Exam 4: Week 14

Methylxanthine indication

(Aminophyline, theophylline) Dilates the bronchioles

Nursing considerations for methylxanthines

(Aminophylline, theophylline) Monitor for AE: GI distress, sleeplessness, hyperactivity, tachycardia Administer with food, avoid caffeine, check HR, crosses placenta

Adrenergic and sympathomimetics indication

(Epinephrine, albuterol, salbutamol) Dilates the bronchioles

Anticholinergic indication for COPD

(Ipratropium) Dilates the bronchioles

Asthma pt teaching

- Identify and avoid triggers - Proper inhalation technique - Perform peak flow monitoring - Create action plan - Learn when and how to seek assistance

Normal PaO2

80-100 mmHg

Optimum SpO2 for COPD

88-92%

Asthma nursing interventions

Administer bronchodilators, administer fluids and humidification, education, ABGs, ventilator patterns, CPAP, BiPAP

What COPD medications should you closely monitor for tachycardia?

Adrenergic- Epinephrine, albuterol, salbutamol Methylxanthine- Aminophyline, theophylline

Short acting beta agonist

Albuterol

At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-Medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer: albuterol (Proventil). morphine. alprazolam (Xanax). propranolol (Inderal).

Albuterol (Proventil)

Common triggers for asthma

Allergens, exercise, foods/drinks, beta blockers, infection, allergic reaction, emotional stress, reflex esophagitis

What genetic abnormality leads to COPD?

Alpha1-antitrypsin deficiency

The nurse at the beginning of the evening shift receives a report at 1900 on the following patients. Which patient would the nurse assess first? An 85 year old with COPD with wheezing and an O2 saturation of 89% on 2 L of oxygen A 74 year old with chronic bronchitis who has BP 128/58, HR 104, and R 26 An 86 year old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office A 62 year old with emphysema who has 300 mL of intravenous fluid remaining

An 86 year old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office

Corticosteroids MOA and considerations

Anti-inflammatory Monitor glucose

Budesonide MOA

Anti-inflammatory. Used long term to prevent and reverse symptoms of inflammation.

A 55-year-old client is scheduled for spirometry testing for evaluation of chronic obstructive pulmonary disease (COPD). The nurse Tells the client that arterial blood gas is performed after spirometry testing States that various blood tests must also be done Asks the client, "What are your allergies?" Explains to the client not to eat or drink before the spirometry test

Asks the client, "What are your allergies?"

Airways affected: Asthma Emphysema Bronchitis CF

Asthma: upper Emphysema: lower Bronchitis: upper CF: all

A client's spouse states that she is worried about her husband because he appears to be breathing "really hard." The nurse performs a respiratory assessment. What findings would indicate a need for further interventions? Pale, paper-thin skin, O2 at 2L/min via nasal cannula BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 °F (38.5 °C) BP 122/82, HR 102, R 24, noted barrel chest, temperature 98.4 °F (36.9 °C) Client states, "It always seems like I just can't catch my breath."

BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 °F (38.5 °C)

Examples of inhaled corticosteroids

Beclomethasone, budesonide, fluticasone

What type of COPD leads to Cor pulmonale?

Both bronchitis and emphysema can lead to cor pulmonale. More common in chronic bronchitis.

Which of the following occupy space in the thorax, but do not contribute to ventilation? Lung parenchyma Bullae Alveoli Mast cells

Bullae

Respiratory drive is triggered by changes in levels of ___.

CO2. This is called a hypercapnic response.

Pulmonary bleb

Cavity in the lung much like a balloon; may rupture to create a pneumothorax Caused by emphysema

CF treatment

Chest physical therapy Pulmonary rehab PAP with PEP Avoid crowds Nutritional counseling Oxygen Feeding tube Transplant Pharm regimen

Two types of COPD

Chronic bronchitis and emphysema

A nurse is caring for a client with COPD. While reviewing breathing exercises, the nurse instructs the client to breathe in slowly through the nose, taking in a normal breath. Then the nurse asks the client to pucker his lips as if preparing to whistle. Finally, the client is told to exhale slowly and gently through the puckered lips. The nurse teaches the client this breathing exercise to accomplish which goals? Select all that apply. Control the rate and depth of respirations Prevent airway collapse Condition the inspiratory muscles Strengthen the diaphragm Release air trapped in the lungs

Control the rate and depth of respirations Prevent airway collapse Release air trapped in the lungs

A client has asthma. Which of the following medications is a commonly prescribed mast cell stabilizer used for asthma? Albuterol Budesonide Cromolyn sodium Theophylline

Cromolyn sodium

A client is being admitted to the medical-surgical unit for the treatment of an exacerbation of acute asthma. Which medication is contraindicated in the treatment of asthma exacerbations? Levalbuterol HFA Albuterol Ipratropium Cromolyn sodium

Cromolyn sodium

When to use asthma controllers

Daily basis to prevent and control bronchospasm

Respiratory rate in COPD patients is controlled by

Decrease in O2 Not increase in CO2

Goal of pharmacologic therapy for COPD

Decrease inflammation and dilate the airway

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath and fatigue for 1 hour after awakening in the morning. Which of the following statements by the nurse would best help with the client's shortness of breath and fatigue? "Drink fluids upon arising from bed." "Raise your arms over your head." "Delay self-care activities for 1 hour." "Sit in a chair whenever doing an activity."

Delay self-care activities for 1 hour

Lung sounds with COPD

Diminished sounds or wheezes.

CF medications

Dornase alfa (cough medicine), CFTR modulators, pancreatic enzymes, bronchodilators, antibiotics as needed for infections

The diagnosis of pulmonary hypertension associated with chronic obstructive pulmonary disease (COPD) is suspected when which of the following is noted? Select all that apply. Left ventricular hypertrophy Elevated plasma brain natriuretic peptide (BNP) Enlargement of central pulmonary arteries Right ventricular enlargement Dyspnea and fatigue disproportionate to pulmonary function abnormalities

Elevated plasma brain natriuretic peptide (BNP) Enlargement of central pulmonary arteries Right ventricular enlargement Dyspnea and fatigue disproportionate to pulmonary function abnormalities

What condition is this: Relies on pursed lip breathing to blow off CO2

Emphysema

What condition is this: Struggles due to strong hypercarbic drive

Emphysema

The nurse has instructed the client to use a peak flow meter. The nurse evaluates client learning as satisfactory when the client Inhales deeply and holds the breath Records in a diary the number achieved after one breath Exhales hard and fast with a single blow Sits in a straight-back chair and leans forward

Exhales hard and fast with a single blow

What is the primary cause of COPD in the US?

Exposure to tobacco smoke (80-90%)

Stage 1 COPD

FEV-1 >80% You may have no symptoms. You might be short of breath when walking fast on level ground or climbing a slight hill

Stage 3 COPD

FEV1 30-49% You may be too short of breath to leave the house. You might get breathless doing something as simple as dressing and undressing.

Stage 2 COPD

FEV1 50-79% If you're walking on level ground, you might have to stop every few minutes to catch your breath

Stage 4 COPD

FEV1 <30% You might have lung or heart failure. This can make it hard to catch your breath even when you're resting. You might hear this called end-stage COPD.

A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client Has a respiratory rate of 28 breaths/minute Reports shortness of breath Has wheezes in the right lung lobes Cannot perform activities of daily living

Has wheezes in the right lung lobes

Nutrition for CF

High fat, high protein Extra salt intake Pancreatic enzymes taken with every meal

Patho results of asthma

Hyperresponsiveness Mucosal edema Mucus production

A physician orders metaproterenol by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication? "I need to call the physician right away if I feel my heart beating fast after using the drug." "I need to hold my breath as long as possible after I take a deep inhalation." "I should use this inhaler whenever I get short of breath." "I can stop using this drug when I begin to feel better."

I need to hold my breath as long as possible after I take a deep inhalation

A nurse notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 65% for a patient with COPD. What stage should the nurse document the patient is in? IV II III I

II

A nurse is assisting a client with mild chronic obstructive pulmonary disease (COPD) to set a goal related to the condition. Which of the following is an appropriate goal for this client? Relieve shortness of breath to a level as close as possible to tolerable. Continue with current level of mobility at home. Increase walking distance around a city block without shortness of breath. Maintain activity level of walking to the mailbox.

Increase walking distance around a city block without shortness of breath

Asthma preventers

Inhaled corticosteroids: Prednisone, solu-medrol, beclomethasone, budesonide Leukotriene receptor agonist: Montelukast

Roflumilast AE

Insomnia, weight loss, depression

A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should: administer pain medication as ordered. instruct the client to drink at least 2 L of fluid daily. maintain the client on bed rest. administer anxiolytics, as ordered, to control anxiety.

Instruct the client to drink at least 2 L of fluid daily

A nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? It increases inspiratory muscle strength. It decreases use of accessory breathing muscles. It helps prevent early airway collapse. It prolongs the inspiratory phase of respiration.

It helps prevent early airway collapse

Pink puffers vs. blue bloaters

PP: Barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe. Person works harder to breathe but the oxygen taken in is adequate to oxygenate the tissues. BB: Insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart failure (Cor Pulmonale)

Signs and symptoms of emphysema

Pink puffers, CO2 retention, dyspnea, pursed lip breathers, distant/quiet breath sounds, wheezes, barrel chest, pulmonary blebs on radiograph, orthopnea, prolonged expiratory time, anxious, thin, use of accessory muscles

If Bullae rupture, it can cause a ___

Pneumothorax

The client is prescribed albuterol 2 puffs as a metered-dose inhaler. Which action by the client demonstrates understanding of administration for this medication? Holds the breath for 5 seconds after administering the medication Carefully holds the inhaler upright without shaking it Positions the inhaler 2 finger widths away from the lips Immediately repeats the second puff after the first puff

Positions inhaler 2 finger widths away from the lips

Goals of CF treatment

Preventing and controlling infections in the lungs Removing and loosening mucus Treating and preventing intestinal blockage Providing adequate nutrition

PFT (pulmonary function test)

Purpose: Assesses respiratory function & determine extent of dysfunction. (FEV1) During: Uses mouthpiece to blow as hard as they can for 8 seconds

Pathophysiology of emphysema

Reduced gas exchange surface area Increased air trapping (increased AP diameter) Decreased capillary network Increased O2 consumption

Diaphragmatic breathing indication

Reduces RR, increases alveolar ventilation and expels more air during expiration

Asthma preventers MOA

Reduces inflammation and prevents issues

Roflumilast indication

Reduces lung inflammation in severe COPD

pH: 7.37 CO2: 63 PO2: 58 HCO3: 35 SaO2: 89%

Respiratory acidosis fully compensated.

Chronic bronchitis can lead to

Right-sided heart failure (Bilateral pedal edema, increased JVD)

Why should you rinse your mouth after corticosteroid use?

Rinse mouth to avoid thrush.

Asthma relievers

SABAs: Beta2 adrenergic agonists like albuterol and salbutamol Anticholinergic: Ipratropium

Long acting beta agonist

Salmeterol

Cor pulmonale

Serious cardiac disease associated with chronic lung disorders. Right ventricular hypertrophy. Increased pressure in the pulmonary artery.

COPD PaO2

Should be at least 60 mmHg

Pursed lip breathing is beneficial to

Slow expiration, prevent collapse of small airways, control rate and depth of respiration

80-90% of COPD is caused by ___

Smoking tobacco

Risk factors of emphysema

Smoking, environmental/occupational exposure, genetics

Stages of COPD

Stage 1: Mild. FEV1 >80% Stage 2: Moderate. FEV 50-79% Stage 3: Severe. FEV 30-49% Stage 4: Very severe. FEV <30%

Bullae tx

Surgically treated with a resection, chest tube

Typical posture of a person with COPD

Tend to lean forward using accessory muscles to breathe May be a result of bronchospasm

A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. This change occurred because:

The airways are so swollen that no air can get through

A client is receiving theophylline for long-term control and prevention of asthma symptoms. Client education related to this medication will include 1- the importance of blood tests to monitor serum concentrations. 2- taking the medication at least 1 hour prior to meals. 3- monitoring liver function studies as prescribed. 4- development of hyperkalemia.

The importance of blood tests to monitor serum concentrations

A commonly prescribed methylxanthine used as a bronchodilator is which of the following? Levalbuterol Albuterol Terbutaline Theophylline

Theophylline

What asthma medication do you need to monitor serum values?

Theophylline

Causes of COPD

Tobacco smoke (80-90% of COPD) Passive smoking Occupational exposure (firefighter, coalminers) Air pollution Genetic abnormalities (Alpha1-antitrypsin deficiency)

COPD positioning

Tripoding: Sitting in chair with feet spread shoulder width apart and leaning forward with elbows on knees. Arms and hands are relaxed. Leaning forward

T or F: Bronchoconstriction can be reversed in asthma

True.

A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when he: wants the head of the bed raised to a 90-degree level. has a pulse oximetry reading of 93%. uses the sternocleidomastoid muscles. sits in tripod position.

Uses the sternocleidomastoid muscles

Forced expiratory volume

Volume of air expired in 1 second during maximal expiration

CF pharmacology indications

- Target gene mutation - Abx to treat lung infections - Anti-inflammatory to lessen airway swelling - Mucus thinning drugs - Bronchodilators to keep airway open - Oral pancreatic enzymes for nutrition - Stool softeners - Acid reducing medications - Specific drugs for diabetes and liver disease

Chronic bronchitis

-A condition in which the bronchi in the lungs are constantly swollen and clogged with mucus -Alveoli become damaged, fibroses, and alveolar macrophage function diminishes.

Asthma Action Plan: Yellow Zone

-Peak flow 50%-79% predicted -Add quick-relief medicine (albuterol) and oral corticosteroid (beclomethasone)

Asthma Action Plan: Red Zone

-Peak flow <50% predicted -Take SABAs and oral corticosteroid -Call 911

Asthma action plan: green zone

-Peak flow >80% predicted -Take long term control medicine and anti-inflammatory medicine daily

If a patient is prescribed montelukast, when should they take the medication?

1 hr before meals or 2 hrs after

T or F: Clear breath sounds means adequate oxygenation

False.

T or F: Blebs usually have intense symptoms

False. They usually have no symptoms.

When to use asthma relievers

For acute attacks. Quickly dilates bronchial airway.

COPD interventions

Fowlers Respiratory tx: beta agonists, anticholinergics, adrenergic, sympathomimetics Mech. soft diet Hydrate (3L/day) Smoking cessation Lowest FiO2 to prevent CO2 retention (O2: 88-92%) Monitor s/s FVE Maintain a PaO2 between 55-60 Baseline ABGs Teach pursed lip breathing and diaphragmatic breathing and tripoding Administer bronchodilators and anti-inflammatory agents

CF pathophysiology

Genetic mutation of a gene causing dysfunction in the CFTR which normally transports chloride ions. Impacts the cells that create mucus, sweat and digestive juices. This causes thick secretions in the lungs, pancreas, liver, intestine and reproductive tract. Thick mucus leads to bronchial mucus plugs, inflammation and damaged bronchioles.

A client with chronic obstructive pulmonary disease tells a nurse that he feels short of breath. The client's respiratory rate is 36 breaths/minute and the nurse auscultates diffuse wheezes. His arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer an ordered nebulizer treatment. The therapist says, "I have several more nebulizer treatments to do on the unit where I am now. As soon as I'm finished, I'll come and assess the client." The nurse's most appropriate action is to: administer the treatment by metered-dose inhaler. give the nebulizer treatment herself. notify the primary physician immediately. stay with the client until the therapist arrives.

Give the nebulizer treatment herself

Chest physical therapy (CPT)

Gravity-assisted bronchial drainage with techniques for secretion removal and breathing techniques.

Bronchodilators for COPD

Key for symptom management.

Normal vs. COPD AP diameter

Normal- 1:2 Emphysema- 1:1

In COPD, the chemoreceptors are chronically exposed to carbon dioxide. Instead of having hypercapnic response driving respiratory effort, ___ drives respiratory effort.

O2. This is called hypoxic drive.

Symptoms of CF

Chronic cough and sputum production. Wheezing, crackles, rattling, rales or stridor. GI abnormalities, sinusitis, salty sweat

Chronic bronchitis pathophysiology

Chronic hypoxemia, cor pulmonale Increased bronchial wall thickness (obstructs air flow) and increased mucus production

Asthma pathophysiology

Chronic inflammatory disease of the airways Hyperresponsive bronchoconstrictor and inflammatory response to different stimuli

Peak flow meter zones

Green 80-100%: asthma under control Yellow 60-79%: asthma caution Red <60%: medical emergency

Cystic fibrosis manifestations

Growth failure, vitamin deficiency Hepatic steatosis Cholelithiasis, cirrhosis Osteoporosis, arthritis Meconium ileus, meconium peritonitis Bronchiectasis, PNA, atelectasis, cor pulmonale, excess mucus productive, reactive airway disease Pancreatitis Hypersplenism Infertility

Asthma controllers

LABAs: Salmetrol

Why would a client with COPD report feeling fatigued? Select all that apply. Lung function gradually decreases over time in clients with COPD. The client is using all expendable energy for activities of daily living (ADLs). The client is using all expendable energy just to breathe. Muscle function gradually decreases over time in clients with COPD.

Lung function gradually decreases over time in clients with COPD. The client is using all expendable energy just to breathe.

Cromolyn sodium moa

Mast cell stabilizer. Prevents the release of mast cells that would normally attract inflammatory cells

Qualifications for long term oxygen therapy

Reserved for those who have a PaO2 <55 mmHg or evidence of tissue hypoxia, RHF, decreased LOC, or edema

For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? Keeping the client in semi-Fowler's position Encouraging the client to drink three glasses of fluid daily Using a Venturi mask to deliver oxygen as ordered Administering a sedative as ordered

Using a venture mask to deliver oxygen as ordered

A client with cystic fibrosis is admitted to the hospital with pneumonia. When should the nurse administer the pancreatic enzymes that the client has been prescribed? Three times a day regardless of meal time After meals and at bedtime With meals Before meals

With meals

Three primary symptoms of COPD

Chronic cough, sputum production and dyspnea

Emphysema ABGs

Compensated respiratory acidosis

Nursing implications of adrenergic and sympathomimetics

(Epinephrine, albuterol, salbutamol) Monitor for AE: tachycardia, anxiety, urine retention Instruct proper inhaler use, sleep disturbances

Nursing considerations for anticholinergics

(Ipratropium) Monitor AE: Dry mouth, blurred vision, cough Do not exceed 12 doses in 24 hours

Indication for corticosteroids in COPD

(Prednisone, solu-medrol, beclomethasone, budesonide) Anti-inflammatory.

Nursing considerations for corticosteroids

(Prednisone, solumedrol, beclomethasone, budesonide) Monitor AE: Cardiac dysrhythmias, insomnia, hyperglycemia Instruct proper inhaler use, endocrine issues, encourage oral care after use

Emphysema

-Abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli -Decreased elasticity in the alveoli. Scar tissue formation over time, narrowing airways. -Decreased alveolar surface area increases in "dead space," impaired oxygen diffusion. Air trapping.

MDI administration (9 steps)

1. Remove the cap, hold inhaler upright 2. Shake the inhaler 3. Tilt head back slightly and breathe out slowly 4. Position inhaler 1-2 inches from mouth 5. Breathe in slowly 6. Hold breath for 10 seconds 7. Repeat puffs. 15-30 seconds between puffs. 8. Apply cap 9. Rinse mouth after inhalation when using corticosteroid MDI

Risk factors for asthma

Family history Exposure to pollution

Common inhaler combinations

Fluticasone + salmeterol Ipratropium + albuterol

Hypoxic drive

Form of respiratory drive in which the body uses oxygen chemoreceptors instead of carbon dioxide receptors to regulate the respiratory cycle. Seen in patients with COPD.

Chronic bronchitis signs and symptoms

Generalized cyanosis, "blue bloaters", right sided heart failure, JVD, crackles, expiratory wheezes, cool dusty to cyanotic, sputum production, respiratory acidosis, hypercapnia, tachypnea, clubbing, cough, use of accessory muscles to breath

What COPD medication can cause dry mouth, blurry vision and a cough?

Anticholinergic- Ipratropium.

What condition is this: A form of COPD that does not struggle due to loss of hypercarbic drive

Chronic bronchitis

What condition is this: Chronic hypoxia leads to a dusky or cyanotic color.

Chronic bronchitis

What condition is this: Diagnosis made if chronic sputum with cough daily for >3 months for 2 consecutive years

Chronic bronchitis

What condition is this: A condition in which the lungs are constantly swollen, inflamed and clogged with mucus. The excess mucus causes a chronic cough.

Chronic bronchitis.

COPD

Chronic Obstructive Pulmonary Disease Slowly progressive inflammatory respiratory disease of airflow obstruction

COPD meds

Corticosteroids MDIs: Bronchodilators, anticholinergics, combination agents

Chronic bronchitis diagnosis

Cough and sputum production for at least 3 months in each of 2 consecutive years

Asthma signs and symptoms

Cough, night cough, dyspnea, wheezing, generalized chest tightness, expiration requires effort, hypoxemia, diaphoresis, tachycardia

What condition is this: Deflated, damaged alveoli leads to blebs and bullae.

Emphysema.

What condition is this: Overinflated airways lead to loss of elasticity. Inflammation narrows airways and air sacs eventually collapse.

Emphysema.

Barrel chest is associated with

Emphysema. Pink puffers

A client has chronic obstructive pulmonary disease (COPD) and is exhibiting shallow respirations of 32 breaths per minute and a pulse oximetry of 93% despite receiving nasal oxygen at 2 L/minute. What action should the nurse take? Encourage the client to take deep breaths. Increase the flow of oxygen. Teach the client to perform upper chest breaths. Encourage the client to exhale slowly against pursed lips

Encourage the client to exhale slowly against pursed lips

When to use humidification

If administering greater than 4L/min

Which measure may increase complications for a client with COPD? Increased oxygen supply Administration of antitussive agents Decreased oxygen supply Administration of antibiotics

Increased oxygen supply

Bullae

Large blebs formed together

A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess? Heart rate Lung sounds Respiratory rate Skin color

Lung sounds

What medication should you ensure proper oral care after use in COPD patients?

MDIs with corticosteroids should always be proceeded with good oral care.

COPD diet

Mechanical soft, high-calorie, low-carbohydrate, high-fat, small frequent feedings

A nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Choose all that apply. Mucus secretions that block airways Inflamed airways that obstruct airflow Decreased numbers of goblet cells Overinflated alveoli that impair gas exchange Dry airways that obstruct airflow

Mucus secretions that block airways Inflamed airways that obstruct airflow Overinflated alveoli that impair gas exchange