NUR 132 Oxygenation

Stridor

Wheezing heard on inspiration This is not good They can't get the air in

Respiratory therapy

Respiratory and physical therapy Breathing retraining Effective coughing Airway Clearance Techniques (ACT) Airway clearance devices (ACD) Acapella

If they ask about having another attack

Yes they will have another attack but management is important to reduce them

COPD depression/anxiety

Approximately 50% of COPD patients experience depression. If patient become anxious because of dyspnea, teach pursed lip breathing. Ask them how they are feeling Be careful not to become anxious themselves Give them breaks

Percussion LOOK UP FOR TEST

Hyper resonance- people with advanced lung disease have these Resonance

ABG findings

ABG typical findings Low PaO2 (hypoxemia) ↑ PaCO2 (Hypercarbia) ↓ pH ↑ Bicarbonate level found in late stages of COPD

You receive the following orders: Albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment STAT Albuterol (Ventolin) inhaler 2 puffs q4h Metaproterenol sulfate (Alupent) 0.4% nebulizer treatment q3h Fluticasone (Flovent) 250 mcg by MDI twice daily What is the rationale for the albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment STAT (immediately)?

ALBUTEROL relaxes and opens the airway Improves cilia to move the jucus Patient will feel shaky and their HR and BP will go up Ipratropium- inhibits secretions This combination is the most effective for better airflow

Signs & Symptoms of Respiratory Failure

Abnormal ABGs Decreased O2 stats Can't talk because they can barely breath Cannot lay their head down Initially tachycardic then has bradycardia Cyanosis Confusion If they had wheezing and now don't hear anything that is bad Preparing to incubate and ventilate

Acute bronchitis

Acute Vs. Chronic Acute an inflammation of the lower respiratory tract that is usually due to infection can be bacteria Or viral Goes away on its own When our immune system responds to an infection the bronchioles become inflamed and mucus so there isn't adequate oxygen

Asthma prevalence

Affects about 16 million Americans As adults Women are 66% more likely to have asthma than men but the opposite is true among children Older adults may be undiagnosed.

Individual risk factors

Age Smoking-vasoconstrictor increases HR and BP, vascular changes because of decreased oxygen. In our lungs it is damaging structures and causing scarring Presence of chronic medical conditions, such as chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), Heart Failure (HF)- When people with lung problems get sick they heal slower and take longer to get better. It is also harder to do surgery Immunosuppression- cancer, HIV, transplants Reduced state of cognition- Brain injury-the brain controls breathing so certain injuries can cause respiratory problems. Prolonged immobility- cannot take deeper breaths so alveoli are collapsing and not getting rid of secretions and not getting as much air

Description of COPD

Airflow limitation not fully reversible Generally progressive Abnormal inflammatory response of lungs to noxious particles or gases Includes Chronic bronchitis Emphysema Distinguishing symptoms can be difficult with co-morbidities.

Airway clearance device

Airway clearance device: Flutter mucus clearance device- steel ball in the mouthpiece Produces vibration in lungs to loosen mucus for expectoration Can be used in any position Hand-held device Acapella Vibrates lungs to shake free mucous plugs Improves clearance of secretions Faster and more tolerable than CPT

Gas exchange in the lungs

Alveoli increas s the surface area of the lungs.

Emphysema

An abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis. Reddish complexion- in an attempt to compensate the body creates more and more red blood cells but it doesn't end up helping. Hyperventilation Tachypnea- high respiratory rate Pursed lip breathing- technique to improve function of lungs Person thin, cachectic- one reason is that a full stomach puts pressure on the diaphragm and makes it even harder to breathe

Teaching about asthma

Avoiding triggers Affects of medications Use a spacer Rinse their mouth after Journal for the triggers If they overuse the SABA they can have more hyperresponsiveness Follow up appointments are important

Long-acting anticholinergic

Block action of acetylcholine Usually used in combination with a bronchodilator Most common side effect is dry mouth. Tiotropium (Spiriva) Have them rinse their mouth after to prevent thrush peak 30 minutes to an hour and lasts 4-6 hours Act on our parasympathetic nervous system Prevents resting and digesting so that the blood continues to go to the lungs

Blood pressure 152/84 mm Hg Pulse rate 124 beats/min Respiratory rate 42 breaths/min Temperature 100.4 ° F (38.4 ° C) Are these vital signs (VS) acceptable? State your rationale.

Blood pressure is too high Temp is high because of inflammation Metabolic rate increases as he works harder to breath affecting temp.

Bronchodilators

Bronchodilators Relax smooth muscle in the airway Improve ventilation of the lungs ↓ Dyspnea and ↑ FEV1 Inhaled route is preferred. Commonly used bronchodilators β2-Adrenergic agonists Methylxanthines Overuse can cause hyper-responsiveness and bronchospasm

Acute respiratory failure

Caused by Exacerbations Cor pulmonale Discontinuing bronchodilator or corticosteroid medication Overuse of sedatives, benzodiazepines, and opioids Surgery or severe, painful illness involving chest or abdomen

COPD cigarette smoking

Clinically significant airway obstruction develops in 15% of smokers. 80% to 90% of COPD deaths are related to tobacco smoking. Can affect passive smokers (second-hand smoke) Effects on respiratory tract Increased production of mucus Hyperplasia of mucous glands Lost or decreased ciliary activity Carbon monoxide ↓ O2 carrying capacity ↑ Heart rate Impaired psychomotor performance and judgment

RSV collaborative management

Cool, humidified oxygen When sats < __90%________ IV fluids Positioned with head and chest at a 30- 40 degree angle to __maintain airway, take pressure off the diaphragm _______ Signs & symptoms of dehydration Cardiorespiratory monitoring Monitor for apnea Anxiety, restlessness, irritability Assess every 1-2 hours Isolate them from other babies Wash hands Gown and glove Educate the family about gown and gloves as well Prevention is key Synagis is a drug that is given to at risk babies to prevent contraction of this

COPD complications

Cor pulmonale Exacerbations of COPD Acute respiratory failure Depression/anxiety

Most effective meds to treat asthma are

Corticosteroids

Corticosteriods

Corticosteroids Reduce bronchial hyperresponsiveness Decrease mucous production Are taken on a fixed schedule Best way to give these is inhaled Can cause hyperglycemia, immunosuppressants so will have a hard time fighting infection If they can't breath give it IV can't just stop once given systemically need to taper Rinse mouth after to prevent thrush Have women do weight bearing activity Corticosteroids (e.g., beclomethasone, budesonide) Suppress inflammatory response Inhaled form is used in long-term control. Systemic form to control exacerbations and manage persistent asthma

Pathophysiology of COPD

Defining features Irreversible airflow limitations during forced exhalation due to loss of elastic recoil Airflow obstruction due to mucous hypersecretion, mucosal edema, and bronchospasm Primary process is inflammation. Inhalation of noxious particles Mediators released cause damage to lung tissue. Airways inflamed Parenchyma destroyed Supporting structures of lungs are destroyed. Air goes in easily, but remains in the lungs. Bronchioles tend to collapse. Pulmonary vascular changes Blood vessels thicken. Surface area for diffusion of O2 decreases.

Emphysema

Destroys some of air sac walls Wheezing SOB tightness in chest

COPD manifestations

Dyspnea usually prompts medical attention. Occurs with exertion in early stages Present at rest with advanced disease Physical examination findings Wheezes Decreased breath sounds Prolonged expiratory phase ↑ Anterior-posterior diameter Use of accessory and intercostal muscles Sputum/Mucus Bluish-red color of skin Polycythemia and cyanosis Characteristically underweight with adequate caloric intake Chronic fatigue

Moderate persistent

Everyday Need a SABA Maybe even a LABA

Factors causing obstruction asthma

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

Crackles

Fluid in the lungs Crackly like if you rub your hair together

COPD prevalence

Fourth leading cause of death in the United States More women die than men Death rates in Hispanics are lower than in any other ethnic group

RSV goals

Gas Exchange Prevention of transmission Maintain fluid balance Reduce fever Decrease anxiety

Mild persistent

Greater than two times a week but not everyday Does affect ADLS

Primary prevention

Hand washing Immunizations Stop smoking Inspirex- to prevent post op complications and pneumonia

Exacerbations of COPD

Happens when they have it and then they get sick on top of that so they have to go to the hospital. Frequency increases as the disease progresses. They have more damage with each exacerbation so it is important to stop them from happening Signaled by change in usual Dyspnea Cough Sputum Associated with poorer outcomes Primary causes Infection Air pollution

RSV ETIOLOGY AND INCIDENCE

Highly communicable Most often spread through contact with older child or adult Acquired mainly through contaminated surfaces and hand to hand transmission Requires meticulous hand hygiene Children who are hospitalized with this are more likely to have asthma later

COPD diagnostic studies

History, and physical examination are important in the diagnostic workup. Diagnosis confirmed by pulmonary function tests 6-Minute walk test to determine O2 desaturation in the blood with exercise ECG can show signs of right ventricular failure. Chest x-rays- Shows hyperinflation of lungs & flattened diaphragm

You are also providing teaching about peak flow monitoring (PFM). What will you teach B.T. about the about the device and it's purpose?

If the number is green have good flow of air and good control Yellow make an app with Doctor Red need help right away Measures expiratory volume Important for kids because they will not know when their symptoms are getting worse

Consequences of impaired gas exchange

Impairment of gas exchange occurs when the diffusion of gases (oxygen and carbon dioxide) becomes impaired because of Ineffective ventilation Reduced capacity for gas transportation (reduced hemoglobin and/or red blood cells) Inadequate perfusion

Inspection

Inspection Normal relaxed breathing, No use of accessory muscles like abdominal muscles, no bulging neck veins Want to see equal expansion, rise and fall Rate 12-20

Pathophysiology of RSV

It is the common cold that affects babies In some of these children exacerbations can cause the children to have to go to the hospital

Tell asthmatic people to

Keep a diary so that they can identify trends and keep them from doing the triggers

COPD collaborative care

O2 therapy is used to Reduce work of breathing Maintain PaO2 (O2 saturation level usually < 95%) Reduce workload on the heart Oxygen saturation determined by pulse oximetry Need for oxygen determined by ABG values [Client who is hypoxemic with chronic hypercarbia requires lower levels of O2 delivery (1-2L /min via nasal cannula) since a low arterial O2 level is the primary driving force for breathing]*** if they have too much oxygen they lose the stimulation to breathe Breathing retraining Decreases dyspnea, improves oxygenation, and slows respiratory rate Pursed lip breathing: Prolongs exhalation and prevents bronchiolar collapse and air trapping Effective coughing Main goals Conserve energy. Reduce fatigue. Facilitate removal of secretions. Abdominal surgery can put them into respiratory failure if they have been using their accessory muscles to breathe and now they can't

Common lab tests

Laboratory tests Arterial blood gases, complete blood count- red blood cell count because they carry oxygen; sputum- looking for infection and looking for what color it is; biopsy- when you suspect that there is a cancerous mass Radiologic studies Chest x-ray- can see size, obstruction etc; CT and MRI scans, ventilation/perfusion (V/Q) scan- how much your breathing in and how much you are perfuming; positron emission tomography (PET)- will indicate cancerous areas; Pulmonary function studies- review the normal levels in Lewis. Main diagnostic tool, machine that the patient forcefully exhales into and it measures the amount of air that comes out. Assessing function of the lungs. Endoscopy- flexible scope is inserted in your mouth to your windpipe to visualize your lungs. They can take samples of the tissue. Nursing considerations is that you are prepping the patient, they have to be NPO because they are at risk for aspiration. Then assess gag reflex after they come back. More immediate problems can cause a hemorrhage, collapsed lung, perforation

Mild intermittent

Less than two times a week Does not interfere with daily activity A symptomatic between exacerbations

Leukotriene modifiers or inhibitors

Leukotriene modifiers or inhibitors (e.g., zafirlukast, montelukast, zileuton) Block action of leukotrienes—potent bronchoconstrictors Have both bronchodilator and antiinflammatory effects Not indicated for acute attacks Used for prophylactic and maintenance therapy These are a pill used orally Add on therapy not used by themselves

COPD drug therapy

Long-term control medications Achieve and maintain control Quick-relief medications Treat symptoms of exacerbations

Methylxanthines

Methylxanthines (e.g., theophylline) Less effective long-term bronchodilator Alleviates early phase of attacks but has little effect on bronchial hyperresponsiveness Narrow margin of safety Not a first line because many drug interactions Can cause seizures and arrhythmias

RSV clinical symptoms

Mild upper respiratory infection develops Serous nasal drainage Sneezing Low grade fever Anorexia Acute respiratory distress Tachypnea- RR 60-80 breaths/min Tachycardia- HR > 140 beats /min Wheezing, crackles, or rhonchi Intercostal and subcostal retractions with or without nasal flaring Cyanosis Difficult/poor feeding Hypothermia to 105.8 F (41 C)

Stages/classification of COPD

Mild- almost no symptoms major considerations are getting them to quit smoking Moderate- some meds

Chronic bronchitis

Mucus in lungs always Chronic cough that produces mucus

Life considerations

Newborns are at risk because they don't have fully functional lungs so changes are detrimental Children are at risk for many diseases Most people develop asthma in childhood Elderly- decreases in lung function capacity Alveoli are less elastic

Auscultation

Normal breath sounds No adventitious lung sounds

COPD nutritional therapy

Nutritional therapy Weight loss and malnutrition are common. Pressure on diaphragm from a full stomach causes dyspnea. Difficulty breathing while eating leads to inadequate consumption. To decrease dyspnea and conserve energy Rest at least 30 minutes before eating. So get them up into the chair before their meal gets there Use bronchodilator. Prepare foods in advance. So that they are not too tired to eat once they are done preparing Nutritional therapy High-calorie, high-protein diet is recommended. Fluids (intake of 3 L/day) should be taken between meals. Helps to keep secretions thin so that they can cough them up Eat five to six small meals to avoid bloating and early satiety. Cold foods may cause less fullness than hot foods. Avoid Foods that require a great deal of chewing Exercises and treatments 1 hour before and after eating Gas-forming foods

Independent interventions for someone in an asthma attack

O2 Loosen or remove their clothes Make the environment more relaxing Encourage deep breathing, purse lipped breathing Hydrate them, oral fluids or IV if they can't swallow to thin sectretions Have them sit up in high fowlers preferably with something with an armrest

Assessment: history

Past medical history Family history Current medications-interactions, some meds can cause respiratory problems, allergic reactions Lifestyle behaviors- smoking Occupation- environmental exposure to toxins, coal miners, farmers, pollution, chemicals Social environment- Problem-based history- what brings you here to the hospital

COPD nursing care

Patient Teaching Medication management Prevent/treat complications. Management of ADL's Smoking cessation (if applicable)

Severe persistent

Physical activity requires limitation Everyday several times a day Need SABA and LABA

Risk factors COPD

Risk factors Cigarette smoking Occupational chemicals and dust Air pollution Infection Heredity- lack antitryspin, small percentage Aging α-Antitrypsin (AAT) deficiency Genetic risk factor for COPD Accounts for 3% of COPD

COPD

Sitting in tripod position in order to optimize gas exchange As disease progresses have dyspnea with rest Core-pulminale- heart failure Orthopnea- SOB while lying down

Collaborative interventions

Smoking cessation Pharmacotherapy -Types of drugs -Medication administration Nutrition therapy-an issue with lung disease especially with COPD because they have a higher metabolic need and needs more calories Positioning- sitting up, 90% is optimal, postural drainage Airway Clearance Techniques- occapella Oxygen therapy devices- improves outcomes to patients. Max liters for a nasal cannula is 6. After that masks, non rebreather which a patient cannot remain on. Want to make sure they are not building up too much CO2 Airway suctioning- Endotracheal tubes and tracheostomy tubes- Mechanical intubation- if they cannot breathe for themselves Chest tube management- when they have developed complications ex if someone has a collapsed lung

Wheezing

Sounds like musical notes generally on expiration Doesn't go away after the person coughs It is an exemptions airway

Patients who have difficulty coordinating inhalation with use of their metered dose inhaler an be helped by use of a

Spacer

Pathophysiology of asthma

Starts with chronic inflammation, caused by a trigger This inflammation causes airway hyperrespinsiveness so decreased airflow Triggers are exercise, stress, smoking, candles, perfumes, scents, extreme temperatures, allergens Mast cells cause damage along the basement membrane of the bronchiole walls, so decreased oxygenation This damage further releases more mediators that come when we have inflammation and causes even more garage and inflammation and swelling Swelling causes more vasoconstriction Vaso permeability causes more mucus production and more reduced airflow Then spasms

Palpation

Tactile phremitis When patient is inspiring and moving through there are vibrations Have the patient say 99 or blue moon as they are inspiring If you don't hear vibrations there can be obstruction or a collapsed lung Near the clavicle in the front or near the scapula in the back

When combination inhalation aerosols are prescribed without specific instructions for the sequence of administration, you need to be aware of the proper recommendations for drug administration. What is the correct sequence for administering treatments?

Take the beta agonist first Wait 5 minutes between types of inhalants Risk of toxicity when they are all taken at the same time Short acting before long acting so that the long term one can work better

Assessment: examination

Vital signs Heart rate, respiratory rate, blood pressure, temperature, oxygen saturation Inspection- looking for distress, patterns Breathing effort Skin color Thorax Extremities- make sure that oxygen rich blood is present and getting to the extremities Auscultation of lung sounds

Definition

The process by which oxygen is transported to cells and carbon dioxide is transported from cells (Giddens, 2013).

Pulmonary blebs and bullae

These can occur because of abnormalities in our gas exchange and they may have to be removed. Bullae can rupture and cause a pneumothorax (collapsed lung) which causes huge problems Caused because of the trapped air

If the patient has exercise induced asthma

They need to take their medication 30 minutes before they exercise Especially important in children because they want to fit in

Pt. states he had taken Advair that morning, then again when he started to feel short of breath. Is fluticasone/salmeterol (Advair) appropriate for use during an acute asthma attack? Explain.

This is not appropriate because it is a long acting not a short acting

Three types of anti inflammatory drugs

Three types of antiinflammatory drugs Corticosteroids Leukotriene modifiers Monoclonal antibody to IgE this one not on test

You ask the pt. to demonstrate the use of MDI. He vigorously shakes the canister, holds the aerosolizer at an angle (pointing toward his cheek) in front of his mouth, and squeezes the canister as he takes a quick, deep breath. What common mistakes has the pt. made when using the inhaler?

Timing is off Pointing at the cheek Need to take a slow deep breath Needs to hold breath after If don't rinse mouth can develop candidiasis Didn't use a spacer

What is the rationale for a oral steroid "burst"?

To decrease inflammation and decrease hyper-responsiveness which is probably why she's having more episodes

The strongest predisposing factor for asthma is an allergy?

True

Chronic bronchitis

obstructive pulmonary disease characterized by excessive production of mucus and chronic inflammatory changes in the bronchi Bluish color of lips & skin- late signs History of cough with sputum Swollen legs & ankles-late sign due to heart failure. So much pressure in the lungs it creates pulmonary hypertension and pressure on the right side so you see right sided heart failure Distended neck veins CO2 retainer- cannot expel CO2 PaO2 ↓ (hypoxemia) PaCO2 ↑ (acidosis)

B2 andrenergic agonists

β2-Adrenergic agonists Effective for relieving acute bronchospasm Onset of action in minutes and duration of 4 to 8 hours Prevent release of inflammatory mediators from mast cells Short acting albuterol (AccuNeb, Proventil HFA, ProAir HFA, Ventolin HFA) levalbuterol (Xopenex, Xopenex HFA). β2-Adrenergic agonists Long-acting beta-agonists daily basis relax the muscles lining the airways that carry air to the lungs Often in combination with a corticosteroid (ICS) Metered-dose or dry powder inhaler. Long acting formoterol and budesonide (Symbicort) formoterol and mometasone (Dulera) salmeterol and fluticasone (Advair). Never given as single therapy for anybody with asthma because they take too long to work