugs. It uses positive pressure, can help clear secretions, and stimulate cough reflex § Managing Stable COPD With O2: · The long-term administration of O2 (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival Costs $500/year · Also increases quality of life · Long-term O2 therapy for those who have severe hypoxemia (PaO2 < 55 at rest) · Medicare will pay for home O2 if documented hypoxemia (PaO2 < 55mmHg at rest) · Need teaching to safely use O2 to prevent CO2 narcosis and respiratory depression · O2 is the only treatment shown to alter course of advanced COPD- Both quality of life & survival

can be normal or low. If they have Co2 retention and we put a non-rebreather mask on them, that can falsely increase pulse oximetry reading, so it is NOT GOOD TO USE! (it only reads O2). Usually 2L @ nasal cannula is about all they can handle (higher Co2 = decreased respiratory drive)

Nursing Interventions for COPD: Improve Gas Exchange and Reduce CO2 Retention · Oxygen Therapy: all hypoxic patients, even those with COPD and hypercarbia, should get O2 therapy at rates to reduce hypoxemia and bring SPO2 levels between 88-92% § NORMAL O2 LEVEL FOR CHRONIC BRONCHITIS is 88-92%, thus they benefit from O2 either all day or just at night § NORMAL O2 LEVEL FOR EMPHYSEMA PATIENTS ____________________________________ § Monitor skin breakdown nose and mouth from oxygen device. § Home O2 therapy can improve exercise tolerance and ability to perform on cognitive and physical tests. It improves cardiac function and prevents development of cor polmonale § NO SMOKING NEAR O2 THERAPY: If an older person says they are turning off the O2, then smoking, discuss complete removal of O2 equipment from the home. Everything in the home becomes "oxygen enriched" and is more easily ignited. § CPAP can be used at night to wean patients from mechanical ventilation and improve exertional dyspnea because it keeps narrowed airways open. It also helps prevent CO2 retention and respiratory depression because positive pressure keeps airway open § Intermittent positive pressure breathing (IPPB) is used for frail, debilitated older adults for short-term ventilatory support and delivery of inhalation drugs. It uses positive pressure, can help clear secretions, and stimulate cough reflex § Managing Stable COPD With O2: · The long-term administration of O2 (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival Costs $500/year · Also increases quality of life · Long-term O2 therapy for those who have severe hypoxemia (PaO2 < 55 at rest) · Medicare will pay for home O2 if documented hypoxemia (PaO2 < 55mmHg at rest) · Need teaching to safely use O2 to prevent CO2 narcosis and respiratory depression · O2 is the only treatment shown to alter course of advanced COPD- Both quality of life & survival

· ASK: Systematically identify all tobacco users at every visit. · ADVISE: Strongly urge all tobacco users to quit. · ASSESS: Determine willingness to make a quit attempt. · ASSIST: Aid the patient in quitting. · ARRANGE: Schedule follow-up contact.

Nursing Interventions for COPD: Improve Gas Exchange and Reduce CO2 Retention · Vibratory Positive Expiratory Device: this helps patients remove airway secretions. § It is a small, handheld, plastic pipe with a short, fat stem and perforated lid over the bowl. A movable steel ball is in the bowl. § The patient inhales deeply and then exhales through the device, causing the ball to move and send vibrations to the chest and airways § Vibrations loosen secretions to be coughed out more easily · Stop Smoking: It is never too late to stop smoking. § Use a Smoking IQ test to quiz older smokers § You MUST offer and document treatment of smoking cessation each visit § Investigate community resources for smoking cessation groups, behavior modification methods, § If an older adult wants to smoke during nicotine patch treatment, they should remove the patch and wait at least 2 hours (overnight is better) before smoking § Bupropion for 7-12 weeks can ease tobacco cravings during cessation. It is contraindicated in people with seizure disorders § Smoking cessation is the best way to prevent and slow progression of COPD. Be persistent in educating and urging older adults to quit. Addiction can be tough to beat and you may have to try many times § At least one medication should be added to counseling in absence of contraindications · Nicotine replacements (oral, patch, nasal spray, inhaler) · Antidepressant (Zyban) · Chantix · Group and family support § Brief Strategies To Help The Patient Willing To Quit Smoking (GOLD) 1. 2. 3. 4. 5.

assess breathing rate, rhythm, depth, and use of accessory muscles. Determine if any factors are contributing to increased WOB (respiratory infection)

Nursing Interventions for Chronic Obstructive Pulmonary Disease · For older adults: careful monitoring of treatment of disease, reducing risk factors (smoking), managing stable COPD and preventing progression, assessing and managing anxiety/depression, mucolytic therapy, rehabilitation, managing exacerbations Improve Gas Exchange and Reduce CO2 Retention: airway maintenance, monitoring, breathing techniques, positioning, effective coughing, O2 therapy, exercise conditioning, suctioning, hydration, use of vibratory positive-pressure device · Teach the patient how to be a partner in COPD management by participating in therapies to improve gas exchange and adhering to prescribed drug therapy · Before any intervention, _______________________________________________ · Airway maintenance is the most important focus to improve gas exchange

Soft, High-calorie, high-protein, high-fat foods, LOW CARB (lowers CO2): supplements (Pulmocare), protein shakes

Nutrition & Preventing Weight Loss: Nursing Interventions for COPD § COPD patients often have nausea, early satiety, poor appetite, mealtime dyspnea. WOB raises calorie and protein needs (can lead to malnutrition, loss of muscle mass, strength, lung elasticity, and reduced gas exchange and perfusion) § Malnutrition is common due to energy to prepare/chew/swallow, ABD discomfort fullness, coughing/mucus secretion, and depression § Collaborate with registered dietician for nutrition assessment § Monitor weight and prealbumin levels § Dyspnea management: plan the biggest meal of the day for when they are most hungry and well rested. · 4-6 small meals per day may be needed · Use pursed lip breathing and ABD breathing · Use bronchodilator 30 minutes prior to eating § Food Selection: easy to chew, non-gas-forming to prevent bloating. Avoid dry foods that stimulate coughing. Avoid caffeine that contributes to dehydration · Diet: __________________________________ · For satiety, avoid drinking fluids before meals and during the meal. Eat smaller, more frequent meals · Number of calories = Slightly above resting needs to avoid CO2 · Slow enteral feeding: Pulmocare 28% CHO, FAT 55%, 1.5kcal/ml · Theophylline can cause Vitamin B6 deficiency

· Allow vegetables as desired (cooked) · Allow all types meat (prepare as desired) · Use fresh fruit without sugar · Milk 1-2 cups/day · Cheese 1-2 oz/day · Use nuts to increase PRO and FAT · Three servings starchy foods/day · Avoid concentrated sweets · Frequent feedings/snacks · Commercial PRO powders · Conserve energy

Nutrition & Preventing Weight Loss: Nursing Interventions for COPD § COPD patients often have nausea, early satiety, poor appetite, mealtime dyspnea. WOB raises calorie and protein needs (can lead to malnutrition, loss of muscle mass, strength, lung elasticity, and reduced gas exchange and perfusion) § Malnutrition is common due to energy to prepare/chew/swallow, ABD discomfort fullness, coughing/mucus secretion, and depression § Collaborate with registered dietician for nutrition assessment § Monitor weight and prealbumin levels § Dyspnea management: plan the biggest meal of the day for when they are most hungry and well rested. · 4-6 small meals per day may be needed · Use pursed lip breathing and ABD breathing · Use bronchodilator 30 minutes prior to eating § Food Selection: easy to chew, non-gas-forming to prevent bloating. Avoid dry foods that stimulate coughing. Avoid caffeine that contributes to dehydration · Soft, High-calorie, high-protein, high-fat foods, LOW CARB (lowers CO2): supplements (Pulmocare), protein shakes · For satiety, avoid drinking fluids before meals and during the meal. Eat smaller, more frequent meals · Number of calories = Slightly above resting needs to avoid CO2 · Slow enteral feeding: Pulmocare 28% CHO, FAT 55%, 1.5kcal/ml · Theophylline can cause Vitamin B6 deficiency Guidelines for High-Fat, Low Carbohydrate Diet - - - - - -

§ Avoid crowds, get a pneumonia vaccine and flu vaccine · Pneumonia is a common complication in older adults with COPD · REPORT S/S infection; GET FLU AND PNEUMONIA VACCINES

Patient Education Home Care Management: Nursing Interventions for COPD · Prevent infection: - - - · Proper hydration · Proper use of oxygen · Proper use of medications- MDIs and spacers (older adults benefit). · Immunizations (influenza and Pneumococcal vaccination) · Climate- Avoid high temperatures and humidity · Collaborate with case manager to obtain equipment needed to live functionally § O2 therapy, hospital-like bed, nebulizer, tub transfer bench, shower chairs, scheduled visits from home nurses · Avoid smokes, pollutants, refrain from ill people, avoid excessive heat/cold, and high altitudes. · Drink lots of fluids · Maintain good lifestyle habits · Have spirometry done routinely to know the numbers

increasing fluids especially water

Pharmacology for COPD · Bronchodilator medications are central to the symptomatic management of COPD. Given on an as-needed basis or on a regular basis to prevent or reduce SOB and increase quality of life. · Inhaled Beta2-agonists (relax muscles of the airways), anticholinergics (bronchodilators ie. Atrovent & Spiriva), combination or theophylline (smooth muscle relaxer & bronchial dilator). · TEACH USE OF: MDI - Metered dose Inhaler and DPI - Dry Powder Inhaler Bronchodilators § Anticholinergics · Short Acting-Ipratropium (atrovent) · Long Acting-Spiriva (tiotropium) § Inhaled Beta2-agonists · Short Acting-Rescue-Albuterol (proventil) · Long Acting-Formoterol (foradil) § Theophylline (methylxanthine) § Duoneb (Combination of Atrovent & Albuterol) Anti-inflammatory Medications § Glucocorticoids-if symptomatic · Inhaled-Aerobid, Pulmicort: (WITH INHALED CORTICOSTEROIDS, YOU DON'T GET THE SYSTEMIC EFFECTS (FLUID RETENTION, ELEVATED GLUCOSE) OF ORAL CORTICOSTEROIDS) · Combined with Beta-2 (advair) · PO-prednisone · IV-Methylprednisone · Watch for steroid effects- suppression of adrenal function, hyperglycemia, wt. gain, fluid retention, decreased inflammatory response, increased gastric acid § Cromolyn (Intal)-prophylactically Other Meds § Leukotriene inhibitors · Singulair (Montelukast) for asthma § Monoclonal Antibodies · Omalizumab (Xolair) treats allergic asthma § Mucolytics - questionable effectiveness. (decreases sputum viscosity) · Best mucolytic is ___________________________.

§ Dyspnea § Cyanosis § Prolonged expiration § Scattered crackles, rhonchi & wheezing § Cardiac dysrhythmias § Increased mucus production § Productive cough, more severe in AM § Increased AP diameter § Peripheral edema § Normal respiratory rate § Clubbing of fingers and toes

Symptoms Of COPD · __________Chronic Bronchitis_______:

1. Before use, remove the caps from inhaler and shake the inhaler 2. Tilt head back slightly and breath out fully 3. Open mouth and place mouthpiece 1-2in away from mouth, or close lips around mouthpiece 4. As you breath in deeply through mouth, press down on the canister 5. Continue to breathe in slowly for 5-7 seconds. Then hold breath for 10 seconds. 6. Wait 1 minute between puffs. Replace cap on inhaler. Wash the plastic case and cap daily under warm running tap water.

· Teach Asthma Management: § Non-spacer: 1. 2. 3. 4. 5 .6

1. Before use, remove the caps from inhaler and spacer 2. Insert mouthpiece of inhaler into the non-mouthpiece end of spacer 3. Shake 3-4 times 4. Fully exhale then place mouthpiece into mouth and press down on the canister to release one dose 5. Breath in slowly and deeply. If it whistles, you are breathing in too fast 6. Remove mouthpiece and hold breath for 10 seconds 7. Wait 1 minute between puffs. Replace caps. Wash the plastic case and cap daily under warm running tap water. Clean the spacer once per week

· Teach Asthma Management: § Spacer: 1. 2. 3. 4. 5. 6. 7.

anxiety

· Why Dyspnea in COPD? § COPD is described as airflow limitation from irritation and inflammation which cause airway narrowing d/t swelling and mucus production. Lung tissue is destroyed reducing surface area for oxygen and carbon dioxide to exchange. There is also a decrease in elasticity preventing the lung to go back to its resting position causing the patient to have to push the air out. § Because of the narrowing of the bronchioles and the increased work of breathing needed to push the air out, the patient feels the sensation of dyspnea. § Other Possible Causes of Dyspnea that are NOT COPD to assess for!!!!!: · Fluid overload, worsening crackles or wheezes with edema = CHF · Pain and arrhythmias = Ischemia · Sudden dyspnea with worsening oxygenation = PE · Sharp chest or shoulder pain with new unequal breath sounds = PNX · New fever, leukocytosis with purulent sputum=nosocomial pneumonia · No change in saturation, exam or ABG and a previous display of nervousness = ____________________ (this diagnosis is one made after all these others have been ruled out)

cough and sputum production present on most days for 3 months for 2 successive years or for 6 months in 1 year

· COPD Includes: Chronic Bronchitis, Emphysema, Asthma · Chronic Bronchitis: an inflammation of the bronchi and bronchioles caused by exposure to irritants (smoking). Irritant triggers inflammation, vasodilation, mucosal edema, congestion, and bronchospasm. It only affects the airway, NOT the alveoli § Chronic inflammation increases mucus-secreting cells, resulting in thick mucus. Bronchial walls thicken and impair airflow. Together, these create a breeding ground for bacteria and leads to chronic infection which narrows airway § PaO2 decreases (hypoxemia), PaCO2 increases (respiratory acidosis) § It is defined as a _____________________________________

1. GET THEM UP RIGHT 2. GIVE THEM THE RESCUE INHALER 3. ADMINISTER O2 4. Monitor Cardio (for changes in rhythm due to low O2), they may need early intubation (if airway is constricted)

· IN AN ACUTE ASTHMA ATTACK 1. 2. 3. 4.

Advair, dulera, symbicort

· Long-Acting Beta Agonists and Inhaled corticosteroid combinations: ____________

alpha1-antitripsyn (AAT)

· Risk Factors for Chronic Obstructive Pulmonary Disease: Smoking, occupational dust/chemicals, environmental tobacco smoke (ETS), Indoor/outdoor air pollution § Genes: ____________________ deficiency § Infections § Socio-economic status § Aging populations § Asthma

1. Load the drug by turning the device to next dose, inserting the capsule into the device, or inserting the disk or compartment into the device 2. Exhale, then place lips over the mouthpiece and breath in forcefully (breath pulls in med) 3. Remove inhaler from mouth as soon as you breathe in. Don't breathe into the inhaler or place inhaler in water 4. Never wash the inhaler. Never shake the inhaler. Keep it in a dry, room-temperature place

· Teach Asthma Management: § Dry Powder Inhalers: 1. 2. 3. 4.