Asthma & COPD - Sherpath

A 55-yr-old patient with increasing dyspnea is being evaluated for a possible diagnosis of COPD. When teaching a patient about pulmonary spirometry for this condition, what is the most important question the nurse should ask?

"Have you taken any bronchodilators today?" *Spirometry will help establish the COPD diagnosis. Bronchodilators should be avoided at least 6 hours before the test. Spirometry does not involve being placed in an enclosed area such as for magnetic resonance imaging (MRI). Contrast dye is not used for spirometry. The patient may still have spirometry done if metal implants or prostheses are present because they are contraindications for an MRI.

The nurse provides dietary teaching for a patient with COPD who has a low body mass index (BMI). Which patient statement indicates that the teaching has been effective?

"I can have ice cream as a snack every day." *High-calorie foods such as ice cream are an appropriate snack for patients with COPD. Fluid intake of 3 L/day is recommended, but fluids should be taken between meals rather than with meals to improve oral intake of solid foods. The patient should avoid exercise for an hour before meals prevent fatigue while eating. Meat and dairy products are high in protein and are good choices for the patient with COPD.

Which instruction should the nurse include in an exercise teaching plan for a patient with COPD?

"Use the bronchodilator before you start to exercise." *Use of a bronchodilator before exercise improves airflow for some patients and is recommended. Shortness of breath is normal with exercise and not a reason to stop. Patients should be taught to breathe in through the nose and out through the mouth (using pursed-lip technique). Upper-body exercise can improve the mechanics of breathing in patients with COPD.

The nurse receives a change-of-shift report on the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first?

A patient with a respiratory rate of 38 breaths/min *A respiratory rate of 38/min indicates severe respiratory distress, and the patient needs immediate assessment and intervention to prevent possible respiratory arrest. The other patients also need assessment as soon as possible, but they do not need to be assessed as urgently as the patient with tachypnea. - Pt. with jugular venous distention and peripheral edema - Pt. with loud expiratory wheezes - Pt. who has a cough productive of thick, green mucus

A patient seen in the asthma clinic has recorded daily peak flow rates that are 75% of the baseline. Which action will the nurse plan to take next?

Administer bronchodilator and recheck the peak flow. *The patient's peak flow reading indicates that the condition is worsening (yellow zone). The patient should take the bronchodilator and recheck the peak flow. Depending on whether the patient returns to the green zone, indicating well-controlled symptoms, the patient may be prescribed oral corticosteroids or a change in dosing of other medications. Keeping the next appointment is appropriate, but the patient also needs to be taught how to control symtpoms now and use the bronchodilator.

A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, "I wish I were dead! I'm just a burden on everybody." Based on this information, which nursing diagnosis is most appropriate?

Chronic low self-esteem related to physical dependence. *The patient's statement about not being able to do anything for himself or herself supports this diagnosis. Although deficient knowledge, complicated grieving, and ineffective coping may also be appropriate diagnoses for patients with COPD, the data for this patient do not support these diagnoses.

An emergency department nurse is making a general appearance assessment on a preschool child just admitted to the emergency department. Which general assessment findings indicate the child "looks bad"?

Cold extremities Lethargic Color pale *Signs of a child "looking bad" on a general appearance assessment include pale skin, cold extremities, and lethargy.

A patient with COPD has poor gas exchange. Which action by the nurse would support the patient's ventilation?

Encourage the patient to sit up at the bedside in a chair and lean forward. *Patients with COPD improve the mechanics of breathing by siting up in the "tripod" position. Resting in bed with the head elevated in a semi-Fowler's position would be an alternative position if the patient was confined to bed, but sitting in a chair allows better ventilation. The Trendelenburg position or sitting upright in bed with the knees flexed would decrease the patient's ability to ventilate well.

Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider?

Flushing and dizziness *Flushing and dizziness may indicate that the pt. is experiencing an anaphylactic reaction, and immediate intervention is needed. The other information should also be reported, but do not indicate possibly life-threatening complications of omalizumab therapy. - Peak flow reading 75% of normal - Respiratory rate 24 breaths/minute - Pain at injection site

The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority?

Ineffective airway clearance r/t thick secretions in trachea and bronchi. *Airway maintenance and patency is the highest priority for all patients, especially patients with respiratory disorders. Oxygenation is the most important human need. The other diagnoses can apply once the patients airway is kept patent.

The clinic nurse makes a follow-up telephone call to a patient with asthma. The patient reports having a baseline peak flow reading of 600 L/min, and the current peak flow is 420 L/min. Which action should the nurse take first?

Instruct the patient to sue the prescribed albuterol (Ventolin HFA). *The patient's peak flow is 70% of normal, indicating a need for immediate use of short-acting beta2-adrenergic SABA medications. Assessing for correct use of medications or exposure to allergens is also appropriate, but would not address the current decrease in peak flow. Because the patient is currently in the yellow zone, hospitalization is not needed.

A patient is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2 delivery, which action by the nurse is important?

Keep the air entrainment ports clean and unobstructed. *The air entrainment ports regulate the O2 percentage delivered to the patient, so they must be unobstructed. The other options refer to the other types of O2 devices. A high O2 flow rate is needed when giving O2 by partial rebreather or nonrebreather masks. Draining O2 tubing is necessary when caring for a patient receiving mechanical ventilation. The mask can be removed or changed to a nasal cannula at a prescribed setting when the patient eats.

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first?

Listen to the patient's breath sounds *Assessment of the patient's breath sounds will help determine how effectively the patient is ventilating and whether rapid intubation may be necessary. The length of time the attack has persisted is not as important as determining the patient's status as present. Most patients having an acute attack will be unable to cooperate with an FEV measurement. It is important to know about the medications the patient is using but not as important as assessing the breath sounds.

The nurse is caring for a patient with advanced COPD who reports feeling short of breath. The nurse notes that the patients lung sounds are diminished bilaterally and the patients pulse oximetry is 91% on 2 L/min oxygen via nasal cannula. What actions will the nurse take to make the patient more comfortable?

Maintain eye contact and provide calm reassurance. Administer the ordered nebulized bronchodilator. Elevate the head of the patients bed to fully upright. *Patients who are acutely short of breath due to advanced COPD will benefit from nebulized bronchodilator medication to open the airways. Elevating the head of the bed will prevent pressure on the diaphragm from the abdominal contents. A caring demeanor with eye contact will help the patient remain calm until the medication begins to work and the shortness of breath is eased. Patients with COPD should be kept on low-flow oxygen to maintain pulse oximetry as close to 90% as possible.

The nurse is admitting a patient diagnosed with an acute exacerbation of COPD. How should the nurse determine the appropriate O2 flow rate?

Maintain the pulse oximetry level at 90% or greater. *The best way to determine the appropriate O2 flow rate is by monitoring the patient's oxygenation either by arterial blood gases (ABGs) or pulse oximetry. An O2 saturation of 90% indicates adequate blood O2 level without the danger of suppressing the respiratory drive. For patients with an exacerbation of COPD, an O2 flow rate of 2 L/min may not be adequate. Because O2 use improves survival rate in patients with COPD, there is no concern about O2 dependency. The patient's perceived dyspnea level may be affected by other factors (e.g., anxiety) besides blood O2 level.

The nurse reviews the medication administration record (MAR) for a patient having an acute asthma attack. Which medication should the nurse administer first?

Methylprednisolone (Solu-Medrol) 60 mg IV *Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly. - Ipratropium - Salmeterol

A patient who has been experiencing an asthma attack develops bradycardia and a decrease in wheezing. Which action should the nurse take first?

Notify the health care provider. *The patient's assessment indicates impending respiratory failure, and the nurse should prepare to assist with intubation and mechanical ventilation after notifying the health care provider. IV corticosteroids require several hours before having any effect on respiratory status. The patient will not be able to cough or deep breathe effectively. Documentation is not a priority at this time.

The emergency department nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective?

O2 saturation is >90%. *The goal for treatment of an asthma attack is to keep the O2 saturation about 90%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack.

A patient hospitalized with COPD is being discharged home on O2 therapy. Which instruction should the nurse include in the discharge teaching?

O2 use can improve the patient's prognosis and quality of life. *The use of home O2 improves quality of life and prognosis. Because increased dyspnea may be a symptom of an acute process such as pneumonia, the patient should notify the health care provider rather than increasing the O2 flow rate if dyspnea becomes worse. O2 can be supplied using liquid, storage tanks, or concentrators, depending on individual patient circumstances. Travel is possible using portable O2 concentrators.

Which nursing action for a patient with COPD could the nurse delegate to experienced unlicensed assistive personnel (UAP)?

Obtain O2 saturation using pulse oximetry. *UAP can obtain O2 saturation (after being trained and evaluated in the skill). The other actions require more education and a scope of practice that licensed practial/vocational nurses or registered nurses would have. - Adjust O2 to keep saturation in prescribed parameters. - Monitor for increased O2 need with exercise. - Teach the patient about safe use of O2 at home.

The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse?

Obtain an arterial blood gas to check for carbon dioxide retention. *Confusion and disorientation in a patient with severe COPD may likely be due to carbon dioxide retention. An arterial blood gas should be drawn to determine if this is the case. COPD patients should be kept on low oxygen flow rates whenever possible to avoid impeding the drive to breathe. Lowering the head of the bed will increase difficulty of breathing as the abdominal contents press on the diaphragm. A sedative will cause respiratory depression and should be avoided.

A patient with COPD has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which intervention would be most appropriate for the nurse to include in the plan of care?

Offer high-calorie protein snacks between meals and at bedtime. *Eating small amounts more frequently (as occurs) with snacking) will increase calorie intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture such as whole grains may take more energy to eat and get absorbed and lead to decreased intake. Although fruits, juices, and minerals are not contraindicated, foods high in protein are a better choice.

The nurse is caring for a patient with cor pulmonale. The nurse should monitor the patient for which expected finding?

Peripheral edema *Cor pulmonale causes clinical manifestations of right ventricular failure, such as peripheral edema. The other clinical manifestations may occur in the patient with other complications of chronic obstructive pulmonary disease but are not indicators of cor pulmonale. - Elevated temp., finger clubbing, chest pain

Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment?

Pulse oximetry reading of 92% *For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.

The home care nurse is caring for a patient who has severe COPD and home oxygen therapy. The patient tells the nurse that she feels much better after increasing the oxygen flowmeter from 2 L to 5 L/min. The patients pulse oximetry is 98%. What is the priority action of the nurse?

Reduce the oxygen flow rate until the patients pulse oximetry value is 90% - 92%. *The COPD patient should have a pulse oximetry value of approximately 90% - 92% to optimize oxygenation of tissues. High-flow oxygen may lead to respiratory suppression casued by loss of the patients drive to breathe, so the oxygen flow rate should be kept at 2 L/min whenever possible. The nurse should reduce the oxygen flow rate until the patients pulse oximetry is 90% to 92% and educate the patient about oxygen thearpy for COPD.

A patient newly diagnosed with asthma is being discharged. The nurse anticipates including which topic in the discharge teaching?

Self-administration of inhaled corticosteroids *Inhaled corticosteroids are more effective in improving asthma than any other drug and are indicated for all patients with persistent asthma. The other therapies would not typically be first-line treatments for newly diagnosed asthma.

The home health nurse is visiting a patient with COPD. Which nursing action is appropriate to implement for a nursing diagnosis of impaired breathing pattern related to anxiety?

Teach the patient how to use pursed-lip breathing. *Pursed-lip breathing techniques assist in prolonging the expiratory phase of respiration and decrease air trapping. There is no indication that the patient requires O2 therapy or an improved diet. Sedative medications should be avoided because they decrease respiratory drive.

A patient with COPD has coarse crackles throughout the lung fields and a chronic, nonproductive cough. Which nursing intervention will be most effective?

Teach the patient to use the Flutter airway clearance device. *Airway clearance devices assist with moving mucus into larger airways, where it can more easily be expectorated. The otehr actions may be appropriate for some patients with COPD, but they are not indicated for this patient's problem of thick mucus secretions.

The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention?

The patient has stridor with wheezes heard in all lung fields. The patient has become confused and mildly disoriented. The patient is unable to count out loud past 15 after a deep breath. The patients sputum has turned from yellow to greenish-brown. *A patient who is unable to count out loud past 15 after a deep breath is indicative of poor airflow through the airways, which must be addressed promptly. Greenish-brown sputum may indicate pneumonia requiring antibiotic treatment. Stridor and wheezes is indicative of an acute asthma attack. Confusion and disorientation in a patient with COPD may indicate retention of carbon dioxide.

The nurse teaches a patient about pursed-lip breathing. Which action by the patient would indicate to the nurse that further teaching is needed?

The patient puffs up the cheeks while exhaling. *The patient should relax the facial muscles without puffing the cheeks while doing pursed-lip breathing. The other actions by the patient indicate a good understanding of pursed-lip breathing.

The nurse interviews a patient with a new diagnosis of COPD. Which information is most specific in confirming a diagnosis of chronic bronchitis?

The patient reports a productive cough for 3 months every winter. *A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3 months for at least 2 consecutive years. There is no family tendency for chronic bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking history does not confirm the diagnosis.

The nurse takes an admission history on a patient with possible asthma who has new-onset wheezing and shortness of breath. Which information may indicate a need for a change in therapy?

The patient takes propranolol (Inderal) for hypertension. *Beta-blockers such as propranolol can cause bronchospasm in some patients with asthma. The other information will be documented in the health history but does not indicate a need for a change in therapy.

The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful?

The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone. *Readings in the yellow zone indicate a decrease in peak flow. The patient should use short-acting beta2-adrenergic (SABA) medications. Readings in the green zone indicate good asthma control. The patient should exhale quickly and forcefully through the peak flow meter mouthpiece to obtain the readings. Readings in the red zone do not indicate good peak flow, and the patient should take fast-acting bronchodilator and call the health care provider for further instructions. Singulair is not indicated for acute attacks but rather is used for maintenance therapy.

The nurse completes an admission assessment on a patient with asthma. Which information given by patient indicates a need for a change in therapy?

The patient's only medications are albuterol (Ventolin HFAI) and salmetrol (Serevent). *Long-acting beta2-agonists should be used only in patients who also are using an inhaled corticosteroid for long-term control. Salmeterol should not be used as the first-line therapy for long-term control. Using a bronchodilator before exercise is appropriate. The other information given by the patient requires further assessment by the nurse but is not unusual for a patient with asthma.

Which information will the nurse include in the asthma teaching plan for a patient being discharged?

Tremors are an expected side effect of rapidly acting bronchdilators. *Tremors are a common side effect of short-acting beta2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers.

The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action?

Use of accessory muscles in breathing. *Use of accessory muscle indicates that the patient is experiencing respiratory distress, and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required.

The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care?

Walk 15 - 20 minutes a day at least 3 times/week. *Encourage the patient to walk 15 to 20 minutes a day at least three times a week with gradual increase. Shortness of breath is normal with exercise and not an indication that the patient should stop. Limiting exercise to ADLs will not improve the patient's exercise tolerance. A 70-yr-old patient should have a pulse rate of 120 beats/min or less with exercise (80% of the maximal heart rate of 150 beats/min).

A patient is scheduled for spirometry. Which action should the nurse take to prepare the patient for this procedure?

Withhold bronchodilators for 6 to 12 hours before the examination. *Bronchodilators are held before spiromtery so that a baseline assessment of air function can be determined. Testing is repeated after bronchodilator use to determine whether the decrease in lung function is reversible. There is not need for the patient to be NPO. Oral corticosteroids should be held before spirometry. Rescue medications (which are bronchodilators) would not be given until after the baseline pulmonary function was assessed.

A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of COPD. The nurse should plan to teach the patient about:

alpha1-antitrypsin testing. *When COPD occurs in young patients, especially without a smoking history, a genetic deficiency in alpha1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered. There is no indication that the patient requires continuous pulse oximetry. Leukotriene modifiers would be used in aptients with asthma, not with COPD.

The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. The results for which patient will require the most rapid action by the nurse?

pH 7.28, PaCO2 50 mmHg, and PaO2 58 mmHg *The pH, PaCO2, and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis.