Med-Surg Ch. 33 Obstructive Pulmonary Disease: Nursing Management

Seasonal influenze (flu) - risk groups

1. age 65 and older 2. young children 3. people w/underlying health conditions (COPD, HF) 4. immunocompromised

What are the complications of asthma?

1. airway obstruction 2. asphyxia 3. exhaustion 4. dehydration 5. atelectasis 6. pneumothorax 7. mediastinal & subcutaneous emphysema 8. cor pulmonale 9. infection 10. pneumonia 11. status asthmaticus

The nurse is awaiting the arrival of a client from the ED who is being admitted with COPD with cor pulmonale. In caring for this client, the nurse should be alert to which of the following signs and symptoms of right-sided heart failure (select all that apply)? 1. Jugular venous distension 2. Hepatomegaly 3. Dyspnea 4. Crackles 5. Tachycardia

1, 2. Rationale: Signs and symptoms of right-sided heart failure include jugular venous distension and hepatomegaly. Dyspnea, crackles, and tachycardia are signs of left-sided heart failure.

Theophylline tablets are prescribed for a client with COPD. A nurse instructs the client about the medication. Which of the following nursing statements would not be a component of the teaching plan? 1. Take the medication in an empty stomach 2. Take the medication with food 3. Continue to take the medication even if you are feeling better 4. Periodic blood levels will need to be obtained

1. Rationale: The medication should be administered with food, such as milk and crackers to prevent gastrointestinal (GI) irritation. Options 2, 3, 4 are appropriate instructions regarding the use of this medication.

Which of the following is true concerning CF? 1. Tobramycin (TOBI) is an aerosolized medication and the best antibiotic used to treat lower respiratory tract infections in clients with CF. 2. There are no regular vaccinations against pneumococcal infection associated with prevention for clients with CF. 3. Clients with CF do not typically develop cancer disorders as a result of their respiratory disorder. 4. Surgical lung transplantation is not currently a definitive treatment for advanced CF.

1. Rationale: Tobramycin (TOBI) is an aerosolized medication and the best antibiotic used to treat lower respiratory tract infections in clients with CF. The other three responses are false.

What is the criteria for referring a patient for a lung transplant?

1. FEV1 less than 35% of predicted 2. PaO2 less than 55 mmHg 3. PaCo2 greater than 50 mmHg 4. secondary pulmonary HTN

What are the symptoms of COPD?

1. SOB 2. abnormal temperature, pulse, and respirations 3. abnormal breath sounds 4. abnormal breathing pattern 5. dyspnea 6. cough 7. wheezing 8. sputum production 9. abnormal BP and weight 10. peripheral edema 11. jugular vein distention 12. cyanosis 13. clubbing of fingers 14. restlessness memory impairment/confusion 15. pulmonary HTN 16. cor pulmonale 17. polycythemia (elevated RBCs) 18. respiratory infection/ respiratory failure

Treatment for cystic fibrosis

1. antibiotics for infections in the airways 2. N-acetylcysteine (Mucomyst) - decrease sputum & promote excretion 3. dornase alfa (Pulmozyme) - decrease sputum, alleviate airway obstruction, improve pulmonary function 4. ibuprofen *regular vaccination against pneumococcal infection & annual flu vaccine*

Treatment for the flu

1. bedrest 2. increased fluid intake 3. high-calorie nutritious diet 4. analgesics 5. antipyretics 6. antibiotics if bacterial infection 7. cough mouth & nose when coughing 8. wash hands frequently *get immunized*

What medications are commonly used with COPD?

1. beta-adrenergic agonists 2. anticholinergics 3. corticosteroids 4. methylxanthines 5. bronchodilators *annual flu shot and a pneumococcal vaccine*

What happens to the body 8 hours after smoking cessation?

1. carbon monoxide levels drop 2. oxygen levels increase to normal

What are the symptoms of cystic fibrosis?

1. chronic/recurrent productive cough w/sputum 2. wheezine 3. dyspnea 4. recurrent infections 5. bronchiectasis 6. acute/chronic bronchitis 7. pneumonia 8. atelectasis 9. sinusitis 10. nasal polyps 11. clubbing 12. abdominal problems 13. rectal prolapse 14. renal disease 15. diabetes 16. recurrent pancreatitis

What happens to the body 2-3 weeks after smoking cessation?

1. circulation improves 2. walking becomes easier 3. lung function improves up to 30%

What are the three primary symptoms of COPD?

1. cough 2. sputum production 3. dyspnea *these symptoms and exercise tolerance worsen over time*

What happens to the body 1-9 months after smoking cessation?

1. coughing, sinus congestion, fatigue, and SOB decrease 2. cilia in the lungs regenerate, improving handling of secretions 3. energy increases

What is the treatment for asthma?

1. daily inhaled corticosteroids 2. long-acting inhaled beta2-adrenergic agonist 3. inhaled mast cell stabilizers 4. leukotriene modifiers 5. short-acting inhalers (albuterol)

Patient teaching for COPD

1. disease 2. smoking cessation 3. anxiety reduction 4. relaxation techniques 5. travel restrictions 6. energy conservation

What are the symptoms of the flu?

1. fever 2. malaise 3. H/A 4. nonproductive cough 5. pharyngitis 6. rhinitis 7. otitis media 8. N/V Auscultation 1. coarse rhonchi 2. wheezes 3. prolonged expiration

Nutrition in cystic fibrosis

1. give pancreatic enzymes w/meals and snacks 2. monitor stools for bulky, foul-smelling stool (indicates malabsorption) 3. maintain a well-balanced, increased calorie, high-protein diet; only 80-85% of nutrients are absorbed 4. give adequate salt 5. administer fat-soluble vitamins A, D, E, and K 6. give supplemental iron 7. give tube feedings & total parenteral nutrition as needed 8. monitor daily weight

What are the nursing diagnoses for COPD?

1. impaired gas exchange r/t airflow obstruction from collapsed alveoli and narrow bronchioles 2. anxiety r/t breathlessness, ineffective coping, and reduced socialization 3. ineffective breathing pattern r/t increased mucous production and air trapping 4. activity intolerance r/t fatigue and hypoxemia 5. nutrition imbalance, less than body requirements, r/t increased energy expenditure from breathing difficulties

What are the nursing diagnoses for asthma?

1. ineffective airway clearance r/t bronchospasm, mucosal edema, and increased mucous production 2. impaired gas exchange r/t bronchospasm 3. ineffective breathing pattern r/t bronchospasm 4. activity intolerance r/t hypoxemia and fatigue 5. anxiety r/t illness, loss of control and nursing and medical interventions

What are the nursing diagnoses for cystic fibrosis?

1. ineffective airway clearance r/t thick, tenacious mucus in airway 2. impaired gas exchange r/t airway obstruction 3. nutritional imbalance, less than body requirements, and malabsorption of fats in intestine, r/t absence of pancreatic enzymes 4. deficient knowledge regarding self-care and medication management

What are the indications for noninvasive ventilator support with a mask or invasive intubation with mechanical ventilation?

1. labored breathing w/RR over 30 2. restlessness 3. severe hypoxia 4. moderate to severe respiratory acidosis 5. decreased LOC 6. respiratory arrest 7. shock 8. sepsis 9. metabolic abnormalities

What happens to the body 10 years after smoking cessation?

1. lung cancer death rate corresponds to that of nonsmokers 2. precancerous cells are replaced 3. risk for cancer of mouth, bladder, throat, kidney, and pancreas decreases

What happens to the body 48 hours after smoking cessation?

1. nerve endings repair 2. ability to sell and taste is enhanced

What are the complications of COPD?

1. pneumonia 2. atelectasis (complete or partial collapse of a lung or section of lung) 3. pneumothorax 4. cor pulmonale 5. chronic hypoxemia (leads to pulmonary HTN)

Directions for using a metered dose inhaler (MDI)

1. remove cap and hold inhaler upright 2. shake inhaler 3. tilt head back slightly & breathe out slowly 4. position inhaler 1-2 inches from open mouth or use a spacer (place lips around spacer) 5. breath in slowly as you press down on inhaler 6. continue breathing as medication is released 7. breathe in slow and deep for 3-5 seconds 8. hold breath for 8-10 seconds then release 9. repeat as necessary w/1-2 minutes between puffs *rinse mouth after inhaled corticosteroids*

What happens to the body 5 years after smoking cessation?

1. risk for lung cancer drops by half 2. stroke risk lessens 3. risk for cancer of the mouth and throat is half that of a smoker

What tests are used to diagnose COPD?

1. spirometry 2. CXR 3. thoracic CT 4. ECG 5. ABGs 6. CBC

What are the symptoms of asthma?

1. wheezing 2. breathlessness 3. chest tightness 4. coughing 5. breathlessness 6. increased respiration 7. tachycardia 8. pulsus paradoxus 9. chest deformity

A client with COPD who weighs 143 pounds is to receive 30 mg/kg of methylprednisolone (Medrol) IV. What is the correct dose in milligrams that the client should receive?

1950 mg convert the client's weight from pounds to kilograms by dividing 143 pounds by 2.2 kg. This equals 65 kg. Next multiply the 65 kg by 25 mcg. This equals 1950 mg. 143 lb/2.2 kg = 65 kg. 65 kg + 25 mcg = 1950 mg

A client with asthma is treated for acute exacerbation in the ED. A nurse reports which of the following, knowing that it is not an indication that the condition is improving? 1. Increased wheezing 2. Decreased wheezing 3. Warm, dry skin 4. A pulse rate of 80 beats per minute

2. Rationale: Decreased wheezing in a client with asthma may be incorrectly interpreted as a positive sign when, in fact, it may signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing may actually signal that the child's condition is improving. The normal pulse rate is 60 to 80 beats per minute. Warm, dry skin indicates improvement in condition, as the client is normally diaphoretic during exacerbations.

A nurse is teaching a client about the use of a respiratory inhaler. Which of the following would not be a component of the teaching plan? 1. Remove the cap and shake the inhaler 2. Press the canister down with your finger as you breathe in 3. Inhale the mist and quickly exhale 4. Wait one minute between puffs if more than one puff is prescribed

3. Rationale: The client should be instructed to hold his or her breath at least 5 to 10 seconds before exhaling the mist. Options 1, 2, and 4 are accurate instructions regarding the use of the inhaler.

Which of the following is true of the pathophysiology of asthma? 1. Asthma occurs in three phases: the early phase, the intermediate phase, and the late phase. 2. The late phase begins within one to two days of exposure to the trigger and may last for up to approximately a week. 3. The development of an IgE is a strong predisposing factor for developing asthma. 4. Step 1 is the most severe classification category of acute asthma.

3. Rationale: The development of an IgE is a strong predisposing factor for developing asthma. The other responses are false.

Low-flow oxygen therapy is prescribed for the client with COPD. What is the most essential action for the nurse to initiate? 1. Anticipate the need for humidification 2. Notify the health care provider that this order is contraindicated 3. Place the client in high-Fowler's position 4. Schedule nursing care to allow frequent observations of the client

4. Rationale: In a client with COPD, the stimulus to breathe is low oxygen levels. Frequent nursing observations are necessary to see how the client tolerates low-flow oxygen administration. 1 is incorrect. Humidification is necessary, but this is not the most important nursing intervention. 2 is incorrect, because client's with COPD and hypoxemia need oxygen. 3 is incorrect, because the client with COPD will probably need to be placed in high-Fowler's position, but this is not the most important nursing intervention.

A sweat test is performed on a child with a suspected diagnosis of CF. The nurse reviews the test results and determines that which of the following is a positive test result for CF? 1. Chloride level of 20 mEq/L 2. Chloride level of 30 mEq/L 3. Chloride level of 40 mEq/L 4. Chloride level of 70 mEq/L

4. Rationale: In a sweat test, sweating is stimulated on the child's forearm with pilocarpine, the sample is collected on absorbent material, and the amounts of sodium and chloride are measured. A chloride level greater than 60 mEq/L is considered to be a positive test result. A chloride level of 40 mEq/L is suggestive of cystic fibrosis (CF) and requires a repeat test.

A nurse instructs a client to use pursed-lip breathing. The client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination

4. Rationale: Pursed-lip breathing facilitates maximal expiration for client's with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purpose of this breathing.

What is pursed-lip breathing?

breathe in slowly through the nose, hold for a count of three, purse the lips as if whistling, exhale slowly for six slow counts *continue until dyspnea subsides*

What is asthma?

chronic inflammatory disorder characterized by episodic exacerbations of acute inflammation of the airways

Why is pursed-lip breathing used in COPD?

helps prevent or reduce the air trapped in the lungs of patients w/COPD also promotes relaxation

What is chronic obstructive pulmonary disease (COPD)?

inflammatory respiratory disease, largely caused by exposure to lung irritants characterized by a progressive and incompletely reversible airflow obstruction *chronic bronchitis & emphysema are not a part of COPD*

What is cystic fibrosis?

inherited, autosomal recessive, chronic, progressive, and frequently fatal disease of the body's exocrine mucus-producing glands that primarily affects the respiratory, digestive, and intestinal systems and pancreas *leads to lung infections, poor digestion, and poor food absorption*

What is the only definitive treatment for advance cystic fibrosis?

lung transplant

Surgery for COPD

not frequently used 1. lung volume reduction surgery (LVRS) to improve dyspnea, diaphragmatic function, airflow, & exercise capacity 2. bullectomy - removes bullae (enlarged airspaces that don't contriibute to ventilation) - helps reduce dyspnea and improves lung function 3. single or double lung transplant

Oxygen therapy for COPD

often induced in stage III indications - PaO2 below 55 mmhg or SaO2 below 88%; evidence of tissue hypoxia & organ damage oxygen titrated to keep SpO2 above 90%

How is asthma diagnosed?

pulmonary function test

What happens to the body 24 hours after smoking cessation?

risk for MI begins to decrease

What happens to the body 2 years after smoking cessation?

risk for coronary hear disease equals that of those who never smoked

What happens to the body 15 years after smoking cessation?

risk for coronary heart disease equals that of a nonsmoker

What happens to the body 1 year after smoking cessation?

risk for coronary heart disease is half that of a smoker

What is status asthmaticus?

severe asthma attack with bronchospasm that doesn't respond to conventional therapy

What test is used to confirm COPD?

spirometry

What happens to the body 20 minutes after smoking cessation?

temperature, pulse, and BP return to normal