109- TEST 2- Acute and Chronic respiratory

oxygen therapy

Early indication for nursing interventions. • Complementary tool for use during vital signs assessment & respiratory assessment. • Interpretation of the oxygen saturation results and necessary interventions are the responsibility of the nurse. goal O2 is usually administered to treat hypoxemia caused by a variety of problems such as COPD, shock, pulmonary emboli, and many others. Goals for O2 therapy are to keep the SaO2 greater than 90% during rest, sleep, and exertion or the PaO2 greater than 60 mm Hg PaO2 < 60 SaO2 (pulse ox) > 90 during rest, sleep and exercise promoting oxygen Maintain a patent airway. • Encourage ambulation. • Maintain or improve pulmonary ventilation and oxygenation. • Position the client to allow for chest expansion. • Provide frequent changes in position. • Give pain medications as needed. • Avoid use of flammable, votile materials • Ground electrical equipment • Know location(s) of fire extinguishers • Ensure electric devices are functional Nursing CAre Assess nasal & oral mucousa membranes • Inspect skin around clients ears, nares, and face. Note pressure points for signs of irritation. • Provide mouth care every 8 hours • Position tubing to avoid traction • Pad tubing in areas that put pressure on the skin • Lubricate the client's nostrils, face, and lips with nonpetroleum cream pulse oximeter • A noninvasive device that measures a client's arterial blood oxygen saturation. • Detects presence of hypoxemia before visible signs develop • Measures SaO2 by means of a sensor. • Normal SaO2 is 95%-100%. The nurse knows that the primary function of the alveoli is to 1. Carry out gas exchange. 2. Store oxygen. 3. Regulate tidal volume. 4. Produce hemoglobin. The structure that is responsible for returning oxygenated blood to the heart is the 1. Pulmonary artery. 2. Pulmonary vein. 3. Superior vena cava. 4. Inferior vena cava. Face Tent • To provide oxygen when a mask is poorly tolerated • Provides varying concentrations of oxygen • Provides high humidity Face Mask Covers the nose and mouth Used for moderate O2 support & higher concentration of oxygen and/or humidity. Nasal Cannula Inexpensive, most common device Delivers low concentration of oxygen (24%-45%) @ flow rates of 2-6L per minute Allows client flexibility to eat & talk NPPV • Noninvasive Positive Pressure Ventilation (NPPV) • Delivery of air or oxygen under pressure without the need for an invasive tube • Most Common Device:_________________ • Nurse's Primary Role: _________________ • Medical Diagnosis: COPD, Obstructive Sleep Apnea, Respiratory Failure, Pulmonary Edema • Ineffective Airway Clearance- Inability to clear or psychological energy to endure or complete required or desired daily activities. secretions or obstructions from the respiratory tract to maintain a clear airway. • Ineffective Breathing Pattern • Impaired Gas Exchange • Activity Intolerance- Insufficient physiological

Lung Cancer

Lung cancer is the leading cause of cancer death in the United States. Signs and symptoms +Chronic coughing +coughing up blood +Wheezing sound +Chest and Bone Pain +Difficulty swallowing +Raspy, Hoarse Voice +Shortness of breath +Unexplained weight loss +Nail clubbing Symptoms may include persistent cough, chest pain, dyspnea, weight loss, or hemoptysis. Changes in normal respiratory patterns or hoarseness, as well as pneumonia, bronchitis, epigastric pain, symptoms of brain metastasis, arm or shoulder pain, or swelling of the upper body are other possible signs. Causes Approximately 80% of lung cancers are related to cigarette, pipe, and cigar smoking. Lung cancer is 10 times more common in smokers than in nonsmokers. In particular, squamous cell and small cell carcinoma are associated with smoking. Other risk factors include exposure to carcinogenic industrial and air pollutants (e.g., asbestos, coal dust, radon, and arsenic) and family history. The vast majority are caused by carcinogens in tobacco smoke, including secondhand smoke. Other risks include exposure to carcinogenic industrial and air pollutants (asbestos, uranium, arsenic, nickel, chromium, iron oxides, coal dust, and radioactive dusts), concentrations of radon gas, and familial susceptibility. Physical Examination Many people are asymptomatic. As the disease progresses, symptoms are cough, dyspnea, wheezing, and hemoptysis. The clinical manifestations of lung cancer depend on the type and location of the tumor. Because the early stages of this disease usually produce no symptoms, it is most often diagnosed when the disease is at an advanced stage. Diagnostic Highlights +Chest x-ray +Computed tomography scan +Cytological sputum analysis +Bronchoscop Diagnostic tests include a chest x-ray, CT scan, cytological sputum analysis, and bronchoscopy. Other tests include needle biopsy, magnetic resonance imaging, thoracentesis, thoracotomy, mediastinoscopy, or pulmonary function tests. +Other Tests: Magnetic resonance imaging, thoracentesis, thoracoscopy, closed-check needle biopsy, fluoroscopy, positron emission tomography, bone scan, mediastinoscopy, bone marrow biopsy, complete blood count, arterial blood gas Primary Nursing Diagnosis Diagnosis: Ineffective airway clearance related to obstruction caused by secretions or tumor as evidenced by cough, dyspnea, wheezing, and/or hemoptysis Outcomes: Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level Interventions: Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring Treatment The treatment of lung cancer depends on the type of cancer and the stage of the disease. Surgery, radiation therapy, and chemotherapy are all used. Unless the tumor is small without metastasis or nodes when discovered, it is often not curable.Radiation therapy is sometimes the primary treatment for lung cancer, particularly in patients who are unable to undergo surgery Maintain a patent airway. Position the head of the bed at 30 to 45 degrees. Increase the patient's fluid intake, if possible, to assist in liquefying lung secretions. Provide humidified air. Suction the patient's airway if necessary. Assist the patient in controlling pain and managing dyspnea. Assist the patient with positioning and pursed-lip breathing. Allow extra time to accomplish the activities of daily living. Teach the patient to use guided imagery, diversional activities, and relaxation techniques. Provide periods of rest between activities. Treatment includes lung surgery, radiation therapy, and chemotherapy (including epidermal growth factor receptor blockers) often provided serially or in combination. Discharge and Home Healthcare Guidelines Be sure the patient understands any medication prescribed, including dosage, route, action, and side effects. Provide the patient with the names, addresses, and phone numbers of support groups, such as the American Cancer Society, the National Cancer Institute, the local hospice, the Lung Cancer Alliance, and the Visiting Nurses Association. Teach the patient how to maximize her or his respiratory effort. The nurses assessment of a client with lung cancer reveals the following: copious secretions, dyspnea, and cough. Based on these findings, what is the most appropriate nursing diagnosis? early signs and symptoms of Lung cancer?One of the most common symptoms of lung cancer, and often the one reported first, is a persistent cough. Blood tinged sputum may be produced because of bleeding caused by the cancer. The patient may complain of dyspnea or wheezing. Chest Pain, if present may be localized or unilateral, ranging from mild to severe Does this mean Lung Cancer signs and symptoms will appear early in the disease process The clinical manifestations of lung cancer are usually nonspecific and appear late in the disease process. Symptoms may be masked by a chronic cough attributed to smoking or smoking related lung disease. Manifestations depend on the type of primary lung cancer, its location, and metastatic spread. Why is the survival rate for lung Cancer so poor?High mortality rate of lung cancer and the causal effect of cigarette smoking. Lung cancer is one of the most frequently occurring neoplasms and usually has a poor prognosis because most of the patients present with advanced or metastatic disease at the time of diagnosis. May be vague at first and unfortunately, symptoms appear late in disease treatments for lung cancer? Radiation therapy Chemotherapy Surgical Therapy Stereotactic body radiotherapy (SIBRT) aka stereotactic surgery or radiosurgery Targeted therapy Immunotherapy Bronchoscopic laser therapy Photodynamic therapy Airway Stenting Radiofrequency Ablation Nursing Diagnosis for : lung cancer reveals the following: copious secretions, dyspnea, and cough ineffective airway clearance

O2 home teaching

Teach the patient to leave O2 canister in holder Avoid smoking and candles No wool or oil-based product

To detect early signs or symptoms of inadequate oxygenation, the nurse would examine the patient for

apprehension and restlessness.

cystic fibrosis (CF)

Cystic fibrosis (CF) is a multisystem genetic disease of the exocrine glands-those glands with ducts such as the mucous, salivary, and sweat-producing glands. CF, originally called CF of the pancreas, is also associated with the glands of the respiratory system and the skin, and it has the potential for multiple organ involvement. The lungs are most frequently affected, but the gastrointestinal (GI) tract (including the small intestine and pancreatic and bile ducts) and eventually the reproductive organs are affected as well. Causes The responsible gene, the CF transmembrane conductance regulator (CFTR), is mapped to chromosome 7. The underlying defect of this autosomal recessive condition involves a defective protein that interferes with chloride transport, which in turn makes the body's secretions very thick and tenacious. The ducts of the exocrine glands subsequently become obstructed. signs and symptoms Parents often report that the child's skin has a characteristic taste of salt when they kiss the child. Hence, this classic early symptom is referred to as the "kiss of salt." In addition, during the first year or two of life, the child experiences repeated upper respiratory infections such as nasopharyngitis, croup, bronchiolitis, and pneumonia. Although the child has a voracious appetite, he or she does not gain weight and has steatorrhea (frequent foul-smelling, fatty stools). Moreover, the child may not achieve developmental milestones, particularly in the area of gross motor skills. The newborn may have a meconium ileus. Early in the disease, the lungs have many adventitious breath sounds, such as coughing, rales, rhonchi, and wheezes. The anterior posterior to lateral diameter begins to increase as the disease progresses so that the child appears barrel-chested. Older children may present with chronic cough and sputum production. Clubbing of the nails is indicative of advanced progression of the disease and may be noted in a toddler or a preschooler who has a severe form of the disease. Diagnostic Highlights General Comments: Prenatal and genetic tests are performed to identify fetal disease and carrier status. Failure to thrive and frequent upper respiratory infections often lead to diagnostic testing to confirm the CF diagnosis. Quantitative sweat electrolyte test (pilocarpine iontophoresis). Genotyping. Other Tests: Serum electrolytes, chest x-ray, arterial blood gases, pulmonary function tests, semen analysis, nasal potential difference measurement of the nasal mucosa, pulmonary function tests, bronchoalveolar lavage, sputum microbiology Primary Nursing Diagnosis Diagnosis: Ineffective airway clearance related to excess tenacious mucus as evidenced by coughing, rales, rhonchi, and/or wheezing Outcomes: Respiratory status: Airway patency; Respiratory status: Gas exchange; Respiratory status: Ventilation; Infection control Interventions: Chest physiotherapy; Positioning; Airway management; Surveillance DRUGS +Ibuprofen-Reduces inflammation that causes damage to lung tissue; slows lung deterioration +Ivacaftor-Potentiates CFTR protein, a chloride channel present at the surface of epithelial cells, and thereby facilitates increased chloride transport +Trimethoprim sulfamethoxazole (Bactrim DS); tobramycin; clindamycin; piperacillin; cephalexin; ceftazidime; other aerosol antibiotics. Prevent and treat lung infections +Dornase alfa recombinant Breaks down the DNA from neutrophils, loosening secretions +Pancrelipase; lipase (Aids in digestion of fats and proteins) +Other Drugs: Supplement of fat soluble vitamins (A, D, E, K) is necessary for biological pathways. Bronchodilators such as albuterol help open airways. Experimental Therapies: New peptide antibiotics (PA-1420, IB-357, IB-367, and SMAP-29) are being investigated as treatment for resistant bacteria. Gene and lung transplants are also being studied, and families should be informed of these options. Treatment Educate to reinforce the importance of regular CPT and expectoration of the mucus. Encourage increased fluid intake to loosen the secretions and provide frequent mouth care before meals. Teach the parents not to offer cough suppressants, which can lead to obstruction, lung collapse, and infection. Discharge and Home Healthcare Guidelines Teach the patient and family how to prevent future episodes of pneumonia through CPT, expectoration of sputum, and avoidance of peers with common colds and nasopharyngitis. Explain that medications need to be taken at the time of each meal, especially pancreatic enzymes and supplemental vitamins. Teach the parents protocols for home intravenous care, as needed. Teach parents when to contact the physician when temperature is elevated over 100.5°F (38.1°C), sputum has color to it, or the child complains of increased lung congestion or abdominal pain. Also educate parents on the need to keep routine follow-up appointments for medication, laboratory, and general checkups. Teach the patient or parents proper insulin administration and the appropriate signs and symptoms of high and low glucose levels. You're providing care to an 18 year old who has cystic fibrosis. Select all the possible complications this patient can experience due to cystic fibrosis Hearing disturbances Hemoptysis Greasy foul smelling stools Weight gain Meconium ileus Excessive mucus production Coughing infertility dyspnea You're discussing nutrition with your patient who has cystic fibrosis . You explain that it is very important the patient regularly takes fat-soluble vitamins. This includes. Vitamin D,E,K,A Cystic Fibrosis: =GI involvement: must take pancreatic enzymes for digestion with meal =Increased risk for respiratory infections/colonized with pseudomonas: must get flu and pneumo vaccine =Skin has high NaCl content - Sweat test =Diet: low fat, high protein, high calorie =Chest physiotherapy: know positioning for postural drainage =Definitive treatment is lung/pancreas/intestine transplant =ND: Risk for Ineffective Airway clearance, Risk for infection, Risk for constipation, Risk for impaired gas exchange +compromised family Coping +deficient Knowledge regarding pathophysiology of condition, medical management, and available community resources +imbalanced Nutrition: less than body requirements +risk for Infection +ineffective Airway Clearance

Emphysema

is characterized by the loss of lung elasticity and hyperinflation of lung tissue. Emphysema causes destruction of the alveoli, leading to a decreased surface area for gas exchange, carbon dioxide retention, and respiratory acidosis. CAUSES Tobacco smoking is the most common cause of the tissue destruction found in emphysema. Exposure to environmental dust, smoke, or particulate pollution may also contribute to the disease. A small number of people with emphysema may have developed it as a result of alpha-1-antitrypsin deficiencies, a group of genetic illnesses in which there is inadequate protection against destructive enzyme activity in the lung. Complications include cor pulmonale, recurrent respiratory infections, and respiratory failure. SYMPTOMS AND SIGNS Symptoms include difficulty breathing, esp. during exertion. Weight loss, chronic cough, and wheezing are also characteristic. Physical findings include prolongation of expiration, diminished breath sounds, a decrease in the measured distance between the thyroid cartilage and the chin, and heart tones that are audible only in the subxiphoid region of the chest. DIAGNOSIS Emphysema is diagnosed based on the clinical history (usually a long history of smoking), the results of a chest x-ray or CT scan of the lung, and pulmonary function testing. TREATMENT Smoking cessation helps preserve the remaining alveoli. Inhaled bronchodilators and anticholinergics, such as ipratropium, tiotropium, albuterol, or salmeterol may improve respiratory function. Aerosolized corticosteroids reduce inflammation, and mucolytics thin inspissated secretions and aid mucus expectoration. Antibiotics are only used when bacterial infections are identified. Oxygen therapy prevents right-sided heart failure. The respiratory therapist administers oxygen at low-flow settings to maintain adequate oxygenation (Pao2 60 to 80 mm/Hg). Lung volume reduction surgery can eliminate hyperinflated (nonfunctional) portions of the lungs, allowing the healthier lung tissue that is left behind to expand and contract with improved efficiency. The patient is protected from environmental bronchial irritants, such as smoke, automobile exhaust, aerosol sprays, and industrial pollutants. PATIENT CARE The patient's oxygenation, weight, and the results of electrolyte and complete blood count measurements are monitored. The patient is evaluated for infection and other complications and for the effects of the disease on functional capabilities. Prescribed medications are administered by parenteral or oral route or by inhalation. RISK FACTORS for the development of emphysema include cigarette smoking, living or working in a highly polluted area, a family history of pulmonary disease, and substance use (cocaine, intravenous drug use with methadone and methylphenidate). HIV infection is also an independent risk factor for emphysema. Frequent childhood pulmonary infections have been identified as a cause of bronchiectasis. Primary Nursing Diagnosis Diagnosis: Impaired gas exchange related to destruction of alveolar walls as evidenced by dyspnea and/or wheezing Outcomes: Respiratory status: Gas exchange; Respiratory status: Ventilation; Comfort level; Anxiety control Interventions: Airway management; Cough enhancement; Respiratory monitoring; Oxygen therapy; Laboratory data interpretation; Positioning; Smoking cessation assistance; Ventilation assistance Discharge and Home Healthcare Guidelines MEDICATION AND OXYGEN. Be sure the patient and family understand any medication prescribed, including dosage, route, action, and side effects. Arrange for return demonstrations of equipment used by the patient and family. If the patient requires home oxygen therapy, refer the patient to the appropriate rental service and explain the hazards of combustion and increasing the flow rate without consultation from the primary healthcare provider. PREVENTION. Instruct the patient to report any signs and symptoms of infection to the primary healthcare provider. Explain necessary dietary adjustments to the patient and family. Recommend eating small, frequent meals, including high-protein, high-density foods. Recommend smoking cessation programs and provide materials to make follow-up easy. REST AND NUTRITION. Encourage the patient to plan rest periods around his or her activities, conserving as much energy as possible. Pharmacologic Highlights: +Bronchodilators: Anticholinergic agents +Bronchodilators: Beta2-adrenergic agents +Tiotropium +Systemic corticosteroids ---------------------------- A 66 year old client has marked dyspnea at rest, is thin and uses accessory muscles to breathe. He's tachypneic, with a prolonged expiratory phase. He has no cough. He leans forward with his arms braced on his knees to support his chest and shoulders for breathing. This client has symptoms of which of the following respiratory disorders? Emphysema. These are classic signs of emphysema. Clients with ARDS are acutely short of breath and require emergency care; those with asthma are also acutely short of breath during an attack and appear very frightened. Clients with COPD are bloated and cyanotic in appearance. The plan of care for the patient with COPD should include ... -Exercise such as walking -Breathing exercises, such as pursed lip breathing that focus on exhalation. A client with COPD should receive only 1-3 L/min of oxygen, if needed or he may lose his hypoxic drive. Which of the following statements is correct about hypoxic drive? The client breathes only when his oxygen levels dip below a certain point. Clients with COPD breathe when their oxygen levels drop to a certain level; This is known as hypoxic drive. They dont take a breath when their levels of carbon dioxide are higher than normal , as do those with healthy respiratory physiology. If too much oxygen is given, the client has little stimulus to take another breath. In the meantime, his carbon dioxide levels continue to climb, and the client will pass out, leading to respiratory arrest. The nurse plans care for a client with COPD, knowing that the client is most likely to experience what type of acid base imbalance? Respiratory acidosis is most often due to hypoventilation pH is decreased, PaCO2 is increased The nurse instructs a client to use the pursed lip method of 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. Promote carbon dioxide elimination. Pursed lip breathing facilitates maximum expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation +impaired Gas Exchange +ineffective Airway Clearance +Activity Intolerance +imbalanced Nutrition: less than body requirements +risk for Infection +Powerlessness

What teaching is needed for patients being discharged on anticoagulants?

• Bleeding precuations • no asprin • no nsaids • no razors

The nurse is interviewing the mother of a child who is scheduled for a tonsillectomy. Which question is most essential for the nurse to ask the mother?

"Does your child have any bleeding tendencies?" Rationale: Bleeding tendencies are especially significant in a child who is to have a tonsillectomy, as the most common complication is hemorrhage.

Which statement by the patient indicates the discharge teaching for the patient diagnosed with pulmonary embolus is effective? (Select all that apply)

"I will drink extra fluids while on long trips." "I will need to go to the lab monthly for blood draws." "I am going to use a soft-bristled toothbrush."

Which of the following are correct statements regarding use of a metered dose inhalor?

-Shake inhaler before use -Press the inhaler, breathe in slowly for 3-5 seconds -Hold breath for 10 seconds.

Pneumonia (Dr orders Symptoms)

An inflammatory process of the lungs Bacterial, viral, mycoplasma, fungi, parasites, chemicals Community acquired occurs in community or within first 2 days of hospitalization Chills, cough, sputum-rust, hypoxemia, tachypnea, tachycardia Pleuritic pain, myalgia, headache Crackles, wheezing, fatigue, dyspnea, diminished breath sounds CXR and sputum culture Fluids 3L/day to thin secretions, oxygen, supportive treatment or antibiotics Youre providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a Hallmark sign that the patient is developing ARDS? (80-100 is normal PaO2) the patients PaO2 remains at 45. Refractory hypoxemia is a hallmark sign. Although the patient is receiving a high amount of oxygen, the patient is STILL hypoxic. Pneumonia: Viral vs. Bacterial (Bacterial source = sicker child) S/S: Wet cough/crackles, rhonchi TX: hydration, PO intake, O2 therapy An elderly client with pneumonia may appear with which of the following symptoms first?Altered mental status and dehydration Elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response What can the nurse do for a patient with pneumonia and poor appetite?Make sure the patient coughs and uses deep-breathing exercises at least every 2 hours. Encourage drinking 3 L of fluid daily, unless contraindicated, to help expectorate secretions.) provide mouth care before meals diagnostic studies for pneumonia? • H 7 P • History and physical examination • Chest x-ray (Findings reflect areas of infection and consolidation) • Gram stain of sputum • Sputum culture and sensitivity test (Cultures identify organism; sensitivity testing identifies how resistant or sensitive the bacteria are to antibiotics) • Pulse oximetry or ABGs (if indicated) • Complete blood count, WBC differential, and routine blood chemistries (if indicated) • Blood cultures (if indicated) Rapid detection test: Reverse-transcriptase-polymerase chain reaction (Obtained though nasal swabs; sensitivity for influenza in adults ranges between 50% and 60%, and specificity is greater than 90%) other Tests: Arterial and venous blood gases, complete blood count, coagulation profile, bloodcultures, serum lactate level, serum free cortisol value, serum electrolytes, blood urea nitrogen,creatinine, glucose, bronchoscopy. Chest computed tomography and chest ultrasound may becompleted it is advised that client's over age 65 receive a pneumovax to help protect against community acquired pneumonia (CAP). What is the most common pathogen identified in CAP? Streptococcus pneumoniae Viral pathogens account for up to a fourth of CAPs in adults and are most commonly caused by the influenza virus CAP is caused by bacteria that are divided into two groups: typical and atypical. Organisms that cause typical pneumonia include Streptococcus pneumoniae (pneumococcus) Why are older adults at increased risk for the development of all types of pneumonia? People over age 40 are at greater risk to contract all forms of bacterial pneumonia, with older men more susceptible to streptococcal bacterial pneumonia and Klebsiella bacterial pneumonia. Staphylococcal pneumonia tends to strike those who are debilitated or who have a history of influenza or IV drug abuse Potential Complication's pneumonia can lead to complications such as respiratory failure, lung abscess, and septic shock. Infection may spread via the bloodstream and cause endocarditis, pericarditis, meningitis, or bacteremia.

Methylxanthines- - Bronchodilators (Xanthine derivatives) Relaxes bronchial smooth muscle Well absorbed PO - Interacts with beta blockers and Cimetidine

SIDE EFFECTS Many drug interactions Anorexia, N/V, heartburn, cardiac dysrhythmias, BP HR, nervousness, palpitations, insomnia AGENTS -aminophylline, -theophylline (Theodor) ROUTE/ DOSE PO & IV NURSING IMPLICATIONS · Smoking ¯ effectiveness · Narrow therapeutic range (10-20 mcg/ml) · *Avoid caffeine Interacts with many meds

Anti-immunoglobulin E Antibody for allergic type moderate to persistent asthma

SIDE EFFECTS Risk for anaphylaxis AGENTS omalizumab (Xolair) ROUTE/ DOSE SQ q 2-4 wks. NURSING IMPLICATIONS · Kids > 12. Dose based on IgE /wt. Long term control

A commonly prescribed methylxanthine used as a bronchodilator is

Thephylline (Albuterol, levalbuterol, and terbutaline are all Beta 2 adrenergic receptor agonists)

When assessing activity-exercise patterns related to respiratory health, the nurse inquires about

dyspnea during rest or exercise

CHEMICAL CLASS Cardiac Glycosides · Digoxin (Inotrope) Why on?CHF and AF

ACTION · Inhibits Na-K pump which intracellular Na+ and Ca++ and causes cardiac muscle fibers to contract more efficiently · Enhances parasympathetic stim ® slows AV node conduction ®¯ HR · Effects: contraction (+ inotrope) ¯ HR (- chronotrope), CO, ¯ preload ADVERSE EFFECTS Dig. toxicity - anorexia, N.V. bradycardia (1st degree AV block), visual disturbances (yellow haloes) NURSING INTERVENTIONS · Dig. & K wasting diuretic or cortisone combination may cause ¯ K ® dig. toxicity · Monitor K and Dig. levels (0.5-2) · Supplement K · Check rhythm and pulse - hold if < 60 · Eat K rich foods · Assess S&S of Dig. Toxicity · Long half-life therefore loading dose used · ↑ K inhibits action of Dig. · ↑CA and ↓ Mg also precipitate Dig. Toxicity.

COPD

A 58 year old client with a 40 year history of smoking one to two packs of cigarettes a day has a chronic cought producing thick sputum. Peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions? COPD, because of his extensive smoking history and symptoms, the client most likely has COPD. Clients with asthma and emphysema tent not to have a chronic cough or peripheral edema.

Combination Medications

Advair - salmeterol (sympathomimetic) and fluticasone (dorticosteroid) Anoro - u meclidinium (anticholinergic) and vilanteral (LABA) Combivent or Duoneb - ipratropium (anticholinergic) and albuterol (sympathomimetic) Trelegy - u meclidinium, (anticholinergic) and vilanteral (LABA), and fluticasone (dorticosteroid)

A patient with sleep apnea asks the nurse, "what can I do to get better sleep?" what is an appropriate nursing response?

Being overweight is a contributing factor; losing weight can often resolve apnea." (Sleeping pills can cause the patient to become too somnolent Controlling BP and blood sugar does not help with improved sleep)

Mucolytics Liquefy and loosen secretions (breaks disulfide links of mucoproteins) Also increases hepatic glutathione, which is necessary for inactivation of toxic metabolites in Tylenol OD

SIDE EFFECTS N/V, oral sores Dizzy, drowsy Rhinorrhea, bronchospasm AGENTS acetylcysteine (Mucomyst) ROUTE/ DOSE HHN NURSING IMPLICATIONS Wash face, rinse mouth after Rx, gum, hard candy

The nurse and a certified nursing assistant are caring for a group of patients on a medical unit. Which information provided by the assistant warrants immediate assessment by the nurse?

The patient with an asthma attack whose wheezing has stopped. Rationale: A patient with asthma normally has wheezing, but as the obstruction worsens, the wheezing may disappear and may signal an impending respiratory failure.

1. The nurse has provided discharge instructions to a parent of a child who underwent a tonsillectomy. Which of the following statements by the parent indicates a need for further understanding? I will:

provide a straw for drinking liquids." Rationale: a straw could accidently penetrate the incision and cause bleeding

PULMONARY EMBOLISM

signs and symptoms complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. What risks come for elderly, with pulmonary embolism • Advanced age •Surgery, abdominal hysterectomy • Prolonged immobility • MI • Atrial Fibrillation Discuss strategies to prevent Pulmonary Embolisms • Early ambulation of medical and surgical clients • Elevating the legs • External pneumatic • compression of the legs • Active and passive exercising Drug Therapy for Pulmonary Embolism • Lovemox, coumadin • Immediate anticoagulation is required, subcutaneous administration of low molecular weight heparin (enoxaparin [Lovenox], or fondaparinux has been found to be safer and more effective than the use of unfractionated heparin. it is the recommended treatment for patients with PE administered once daily • Unfractionated heparin can be as effective but us more difficult to titrate to therapeutic levels. Warfarin (Coumadin), an oral anticoagulant, should be administrated at the time of diagnosis. Warfarin should be administered for at least 3 months and then reevaluated. alternatives to warfarin include apixaban (Eliquis), dabigatran (Pradaxa) and edoxaban (Savaysa) What diagnostic tests would the doctor order to determine if the client is experiencing a pulmonary embolism versus a heart attack? 12 lead EKG ST segment and T wave changes, but they are not diagnostic for PE. 12 lead EKG cardiac function, MI Other tests: •Lung scans •Chest x-ray •Electrocardiogram •Exhaled carbon dioxide levels •Coagulation studies •Plasma D-dimer levels (just shows clot present, not specific to PE) D-dimer PE clots •Spiral Chest CT with contrast (Most frequently used to dx PE, its reliability diminishes the need for pulm angiography)Spiral CT PE •Pulmonary angiography (Most sensitive and specific test for PE) •V/Q Scan (if pt cannot have contrast for Pulm Angio) VQ scan, pulmonary angiography clots or PE •Venous dopplers DVT PE •Cardiac enzymes heart function, M The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and O2 is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE. New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as O2 administration and notification of the health care provider. Increasing O2 flow rate will usually improve O2 saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

Respirations Across the Lifespan

❑ Newborn 30-60 (35) ❑ 1 Year 20-40 (30) ❑ 5-8 yrs 15-25 (20) ❑ Teen 15-20 (18) ❑ Adult 12-20 (16) ❑ Older Adult 15-20 (16)

purpose of tiotropium (Spiriva).

"This drug will help open up the airways and make breathing easier

Acute respiratory failure

Acute Respiratory Failure Not a disease itself, but a result of a disease/physiological condition

what infectious disease precautions would be used in the hospital for a patient with TB?

Airborne Precautions are used if the organism can cause infection over long distances when suspended in the air such as TB. Patients are placed in a private room, preferably one with negative air pressure and between 6 and 12 changes of air each hr. The door to the isolation room should be kept closed except during necessary patient care encounters. Hospital workers should wear N95 respirator masks when in the room. If patient transport outside the isolation room is necessary, the patient should wear an approved respirator. High-efficiency particulate air (HEPA) masks are worn whenever entering the patient's room. These masks are highly effective at protecting from small particles 5 µm or less in diameter.

When teaching a patient about the most important respiratory defense mechanism distal to the respiratory bronchioles, which topic would the nurse discuss?

Alveolar macrophages

Which assessment finding of the respiratory system does the nurse interpret as abnormal?

Bronchial breath sounds in the lower lung fields

Non- Infectious Respiratory Disorders

Cystic Fibrosis Disorder of blocked chloride transport in cell membranes causing thick mucus that plugs up the lungs, pancreas, liver, salivary glands, and testes. Lung Cancer tumors in the lungs. Smoking causes 80-90% of lung cancer. Sleep Apnea- Breathing disruption during sleep

A patient is admitted with pulmonary edema. The nurse is preparing to administer morphine sulfate. What beneficial effect does morphine have in pulmonary edema?

Decreases anxiety, work of breathing, and vasodilates. Rationale: This is the beneficial effect of morphine on pulm edema.

The nurse should observe for which side effects after administering a bronchodilator?

Dysrhythmia Central Nervous system excitement Tachycardia

Tuberculosis diagnosis tests

Fluorochrome oracid-fast bacillisputum Mycobacterium tuberculosis is a bacterium that resists decolorizing chemicals after staining. Positive; three samples are often obtained Chest x-ray identification of activeTB or old lesions. Radiographic assessment of the lungs Other Tests: Histology or tissue analysis, needle biopsy, purified protein derivative (Mantouxtest); blood cultures, urine cultures, HIV testing, enzyme-linked immunospot (ELISpot) andenzyme-linked immunosorbent assay (ELISA) to detect TB antigens

The nurse is performing chest physiotherapy on a 6-year-old child who has congestion in his left lower lobe. In which position should the nurse place the child?

Right side in Trendelenburg position. Rationale: The affected lobe must be uppermost to be drained by gravity.

Hypoxemia Respiratory Failure (oxygenation failure)- Hypercapnic Respiratory Failure (ventilatory failure)

Hypoxemia Respiratory Failure (oxygenation failure)- Thoracic pressure changes are normal, lungs can move air but cannot oxygenate the pulmonary blood properly. Inadequate O2 tranfer between alveoli and pulmonary capillary bed. + secretions in alveoli, bronchospasm, atelectasis, clot in PA, restrictive lung disease, pneumonia + Restlessness, confusion, agitation, tachypnea, tachycardia Hypercapnic Respiratory Failure (ventilatory failure) - thoracic pressure cant be changed sufficiently to permit adequate air movement in and out of lungs. Insufficient O2 to alveoli, increased Co2 + Airway abnormalities: air trapping CNS abnormalities (opioids) , C-spine injury Decreased RR or increased and shallow, morning headache, increased Co2, muscle weakness, pursed lip breathing.

Cystic fibrosis is suspected. Which physiological assessment is most likely to be seen in the childwith cystic fibrosis?

Large, loose, foul-smelling stools with normal frequency or a chronic diarrhea of unformed stool. rational: Insufficient pancreatic enzyme release causes the typical pattern of protein and fat malabsorption with a person being thin with a low body mass index (BMI) and frequent, bulky, foul smelling stools. Â people with CF have sticky mucus that blocks ducts in the pancreas and prevents enzymes from reaching the small intestine to digest food. Undigested food in the intestines can cause pain, cramping, gas and either loose, greasy, floating stools or constipation and blockages. Everyone with CF (including people who don't need enzyme supplements) has a pancreas that does not make enough bicarbonate to neutralize stomach acid. This can also contribute to pain, cramping, gas and constipation. Bloating and excessive gas also can be caused by small bowel overgrowth, gastric paresis and gastro esophageal reflux disease

Pulmonary Edema

M A D D O G

Anti-cholinergic Results in bronchodilation by blocking action of acetylcholine Better for maintenance. Tx - not for acute

SIDE EFFECTS N, V, cramps, dizzy Drying to oral mucosa, cough, flushing of skin, bad taste, blurred vision Anticholinergic SE AGENTS -tiatropium (Spireva) -ipratropium (Atrovent) -umeclidinium ROUTE/ DOSE HHN MDI Nasal spray NURSING IMPLICATIONS · Don't over use · May be used alternating with albuterol · Assess for palpitations or tolerance

What other treatments may be indicated for ARDS? Figure 67-12

Other positioning strategies to consider for patients with ARDS include continuous lateral rotation therapy (CLRT) and kinetic therapy. CLRT provides continuous, slow, side-to-side turning of the patient by rotating the actual bed frame less than 40 degrees. The bed's lateral movement is maintained for 18 of every 24 hours to simulate postural drainage and to help mobilize pulmonary secretions. In addition, the bed may also contain a vibrator pack that provides chest physiotherapy. This feature assists with secretion mobilization and removal. Kinetic therapy is similar to CLRT in that patients are rotated side-to-side 40 degrees or more. It is important to obtain baseline assessments of the patient's pulmonary status (e.g., respiratory rate and rhythm, breath sounds, ABGs, SpO2) and continue to monitor the patient throughout the therapy

Expectorants Loosens secretions - facilitates ability to coughed up

SIDE EFFECTS Nausea/vomiting, drowsy AGENTS guaifenesin (Robitussin) (Mucinex-tablet form) ROUTE/ DOSE P.O. NURSING IMPLICATIONS · Hydration is key to thin secretions.

Pulmonary Embolus

Pulmonary embolus- Obstruction of blood flow in part of the pulmonary vascular system by a blood clot. +90-95 % come from the leg + immobilization, surgery + obesity + H/o thromboembolism +smoking, pregnancy + SOB + Dyspnea and mild to moderate hypoxemia with low paCO2 + Pleuritic chest pain + Sudden change in mental status Chest Trauma + Decreased breath sounds on affected side + Pleuritic pain + Tachypnea + Sub-q emphysema, crepitus + Dyspnea, decreased O2 stats. Nursing measure to assist in the prevention of pulmonary embolism in a hospitalized patient include all of the following except: Encouraging the patient to dangle his legs over the side of the bed for 30 minutes 4x day. As part of the nursing assessment information, the nurse knows that the majority of pulmonary emboli originate in the: Deep Leg Veins

What teaching should be included for the parents of a child with new tympanostomy tubes?

Report heavy bleeding or bleeding for 3 days. Reports fever or extremely high pain, Avoid blowing nose for 7-10 days, keep ears dry swimming is only allowed with MD approval, should have periodic hearing evaluation

Assessment data T 102.6 Respirations 34/min Productive cough Rhonchi and wheezes R lung fields. Concentrated urine. ABGs are pH 7.43 PaCO2 58 PaO2 62 HCO3 26 What do these ABGs indicate and why are these findings indicative of COPD?

Respiratory acidosis without compensation. Increased Co2 due to air trapping and small airway collapse during exhalation.

The nurse is preparing the patient for a diagnostic procedure to remove pleural fluid for analysis. The nurse would prepare the patient for which test?

Sputum culture and sensitivity

A child has been brought to the emergency room with an asthma attack. What signs and symptoms would the nurse expect to see?

Swelling of the bronchial mucosa, with wheezes starting on expiration and spreading to continuous. Rationale: Asthma causes spasm of the smooth muscles in the bronchi and bronchioles, resulting in prolonged exhalation. Inspirations increase in rate in an effort to relieve hypoxia. The cough would begin as nonproductive, then progress to a profuse mucous; gas trapping is caused by allowing more air to enter the alveoli than can escape, which causes increased depth and rate of respirations.

How is TB passed from one person to another

TB is spread through residue of evaporated droplets and may remain in the air for long periods of time. Thus care should be given when coughing or sneezing He must be careful to cough into a handkerchief that is washed in hot water or discarded."

When the alveoli lose their normal elasticity as a result of emphysema, the nurse teaches the patient exercises that lead to effective use of the diaphragm because...

The residual capacity of the lungs has been increased.

When auscultating the chest of an older patient in respiratory distress, it is best to

begin listening at the lung bases.

The nurse is planning care for a child who must remain in a croup tent continuously. Which goal is of the highest priority?

The tent will deliver mist and cooled air simultaneously while the child is inside. Rationale: The delivery of room air and oxygen will keep carbon dioxide levels decreasing, preventing hypoxia. The humidity will prevent the drying of the mucous membranes and subsequent edema. The tent can be opened or even remain open with the understanding that the treatment will not be affected.

Why are two bronchodilators used together?

Theo-dur must be used regularly to be effective. It does not work right away and should not be used to relieve sudden breathing problems. If sudden shortness of breath occurs, use your quick-relief inhaler such as albuterol as prescribe

When a child vomits bright red liquid several hours after a tonsillectomy, the nurse needs to determine whether the child is bleeding from the operative site. Which nursing action would be most informative?

Visualizing the posterior throat with use of a tongue depressor and flashlight Rationale: Because the operative site can be visualized, the nurse should look for oozing of blood using good lighting and a tongue depressor. The surgical membrane does not pull apart until 4-10 days after surgery.

Questions to ask COPD patient

What have you tried to alleviate your symptoms? • Did you try any prescription or over-the-counter drugs? • Are your breathing problems better, worse, or about the same compared with 6 months ago? •If you use O2, do you ever go out without bringing it with you? How often does this occur?Why? • How do your breathing problems affect your self-care abilities? • Have you ever smoked? Do you smoke now? If so, what have you smoked? Cigarettes?Cigars? Pipes? Electronic cigarettes? • What equipment helps you manage your respiratory problems? How often do you use it?Does it help? Cause problems? • Are you able to maintain your typical activities of daily living? If not, what are you able to do independently? What do you need help with? What have you had to give up Other assessments I would make is check his O2 saturation and capillary refill. If low I wouldput the patient on 2L of oxygen If patient has a productive cough I would evaluate the following characteristics of sputum:amount, color, consistency, and odor.

Pulmonary hypertension pulmonary arterial hypertension (IPAH).

elevated pulmonary pressure resulting from an increase in pulmonary vascular resistance to blood flow through small arteries and arterioles. Idiopathic, heritable, left heart disease (e.g. HF), lung disease (e.g. COPD), hypoxemic vasoconstriction (e.g. OSA), thromboembolic (e.g. PE) treatment bostentan (endothelin antagoinst), prostacyclin analogs or sildenafil Control underlying disease process if possible Oxygen administration to decrease vasoconstriction Avoidance of exercise/exertion Vasodilators/diuretics Viagra-off label treatment Advanced PH is irreversible Lung or heart/lung transplant only option - prevention of clot formation: warfarin - prostacyclin agent - fiolan - dioxin - diuretics - O2 therapy - lung transplantation

an adult was born and raised in another country and received the BCG vaccine as a child. Upon taking a tuberculin skin test, a positive result is seen. What information will the nurse base a response on?

the only cause for a positive skin test and negative chest X-ray is exposure to the tubercle bacillus without development of tuberculosis infection the intradermal test does not differentiate active tuberculosis from dormant infections

Obstructive Sleep Apnea

Also called obstructive sleep apnea-hypopnea syndrome (OSAHS) Partial or complete upper airway obstruction during sleep Apneic period may include hypoxemia and hypercapnia - longer than 10 seconds. Hypopnea is shallow respirations (30% to 50% reduction in airflow). Airflow obstruction in OSA occurs because of (1) narrowing of the air passages with relaxation of muscle tone during sleep and/or (2) the tongue and the soft palate falling backward to partially or completely obstruct the pharynx (Fig. 7-4). Each obstruction may last 10 to 90 seconds. Apnea and arousal cycles occur repeatedly. Apneic episodes occur most often during REM sleep when airway muscle tone is lowest. Smokers are more likely to have OSA. OSA is more common in men than in women until after menopause, when the prevalence of the disorder is the same in both genders. Women with OSA have higher mortality rates. OSA patients with excessive daytime sleepiness have increased mortality. How Sleep Apnea Occurs predisposed to obstructive sleep apnea (OSA) has a small pharyngeal airway. During sleep pharyngeal muscles relax = airway to close. Lack of airflow results in repeated apneic episodes. CPAP = continuous positive airway pressure splints the airway open, preventing airflow obstruction. Clinical manifestations Frequent arousals during sleep Insomnia Excessive daytime sleepiness Witnessed apneic episodes Snoring Morning headache Irritability The patient's bed partner may complain about the patient's loud snoring. Morning headaches are related to hypocapnia or increased BP that causes vasodilation of cerebral blood vessels. Obstructive Sleep ApneaComplications can result in Hypertension Cardiac changes Poor concentration/memory Impotence Depression Diagnosis is based on PSG Complications untreated sleep apnea = hnt, dysrhythmias, arteriosclerosis, hf, and cardiovascular-related mortality. PSG = patient's chest and abdominal movement, oral airflow, nasal airflow, SpO2, ocular movement, and heart rate and rhythm are monitored. A diagnosis of sleep apnea requires documentation of apneic events or hypopneas of at least 10 seconds' duration. OSA is defined as more than 5 apnea/hypopnea events per hour accompanied by a 3% to 4% decrease in oxygen saturation. Severe apnea can be associated with apneic events of more than 30 to 50 per hour of sleep. Sleep Apnea Nursing and Interprofessional Mgmt Mild Sleep Apnea Sleeping on one's side Elevating head of bed Avoiding sedatives and alcohol 3 to 4 hours before sleep Weight loss Oral appliance Excessive weight worsens sleep apnea = pressure of adipose tissue in the neck and on the chest restrict ventilation. Oral appliances bring the mandible and the tongue forward to enlarge the airway space, thereby preventing airway occlusion. Severe Sleep Apnea (>15 apnea/hypopnea events/hr) CPAP Poor compliance BiPAP Surgery Uvulopalatopharyngoplasty (UPPP or UP3) Genioglossal advancement and hyoid myotomy (GAHM) CPAP, a nasal mask is attached to a blower, which is adjusted to maintain sufficient positive pressure (5 to 25 cm H2O) in the airway during inspiration and expiration to prevent airway collapse. To ensure successful adherence to CPAP treatment, patients needs to be involved in the selection of the mask and device before the start of therapy. For those with difficulty with CPAP, bilevel positive airway pressure (BiPAP) can deliver a higher inspiration pressure and a lower pressure during expiration. UPPP involves excision of the tonsillar pillars, uvula, and posterior soft palate to remove obstructing tissue. GAHM involves advancing the attachment of the muscular part of the tongue on the mandible. The patient's BMI and snoring suggest possible sleep apnea, which can cause complications such as cardiac dysrhythmias, hypertension, and right-sided heart failure. Melatonin is safe to use as a therapy for jet lag. Short-term use of diphenhydramine in young adults is not a concern. Hot chocolate contains only 5 mg of caffeine and is unlikely to affect this patient's sleep quality. The patient should be told to take the CPAP device to the hospital if an overnight stay is expected. Many patients will be able to use their own CPAP equipment. Patients should be treated for pain and monitored for respiratory depression. Another sleep study is not required before surgery. A person with sleep apnea would not routinely be expected to require postoperative intubation and mechanical ventilation.

Asthma Lewis chapter 28 pp 541-560

Chronic inflammatory disorder of airways Condition of intermittent, reversible airflow obstruction affecting the airways. Triggered by allergens, exercise, by being in cold air, irritants, occupational environmental factors, infections, or foods and medications. asthma is an intermittent, reversible, obstructive lung disease characterized by bronchospasm and hyperreactivity to a multitude of triggering agents (allergens/antigens/irritants). Asthma Treat plan based on Peak Flow meter, bronchodilators, and increase fluids Teach patient/family to identify and avoid triggers Chronic Respiratory: Asthma: · Reversible airflow obstruction · May have genetic component · Triggered by allergens · Bronchoconstriction due to hyper-responsive airways · Decrease peak flow · Treatment based on classification · · A patient with Asthma uses a peak flow meter to? · Monitor airway constriction · Asthma- airway constriction due to hypersensitive airways COMPLICATIONS Severe and life-threatening exacerbations Respiratory rate >30/min Dyspnea at rest, feeling of suffocation Pulse >120/min PEFR is 40% at best Usually seen in ED or hospitalized Severe asthma exacerbations occur when the patient is dyspneic at rest and the patient speaks in words, not sentences, because of the difficulty breathing. Accessory muscles in the neck are straining to try to lift the chest wall, and the patient is often agitated. The peak flow (peak expiratory flow rate [PEFR]) is 40% of the personal best or less than 150 L. Life-threatening asthma Too dyspneic to speak Perspiring profusely Drowsy/confused PEFR <25% Require hospital care and often admitted to ICU The breath sounds may be very difficult to hear, and no wheezing is apparent as the airflow is exceptionally limited. Peak flow is less than 25% of the personal best. Nursing Management Nursing Assessment asthma ABGs Lung function tests Asthma Control Test (ACT) Physical examination Use of accessory muscles Diaphoresis Cyanosis Lung sounds Signs and Symptoms Difficulty breathing, wheezing, cough (either dry or productive of thick, white sputum), chest tightness, anxiety, prolonged expiratory phase, and use of accessory muscles. Clinically, most patients present with episodic wheezing, shortness of breath, and/or cough. Between attacks the patient may or may not have normal respiratory function. Although most asthmatics have mild disease, in some cases the attacks become continuous. This condition (status asthmaticus) may be fatal. Nursing Care/Treatment +During an attack, assess and maintain ABCs, notify RT/MD, and implement collaborative care, such as meds and IV fluid, as ordered. +Stay with Pt and offer emotional support. +Monitor vital signs, and document response to prescribed therapies. Mild episodic asthma is well managed with intermittent use of short-acting inhaled beta-2 agonists, such as levalbuterol. Patients with more severe disease or frequent exacerbations rely on other medications to control the disease, such as inhaled corticosteroids, mast cell stabilizing drugs, e.g., cromolyn, long-acting beta-2 agonists, e.g., salmeterol, inhibitors of leukotrienes, e.g., montelukast, and short-acting beta-2 agonists. IgE blockade with omalizumab, a monoclonal antibody, may be used for severe allergic asthma; its routine use is limited by its cost. Salmeterol and formoterol, both long-acting beta-2 agonists, have been linked to an increased risk of death and carry a black box warning.Acute asthmatic attacks may require high doses or frequent dosing of beta-agonists and steroids. Supplemental oxygen is provided. Increased fluid intake is encouraged to help thin secretions and ease their removal. Antibiotics are used only for bacterial infection. Monitor Monitoring of the acute asthmatic patient includes regular assessments of peak air flow, oxygen saturation, blood gases, and cardiac rhythms. Exhaustion or altered mental status may be signs of impending respiratory failure, which may warrant close noninvasive ventilatory support or endotracheal intubation. DIAGNOSIS Asthma is readily diagnosed clinically during attacks, during which the patient, typically a child or adolescent, develops shortness of breath, cough and wheezing after exposure to smoke, an inhaled allergen, or a respiratory infection. Between attacks, asthma may be diagnosed with spirometry as a decrease in the amount of air a person can exhale in one second during a maximal exhalation. When the diagnosis is uncertain, it can be determined with the use of a methacoline challenge, a test in which a provocative concentration of this muscarinic agonist is given to the patient to inhale and airway responsiveness is measured. PATIENT CARE proper use of inhaled medications, paying special attention to how well the patient uses metered dose inhalers. A spacer device is often used to improve the inhalation of medications into the lower airways.Patients whose breathing is labored are seated in an upright (high-Fowler) position to ease ventilatory effort and are given low-flow oxygen and other prescribed medications. Purulent sputum should be sent to the laboratory for culture and sensitivity, Gram stain, or other ordered studies. The health care provider educates the patient about eliminating exposure to allergens or irritants, e.g., secondhand smoke, cold air, and teaches home measures to prevent or decrease the severity of future attacks. Patient Teaching +Provide Pt and family with literature on asthma. +Explain actions, dosages, side effects, and adverse reactions of meds. +Provide instructions on proper use of metered-dose inhalers. +Provide instructions on proper use of peak-flow meter. +Provide instructions on implementing an asthma management plan. +Teach Pt and family about kinds of triggering agents that can precipitate an attack and how to minimize risk of exposure. +Instruct Pt to seek immediate medical attention if symptoms are not relieved with prescribed meds. CAUSES Exposure to tobacco smoke and viral illnesses are the most frequently identified factors. Other respiratory exposures, e.g., to air pollution, allergens, dust, cold air, exercise, fumes, or medicines, may contribute to asthma attacks. Autonomic and inflammatory mediators (esp. arachidonic acid derivatives such as leukotrienes) play important roles. Which of the following assessment findings would help confirm a diagnosis of asthma in a client suspected of having the disorder? Inspiratory and expiratory wheezes are typical findings in asthma. Circumoral cyanosis may be present in extreme cases of respiratory distress. The client would have decreased forced expiratory volume because asthma is an obstructive pulmonary disease. Breath sounds will be "tight" A client with acute asthma showing inspiratory and expiratory wheezes and a decreased expiratory volumes should be treated with which of the following classes of medication right away ? Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow. (Beta adrenergic blockers arent used to treat asthma and can cause bronchoconstriction. Inhaled and oral steroids may be given to reduce inflammation but arent used for emergency relief.) · · · A 7 year old client is brought to the ER. He is tachypneic and afebrile and has respiratory rate of 36 and a non productive cough. He recently had a cold. From his history, the client may have the following? Acute asthma Percipitating Factors Drugs (aspiring NSAIDs, beta blockers) Infections Pollutants (home and work Laughter (emotion) Occupational Mites Allergies, activity and exercise Temperature Triggers of Asthma Asthma triad: nasal polyps, asthma, and sensitivity to aspirin and NSAIDs + Wheezing develops in about 2 hrs +Sensitivity to salicylates -Found in many foods, beverages, and flavorings Infections Major precipitating factor of an acute asthma attack + Increased inflammation leads to hyper-responsiveness of the tracheobronchial system and acute airflow limitations. Air Pollutants +cleaning products +scented products +cigarette or wood smoke +vehicle exhaust +elevated ozone levels +sulfur dioxide Occupational Asthma is the most common form of occupational lung disease +exposure to diverse agents Arrive at work well, but experience a gradual decline. Mites Microscopic- they feed on skin cells and are found in dust + wash bedding in hot water + Damp dust ( no feather dusters!) + Avoid carpeting and drapery + Avoid furred animals + Avoid or control cockroaches Allergies About 40% of cases are related to an allergic response + May be seasonal or year round depending on exposure to allergen + Primary response from exposure to allergens or irritants is chronic inflammation + Food allergies may cause asthma symptoms -Avoidance diets -rare in adults Activities + ACtivity/excercise induced or exacerbated after exercise + use short acting bronchodilator prior to exercising -Beta 2 adrenergic agonist prevent the release of inflammatory mediators from mast cells. Temperature Exposure to cold air + Exposure to cold air + Dress warmly + Breathing through a scarf or mask may decrease likelihood of symptoms

CHEMICAL CLASS Beta Blockers · Metoprolol (Lopressor) · Atenolol (Antianginal, antidysrhythmics, antihypertensive) "olols"

ACTION · Blocks Beta 1 receptor → ¯ HR, contractility, conduction, renin (¯ BP) · Reduces need for O2 consumption ADVERSE EFFECTS · Hypotension, bradycardia · Dizziness, faintness · Bronchospasm · Behavioral or psychotic response ·Impotence NURSING INTERVENTIONS · Monitor BP & P, rhythm · Assess for bronchospasm Caution with asthma · Taper off over 1-2 weeks to prevent rebound tachycardia, vasoconstriction · DM- check BS freq. because ↓ BS can develop with few Sx.

child with croup is being treated in the ED. Since the nurse's initial assessment, he has become more restless with an increase in RR and HR, but with decreased stridor. What do you suspect? What should you do

I suspect the child is suffering from respiratory distress. Child should be hospitalized along with using humidified oxygen and IV fluids. This is done until respiratory distress subsides and the child can take adequate fluids by mouth

Which statement indicates the need for further teaching for the patient diagnosed with sleep apnea

I'm trying to lose weight and stop smoking." "The continuous airway pressure prevents the collapse of my airway." "Using CPAP at night will help me stay awake during the day." "I'm glad they found out I have sleep apnea from all the X-rays they took."

A parent calls the pediatrician's office about her child who complains of a severe sore throat and refuses to drink fluids or take any pain medications. What is the most important question for the nurse to ask in order to determine the need to be seen in the emergency department? 3-year-old child is admitted to the ER with a sore throat, difficulty swallowing, drooling and high fever. What illness do you suspect? How is this patient prioritized?

"Is the child drooling or do you hear a raspy sound when the child breathes?" I suspect the child has bronchiolitis (respiratory syncytial viral infection).The infant usually has a history of an upper respiratory infection and runny nose (rhinorrhea) that lasts for several days. Infants may have increasing restlessness or depressed sensorium. Infants often have a moderate fever of approximately 102°F (38.9°C), a decrease in appetite, poor feeding, and gradual development of respiratory distress. A cough usually appears after the first few days of symptoms. Some children wheeze audibly.

active TB about measures to prevent transmission of the disease

hand washing is the best tool for prevention of infection. The client should wash her hands very carefully after any contact with body substances, masks, or soiled tissues. The family should also use good hand washing techniques We all need to wash our hands carefully, but especially our daughter.

A 3-year-old underwent a tonsillectomy this morning. As the nurse giving discharge instructions, which comment by the child's mother suggests that she understands the care requirements? The pediatric nurse is monitoring a 2-year-old patient who had a tonsillectomy and adenoidectomy today for complications. Which of the following clinical manifestations would be of most concern to the nurse? (Select all that apply.

"I have bought orange popsicles to give her later today." Frequent swallowing Heart rate 160

The nurse has been teaching the family of a child with croup about emergency care. Which statement made by the parent indicates that teaching was effective?

"If he wakes up coughing a barky cough, I will take him outside into the cool air. If he isn't better in an hour, I will bring him to the ER for a breathing treatment." Rationale: Laryngealtrachealbronchitis (LTB) will fatigue the child unless the airway is opened more. In worsening signs of respiratory distress, epinephrine is given to cause vasoconstriction and a reduction of airway swelling. The child will require monitoring in the hospital setting for side effects and any rebound signs and symptoms. No swelling of the epiglottis is present with LTB; breathing hard describes stage II of the progression of symptoms of LTB, which necessitates being observed in a croup tent along with an oximeter to indicate oxygenation status.

CHEMICAL CLASS ACE Inhibitors · Captopril · Lisinopril (Antihypertensive) "prils"

ACTION · Inhibits the formation of angiotensin II →vasodilation · Blocks the release of aldosterone so promotes sodium and water excretion and K retention ·Reduces peripheral vascular resistance ADVERSE EFFECTS · Hypotension · Hyperkalemia, hyponatremia · Bruising, petechiae, bleeding · Cough African Americans and Asians - ↑ risk angioedema and ↑ cough; Cough ↑ in women NURSING INTERVENTIONS · Monitor VS · Monitor BUN, creatinine, protein, K · Immed. report and Tx angioedema (tongue, glottis, pharynx) · Older adults and African Americans produce less rennin and don't respond as well to angiotensin inhibitors · Do not D/C abruptly · Do not take 2nd and 3rd trim. of pregnancy - ¯ placental flow · Watch for 1st dose syncope

CHEMICAL CLASS Calcium Channel Blockers · Cardizem (Diltiazem) · Nifedipine (Antianginal, antidysrhythmic, antihypertensive) Think "pines"

ACTION · Blocks calcium needed to activate myocardial contraction → relax smooth muscle and ¯ contractility → ¯ workload of heart → ¯ O2 need · Relaxes smooth muscle → vasodilation of coronary & peripheral vessels (↓ SVR) · ¯ AV Node conductivity ADVERSE EFFECTS · Headaches, hypotension · Bradycardia · Dizziness, faintness · Edema (fluids accumulate in interstitial space) · reflex tachycardia (Nifedipine) NURSING INTERVENTIONS · Monitor BP & P, rhythm · Monitor liver & kidney function · Do not D/C abruptly → reflex tachycardia and pain may result · ↑ fluids and fiber to prevent constipation · Safety · Potentiates action of Dig. by ↑ing serum levels first week of therapy so √ Dig levels

CHEMICAL CLASS Angiotensin II Receptor Blockers · Losartan · Irbesartan (Antihypertensive) "artans"

ACTION · Blocks receptors for Angiotensin II, therefore → vasodilation · Blocks the release of aldosterone so promotes sodium and water excretion and K retention · Reduces peripheral vascular resistance A-II responsible for remodeling heart and vessel walls ADVERSE EFFECTS · Hypotension · Hyperkalemic NURSING INTERVENTIONS · Monitor VS · Monitor K, BUN, Creat, protein · Do not D/C abruptly · Immed. report and Tx angioedema (tongue, glottis, pharynx) · Do not take 2nd and 3rd trim. of pregnancy - ¯ placental flow · Older adults and African Americans produce less rennin and don't respond as well to angiotensin inhibitors

Bronchiolitis- Pediatric respiratory Problems

Bronchiolitis- Inflammation of fine bronchioles +Usually 2-12 months (rare after 2 years) +Acute viral infection * respiratory syncytial virus (RSV) +Blockage of smaller bronchioles with mucus and inflammatory products +Serous nasal discharge +Tachypnea >60, retractions, wheezing, rales, nasal flaring, cyanosis +Tachycardia >140 +Difficulty feeding, decreased urine output +Semi- fowler's position and neck slightly extended to keep pressure off diaphragm A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Choose the interventions that would be included in the plan of care (select all that apply) + place the infant in a private room + Place the infant in a room near the nurses station + Ensure that the infants head is in a flexed position + Wear a mask at all times when in contact with the infant + Humidification should be cool. Head should be higher than the chest An infant is hospitalized with RSV bronchiolitis. The priority nursing diagnosis is Treatment: supportive care = no ABX 10-month-old child is admitted to the unit with bronchiolitis: Temperature 102°F;apical pulse 154, R 68; very irritable. Pulse oximetry is 87% on room air. Oxygen therapy is ordered to: relieve hypoxia and cyanosis. What intervention would most significantly decrease transmission of RSV, the causative agent in bronchiolitis? • Meticulous hand washing •Isolation or in room with other RSV patients • Contact/ droplet precautions. • Suction before feedings . Infants are nose breathers. An infant with bronchiolitis exhibits dry mucous membranes and a sunken fontanel. Why is this occurring, and what interventions would you expect to complete? • Dehydration from water loss from tachypnea or poor intake • Patental administration of Fluids (IV fluids) if child cannot take them orally other wise you would offer various clear liquids (juices, pedialyte, ricelyte ) PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters may also be monitored but do not directly assess for pulmonary hypertension.

Influenza

Complications of influenza include pneumonia, myositis, exacerbation of chronic obstructive pulmonary disease, and Reye syndrome. In rare cases, influenza can lead to encephalitis, transverse myelitis, myocarditis, or pericarditis. I would monitor vital signs to detect any change in the rhythm or quality of respirations. The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the-counter pain relievers and increased fluid intake. patients should receive the inactivated influenza vaccination -A 76-yr-old nursing home resident -A 36-yr-old female patient who is pregnant -A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis Current guidelines suggest that healthy individuals between 6 months and age 49 years receive intranasal immunization with live, attenuated influenza vaccine. Individuals who are pregnant, residents of nursing homes, or are immunocompromised or who have chronic medical conditions should receive inactivated vaccine by injection. The corticosteroid use by the 30-yr-old patient increases the risk for infection. Highly contagious, acute viral respiratory infection Three groups of viruses -A, B, C Abrupt onset Headache, muscle aches, fever, chills, fatigue, weakness, anorexia Symptomatic treatment Antiviral medication (if taken first 24-48 hours) Annual vaccination. The pneumococcal and influenza vaccines can be given at the same time in different arms. Antibiotics are ineffective in treating viral infections such as influenza.

Sleep Apnea Sleep apnea: more common in overweight people: treatment is lose weight if mild, CPAP, BiPAP(, surgery if more severe Symptoms and treatments

Diagnosis and Monitoring •Home respiratory monitoring is a cost-effective alternative for diagnosing sleep-related breathing disorders that allows patients the convenience of sleeping in their own home. •Home respiratory monitoring is used as part of a comprehensive sleep evaluation and in patients likely to have moderate to severe obstructive sleep apnea but without heart failure, obstructive lung disease, or neuromuscular disease. •Home respiratory monitoring is used to monitor the effectiveness of non-CPAP therapies for patients with sleep-related breathing disorders. •Wireless monitors can detect changes in vital signs and pulse oximetry, raising an alarm if values fall outside of set parameters. •Your patient may benefit from tele health to diagnose and monitor for sleep apnea in the home. Signs and symptoms Signs of sleep apnea include snoring, insomnia, abrupt awakenings, daytime drowsiness, and early morning headaches. Night sweats may be a manifestation of TB NURSING AND COLLABORATIVE MANAGEMENT CONSERVATIVE TREATMENT Mild sleep apnea (5 to 10 apnea/hypopnea events per hour) may respond to simple measures. Conservative treatment at home begins with sleeping on one's side rather than on the back. Elevating the head of the bed may eliminate OSA in some patients. Instruct the patient to avoid taking sedatives or consuming alcoholic beverages for 3 to 4 hours before sleep. Sleep medications often make OSA worse. OSA is a potentially life-threatening disorder. Because excessive weight worsens sleep apnea, referral to a weight loss program may be indicated. Weight loss and bariatric surgery reduce OSA.33 Instruct the patient on the dangers of driving or using heavy equipment Clinical Manifestations and Diagnostic Studies. Clinical manifestations of sleep apnea include frequent arousals during sleep, insomnia, excessive daytime sleepiness, and witnessed apneic episodes. The patient's bed partner may complain about the patient's loud snoring. Other symptoms include morning headaches (from hypercapnia or increased blood pressure that causes vasodilation of cerebral blood vessels), personality changes, and irritability.Sleep apnea results from increased fat around the neck, leading to snoring and hypoventilation while sleeping. Weight loss can bring substantial improvement in lung function. Poor sleep and sleep deprivation may increase appetite. Sleep deprivation has been associated with obesity. Building up a sleep debt over a matter of days can impair metabolism and disrupt hormone levels. The level of leptin falls in people who are sleep deprived, thus promoting appetite. COMPLICATIONS Complications that can result from untreated sleep apnea include hypertension, right-sided heart failure from pulmonary hypertension caused by chronic nocturnal hypoxemia, and cardiac dysrhythmias. Chronic sleep loss predisposes the person to diminished ability to concentrate, impaired memory, failure to accomplish daily tasks, and interpersonal difficulties. The male patient may experience impotence. Driving accidents are more common in habitually sleepy people. Family life and the patient's ability to maintain employment are often compromised. As a result, the patient may experience severe depression. Cessation of breathing reported by the bed partner is usually a source of great anxiety because of the fear that breathing may not resume. Sleep apnea has been associated with an increased risk of life-threatening dysrhythmias, especially in patients with heart failure. Nocturia, a common finding with cardiovascular patients, also interrupts normal sleep patterns. Fully explore both conditions. Assessment/Diagnosis Assessment of the patient with OSA includes a thorough sleep and medical history. Symptoms of OSA, including daytime sleepiness, snoring, and witnessed apnea, are obvious characteristics of the disorder. Less obvious symptoms may include cardiovascular manifestations, muscle pain, and mood changes. Patients with OSA frequently have co-morbidities, including a history of stroke and cardiovascular disease. PSG is used to make the diagnosis of sleep apnea. The patient's chest and abdominal movement, oral and nasal airflow, SpO2, ocular movement, and heart rate and rhythm are monitored. A diagnosis of sleep apnea requires documentation of apneic events (no airflow with respiratory effort) or hypopnea (airflow diminished 30% to 50% with respiratory effort) of at least 10 seconds' duration. OSA is defined as more than five apnea/hypopnea events per hour accompanied by a 3% to 4% decrease in oxygen saturation. Severe apnea can be associated with apneic events of more than 30 to 50 per hour of sleep.8 Typically, PSG is done in a clinical sleep laboratory with technicians monitoring the patient. In some instances, portable sleep studies are conducted in the home setting. Overnight pulse oximetry assessment may be done to determ A patient with sleep apnea would like to avoid using a nasal CPAP device if possible. To help him reach this goal, the nurse suggests that the patient . lose excess weight

Epiglottitis

Epiglottitis- Severe inflammatory process of the epiglottis and surrounding tissue • Bacterial- H influenza B • Life threatening, very rapid progression • Drooling (cant swallow saliva), dysphagia, dysphonia (muffled voice), distressed respiratory effort (tripod position) • Nasal flaring, retractions, cyanosis, tachycardia, anxious • ICU care • No throat exam with tongue depressor or oral temp Epiglottitis: Medical emergency S/S: Severe sore throat, 4 Ds (drooling, dysphagia, dyspnea dysphonia) Positioning child uses What should you anticipate the MD will order ND: Risk for airway obstruction Which statement is correct regarding the role of the epiglottis? after swallowing, this structure moves downward to prevent swallowing contents from entering the trachea. During a 2 month well visit with a patient and her mother, you educate the parent on the most common cause of epiglottitis. You explain to the mother the most common cause of this condition is the _____. In addition, you explain_____ can help prevent most cases of this condition H. influenzae B, Hib vaccine A young child is admitted with acute epiglottitis. Which is of the highest priority as the nurse plans care? Assessing the airway frequently 4-year-old boy with acute epiglottitis is admitted to the emergency room. He has afever of 102⁰F, is agitated, drools, and insists upon sitting up and leaning forward with the chin thrusting outward. The nurse expects which of the following? the child will cry and resist lying supine when he needs to be examined and X-rayed.

The nurse is caring for a patient at risk for atelectasis. Which nursing measure is most important in preventing atelectasis?

Frequent changes in position especially from supine to upright. Frequent changes in position promote ventilation and prevent secretions from accumulating. Although A and B are both measures the nurse could take, they would not be the primary concern.

Why are sedation and paralysis used with mechanical ventilation?

Patients who remain asynchronous with mechanical ventilation despite aggressive sedative and analgesic dosing may require neuromuscular blockade (paralysis) with agents such asvecuronium or cisatracurium (Nimbex). These drugs relax skeletal muscles by interfering with neuromuscular transmission and, ultimately, promote synchrony with mechanical ventilation. Remember that a patient receiving neuromuscular blockade can appear to be asleep but still possibly be awake and in pain. For this reason, deep sedation and analgesia are essential. The physical discomfort associated with ET intubation and mechanical ventilation often requires sedating the patient and giving an analgesic until the ET tube is no longer needed. The patient may need fentanyl, midazolam, propofol, or other sedatives to blunt the anxiety and discomfort related to intubation. Evaluate the drugs' effectiveness in achieving an acceptable level of patient comfort by using a valid pain scale, sedation scale (e.g., Ramsey Sedation Scale), and/ordelirium scale. In addition, consider using relaxation techniques (e.g., music therapy) to complement drug therapy

Knowing the patient needs precise oxygen, what O2 delivery system would be the nurse's best choice?

Most commonly used device • O2 delivered via plastic nasal prongs • Safe and simple method that allows some freedom of movement. Patient can eat, talk, or cough while wearing device. •Useful for a patient requiring low O2 concentrations • O2 concentrations of 24% (at 1 L/min) to44% (at 6 L/min) can be obtained. Nasal cannula is best as the Oxygen can be easily humidified.

A child is diagnosed with group A streptococcus pharyngitis. In teaching the parents about treatment of the infection, what does the nurse instruct the parents? A few weeks after group A beta-hemolytic streptococcal pharyngitis, the patient reports joint pain, weakness, and rash on the inner aspects of the upper arm and thigh. These assessment findings are indicative of which complication?

Need to complete penicillin or amoxicillin as prescribed Rheumatic fever

Albuterol: Ther. Class.bronchodilators Pharm. Class.adrenergics

Purpose : Treatment or preventionof bronchospasm inasthma or chronic obstructive pulmonarydisease (COPD). Goal isto prevent or relievebronchospasms. Teaching: Shake inhaler well, and allow at least 1 minbetween inhalations of aerosol medication.Prime the inhaler before first use by releasing 4test sprays into the air away from the face.Caution patient also to avoid smoking and otherrespiratory irritants.Inform patient that albuterolmay cause an unusual or bad taste. Advisepatient to rinse mouth with water after eachinhalation dose to minimize dry mouth andclean the mouthpiece with water at least once awk

what is the effect of pancreatic duct obstruction? What would be the medical treatment for this and what is the nursing responsibility for this treatment?

Pancreatic insufficiency is caused primarily by mucous plugging of the pancreatic exocrine ducts, which results in atrophy of the gland and progressive fibrotic cyst formation. • Because of the exocrine dysfunction, pancreatic enzymes such as lipase, amylase and proteases are not made in sufficient amount to allow for absorption of nutrients • Malabsorption of fat, protein, and fat soluble vitamins (A, D, E and K) occurs. Fat malabsorption results in steatorrhea and protein malabsorption results in failure to grow and gain weight. • Standard treatment of infections includes antibiotics for exacerbations and may include chronic suppressive therapy in conjunction with airway clearance. The use of antibiotic should be carefully guided by sputum culture results. Early intervention with antibiotics is useful, and long courses of antibiotics are the usual treatment. • Prolonged high dose therapy may be necessary because many drugs are abnormally metabolized and rapidly excreted in the patient with CF. • Obstruction of pancreatic ducts results in pancreatic ischemia • pain management, breathing patency , vitals, 02 saturation

Pharyngitis Pediatric respiratory problems

Pharyngitis - Inflammation of the pharynx and surrounding lymphoid tissue. +Viral and bacterial (group A strep) +Sore throat +Enlarged tonsils with erythema and white exudate +Difficulty swallowing +Mouth breathing and bad breath Acute pharyngitis of a bacterial nature is most commonly cause by: Nursing management for a patient with acute pharyngitis includes: Applying ice collar for symptomatic relief of the sore throat. Encouraging bed rest during the febrile stage of the illness Suggesting a liquid of soft diet during acute stage of the disease.

RIPE

Rifampin (RIF) Isoniazid (INH) Pyrazinamide (PZA) Ethambutol (EMB) common drugs include isoniazid(INH), rifampin (RIF), ethambutol (EMB), pyrazinamide, ciprofloxacin, and rifapenti Ethambutol (EMB) (Myambutol) and isoniazid (INH may work best to take these pills in the evening right before bed. Rational These medications frequently cause nausea. The nausea maybe decreased if the medications are taken at bedtime

Antitussives Suppresses cough center in medulla

SIDE EFFECTS CNS and resp. depression only with codeine, N, V, A, C, rash, urine retention AGENTS -codeine best one -dextromethorphan (Robitussin DM) ROUTE/ DOSE P.O. NURSING IMPLICATIONS · Best to suppress cough at night only · Patient needs to be hydra- ted to thin secretions · Increased risk constipation with codeine

Mast Cell Stabilizers (Non-steroidal anti-inflammatory) Used prophylactically Can be used along with broncho- dilators Inhibits the release of histamine and other chemical mediators Decrease inflammation & irritation - inhibits immediate response & prevents late response

SIDE EFFECTS Cough, bad taste Throat irritation Rash, headache, N. V Bronchospasm AGENTS cromolyn (Intal) nedocromil (Tilade) Inhaled anti-inflammatory ROUTE/ DOSE MDI, HHN Nasal- for allergies NURSING IMPLICATIONS · Use only as prevention - does not directly bronchodilate · Used for exercise induced asthma, allergic rhinitis · Drink H2O a & p Do not D/C abruptly- rebound Sx

Decongestants Stimulate receptors in nose causing vaso-constriction * nasal spray can result in rebound nasal congestion (heavy use or for longer than 5 days)

SIDE EFFECTS Insomnia Minimal Jittery, Nervousness Seizures in elderly AGENTS -pseudoephedrine (Sudafed) -ephedrine (Ephedsol) Systemic -oxymetazoline (Afrin) local (nasal spray) ROUTE/ DOSE P.O. Nasal inhaler NURSING IMPLICATIONS · Use with caution with hypertension · avoid long-term use caution with glaucoma

What could you do if you cannot correct the alarms on the ventilator?

Start bagging patient with 100% o2 manually. Make sure staff is notified and stay with the patient until a new ventilator is provided. Alarms should always be on. It is important that you check that all ventilator alarms are always on. Alarms alert the staff to potentially dangerous situations such as mechanical malfunction, apnea, unplanned extubation, or patient asynchrony with the ventilator. On many ventilators the alarms can be temporarily suspended or silenced for up to 2 minutes for suctioning or testing while a staff member is in the room. After that time, the alarm system automatically turns back on.

Which of the following will most likely be included in the plan of care? (Select all thatapply) with a diagnosis of exacerbation of COPD, pneumonia, and dehydration

Teach huff coughing Require frequent rest periods throughout the day Teach pursed lip and abdominal breathing

A patient is 2 days post-op surgery. He is now complaining of shortness of breath and had reported his calf had been sore yesterday. How will the nurse interpret the findings?

The patient may be experiencing a pulmonary embolus. Rationale: There is a risk of developing a pulmonary embolism as a result of venous thrombosis in the lower extremity following surgery. More diagnostic testing should follow. SOB may indicate the thrombosis has traveled and may be in the lungs. Emergency intervention should be initiated.

PATIENT AND CAREGIVER TEACHING GUIDE Guidelines for Effective Huff Coughing

When teaching effective coughing, you should: 1. Help the patient assume a sitting position with head slightly fl exed, shoulders relaxed, knees fl exed, and forearms supported by pillow, and if possible, with feet on the fl oor. Then you should instruct the patient to: 2. Inhale slowly through the mouth while breathing deeply from the diaphragm. 3. Hold the breath for 2-3 seconds. 4. Forcefully exhale quickly as if one is fogging up a mirror with one's breath (thus creating a "huff"). (This moves the secretions to larger airways.) 5. Repeat the "huff" one or two more times while refraining from a "regular" cough. 6. Cough when mucus is felt in the breathing tubes. 7. Rest for fi ve to ten regular breaths. 8. Repeat the huffs (three to fi ve cycles) until you feel you have cleared mucus or you become tired.

A student nurse asks the RN what can be measured by arterial blood gases (ABGs). The RN tells the student that the ABGs can measure

acid-base balance oxygenation status. acidity of the blood bicarbonate (HCO3 − ) in arterial blood.

sleep apnea

signs and symptoms Loud snoring Excessive daytime sleepiness Frequent episodes of obstructed breathing during sleep Morning headache Un refreshing sleep Increased irritability Potential Complications Cardiac changes Poor concentration/ memory Impotence Depression dysrhythmia d/t acidosis Hypoxemia Hypertension d/t hypoxemia Hypercapnea Pulmonary Hypertension d/t hypoxemia Right sided heart failure d/t pulm HTN Treatment Non- Surgical change sleep position ( sleeping on ones side, Elevating head of bed, Avoiding sedatives andalcohol 3-4 hours before sleep_Decrease weightCPAP (continuous positive airway pressure)Drug therapy for underlying causeSurgicalAdenoidectomyUvulectomyRemodeling posterior oropharynxBariatric surgery to decrease weight

. Why would an epidural anesthetic be used instead of general anesthesia?

there is less effect on the respiratory system with epidural anesthesia. Rationale: Epidural anesthesia does not cause resp. depression, but general anesthesia can, especially in a client with COPD. This type of intra spinal anesthesia provides safe and effective pain relief for patients of all ages with less risk of adverse effects than general anesthesia. Respiratory function is not affected by giving spinal and epidural anesthesia at lumbar level, except in morbidly obese patients where the neuraxial blockade has been shown to produce a20-25% fall in expiratory functional volume (FEV1, forced vital capacity) and that may interfere with the ability to cough and to clear bronchial secretions as a result of blocking the abdominal wall muscle

small child with Cystic Fibrosis.....What dietary suggestions can the nurse recommend to the child's mother to enhance his growth?

high-protein, high-calorie meals with skim-milk milkshakes between meals. RATIONAL: Added dietary salt is indicated whenever sweating is excessive, such as during hot weather, when fever is present, or from intense physical activity. Fat, protein, dairy, fruits, and vegetables. High protein, low fat, high calorie diet, administration of digestive enzymes before meals

The nurse is performing an assessment on the patient with suspected bacterial pharyngitis. Which assessment finding is most indicative of a bacterial versus viral infection? A patient with an acute pharyngitis is seen at the clinic with fever and severe throat pain that affects swallowing. On inspection, the throat is reddened and edematous with patchy yellow exudates. The nurse anticipates which of the following collaborative interventions?

positive throat culture A rapid strep antigen test and throat culture

How does a mechanical ventilator using PEEP benefit the client with Acute Respiratory Distress Symptom

A ventilator using PEEP benefits the client by increasing functional residual capacity and improving oxygenation

chronic obstrictive pulmonary disease (COPD)

· Chronic inflammation of airways · Permanent structural changes · Smoking · Severe recurrent res. infections · Slow onset of symptoms · Early - chronic ,daily intermittent cough, may be productive Chronic obstructive pulmonary disease (COPD) encompasses two diseases: emphysema and chronic bronchitis. Most clients who have emphysema also have chronic bronchitis. COPDis irreversible.COPD typically affects middle‑age to older adults. · Diagnosis Common symptoms of COPD include shortness of breath, cough, phlegm, and wheezing. A definitive diagnosis of COPD involves measuring lung function using spirometry, which is a noninvasive outpatient procedure. Treatment . Management should include smoking cessation and abstinence; limiting exposure to secondhand smoke, dusts, fumes, and gases; pharmacological treatment with bronchodilators and corticosteroids; supplemental oxygen therapy; pulmonary rehabilitation; collaborative self-management; and surgery . Health promotion & disease prevention ● Promote smoking cessation. ● Avoid exposure to secondhand smoke. ● Use protective equipment, such as a mask, and ensure proper ventilation while working in environments that contain carcinogens or particles in the air. ● Influenza and pneumonia vaccinations are important for all clients who have COPD, but especially for older adults. Assessment: risk factors ● Advanced age: Older adult clients have a decreased pulmonary reserve due to normal lung changes. ● Cigarette smoking is the primary risk factor for the development of COPD. ● Alpha1‑antitrypsin (AAT) deficiency ● Exposure to environmental factors (air pollution) Assessment: expected findings Chronic dyspneaPHYSICAL ASSESSMENT FINDINGS ● Dyspnea upon exertion ● Productive cough that is most severe upon rising in the morning ● Hypoxemia ● Crackles and wheezes ● Rapid and shallow respirations ● Use of accessory muscles ● Barrel chest or increased chest diameter (with emphysema) ● Hyperresonance on percussion due to "trapped air" (with emphysema) ● Irregular breathing pattern ● Thin extremities and enlarged neck muscles ● Dependent edema secondary to right‑sided heart failure ● Clubbing of fingers and toes (late stages of the disease) ● Pallor and cyanosis of nail beds and mucous membranes (late stages of the disease) ● Decreased oxygen saturation levels (expected reference range is 95% to 100%) ● In older adults or clients who have dark‑colored skin, oxygen saturation levels can be slightly lower COPD lab tests ● Increased hematocrit level is due to low oxygenation levels. ● Use sputum cultures and WBC counts to diagnose acute respiratory infections. ● Arterial blood gases (ABGs)- Hypoxemia (decreased PaO2 less than 80 mm Hg)- Hypercarbia (increased PaCO2 greater than 45 mm Hg) ● Serum electrolytes 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. COPD nursing care 1 ● Position the client to maximize ventilation (high‑Fowler's). ● Encourage effective coughing, or suction to remove secretions. ● Encourage deep breathing and use of an incentive spirometer. ● Administer breathing treatments and medications. ● Administer oxygen as prescribed. ● Monitor for skin breakdown around the nose and mouth from the oxygen device. ● Promote adequate nutrition.- Increased work of breathing increases caloric demands.- Proper nutrition aids in the prevention of infection.- Encourage fluids to promote adequate hydration.- Dyspnea decreases energy available for eating, so soft, high‑calorie foods should be encouraged. ● Monitor weight and note any changes Incentive spirometry Incentive spirometry is used to monitor optimal lung expansion.NURSING ACTIONS: Show the client how to use the incentive spirometry machine.CLIENT EDUCATION: Instruct the client to keep a tight mouth seal around mouthpiece and to inhale and hold breath for 3 to 5 seconds. As the client inhales, the needle of the spirometry machine will rise. This promotes lung expansion. Complications If you have COPD, you also may often have colds or other respiratory infections such as the flu, or influenza. Nursing Assessment Objective data General Debilitation, restlessness, assumption of upright position Integumentary Cyanosis (bronchitis), pallor or ruddy color, poor skin turgor, thin skin, digital clubbing, easy bruising; peripheral edema (cor pulmonale) Respiratory Rapid, shallow breathing; inability to speak; prolonged expiratory phase; pursed-lip breathing; wheezing; rhonchi, crackles, diminished or bronchial breath sounds; ↓ chest excursion and diaphragm movement; use of accessory muscles; hyperresonant or dull chest sounds on percussion Cardiovascular Tachycardia; dysrhythmias, jugular vein distention, distant heart tones, right-sided S 3 (cor pulmonale), edema (especially in feet) Gastrointestinal Ascites, hepatomegaly (cor pulmonale) Musculoskeletal Muscle atrophy, ↑ anterior-posterior diameter (barrel chest) Possible Diagnostic Findings Abnormal ABGs (compensated respiratory acidosis, ↓ PaO 2 or SaO 2 , ↑ PaCO 2 ), polycythemia, pulmonary function tests showing expiratory airfl ow obstruction (e.g., low FEV 1 , low FEV 1 /FVC, large RV), chest x-ray showing fl attened diaphragm and hyperinfl ation or infi ltrates NURSING DIAGNOSIS Ineffective breathing pattern related to alveolar hypoventilation, anxiety, chest wall alterations, and hyperventilation as evidenced by assumption of three-point position, dyspnea, increased anterior-posterior diameter, nasal fl aring, orthopnea, prolonged expiration, pursed-lip breathing, use of accessory muscles to breathe PATIENT GOALS 1. Returns to baseline respiratory function 2. Demonstrates an effective rate, rhythm, and depth of respirations COPD (Chronic Bronchitis and Emphysema) Huff coughing, diaphragmatic breathing, pursed lip breathing (How do these help the patient?) nutrition, medications, and patient teaching re: when to call MD/exacerbations. Arrange for the patient's caregiver to be present during the teaching. Hypoxemia interferes with the patient's ability to learn and retain information, so having the patient's caregiver present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed. The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of O2 or medications. Reduced excursion The technique for palpation for chest excursion is shown in the illustrated technique. Reduced chest movement would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion. Accessory muscle use and tripod positioning would be assessed by inspection. 1-antitrypsin testing. When COPD occurs in young patients, especially without a smoking history, a genetic deficiency in 1-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 patients with asthma, not with COPD. Cimetidine interferes with the metabolism of theophylline, and concomitant administration may lead rapidly to theophylline toxicity. The other patient information would not affect whether the theophylline should be administered or not. 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. nursing diagnosis of imbalanced nutrition: less than body requirements. Offer high-calorie protein snacks between meals and at bedtime.Eating small amounts more frequently (as occurs with snacking) will increase caloric 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 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. 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. Walk 15 to 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 increases. 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 ). 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. Patients with COPD improve the mechanics of breathing by sitting 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.

Tuberculosis (TB)

"Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (e.g., chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing. Tuberculosis - an infectious disease caused by mycobacterium tuberculosis ·A gram + acid fast bacilli ·Fatigue, lethargy, nausea, anorexia, weight loss, low grade fever ·Night sweats ·Cough, sputum ·Chest tightness, chest pain ·+ Skin test ·Combination drug therapy for 6-9 months. Arrange for a daily meal and drug administration at a community center.Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient's situation. Drug Rifampin Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol, which is a different tuberculosis medication. Tuberculosis (TB) is endemic in many parts of Asia, and the incidence of TB is much higher in immigrants from Vietnam than in the general U.S. population. Yellow-tinged sclera Noninfectious hepatitis is a toxic effect of isoniazid, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider. After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?Ask the patient whether medications have been taken as directed.The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated Which of the following symptoms is common in clients with TB? · weight loss The nurse should include which of the following instructions when developing a teaching plan for clients receiving INH and rifampin for treatment of TB? Limit alcohol intake Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice. Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for Mycobacterium tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB. A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? Sputum smears for acid-fast bacilli are negative.Repeated negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment. The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family member. ·I should always cover my mouth and nose when sneezing and coughing ·I should use paper tissues to cough in and dispose of them propertly ·I can use regular plates and utensils when i eat A client is HIV positive and has had a PPD skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as ·POSITIVE (healthy population 15mm or > Immigrants, long term care resident or prisoner 10mm or > HIV +, immunosuppressed 5mm or > ) Isoniazed (INH) and rifampin (Rifadin) have been prescribed for a client with TB. The nurse reviews the medical record of the client. Which of the following, if notes in the clients chart history, would require physician notification? aHeart disease bAllergy to penicillin cHepatitis B dRheumatic fever diet Eat frequent small, high-calorie diet. Rationale: The goal is to maintain normal weight or allow for weight gain. Weight loss may have occurred during the disease process, so small, frequent meals would be tolerated best. Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation. Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?Use and side effects of isoniazid.The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test result. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection. A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue. Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB.

The nurse can best determine adequate arterial oxygenation of the blood by assessing?

. arterial oxygen tension

During the respiratory assessment of the older adult, the nurse would expect to find

. increased residual volume increased anteroposterior (AP) chest diameter.

When should the nurse schedule the chest percussion treatment? Cystic Fibrosis

1 hour before meals or 2 hours after meals ( 1-2 hours after a meal) Why? - Schedule Tx 1hr before or 2hr after meals & at bedtime (decrease vomiting/aspiration) -Chest physical therapy (CPT), or postural drainage and percussion (PD & P), uses gravity and percussion (clapping on the chest and/or back) to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Unclogging the airways is key to keeping lungs healthy. Generally, each treatment session can last for 20 to 40 minutes. PD & P is best done before meals or one and a half to two hours after eating, to decrease the chance of vomiting. Early morning and bedtimes are usually recommended. The length of PD & P and the number of times of day itis done may need to be increased if the person is more congested or getting sick. Your CF doctor or therapist will help you know what positions, how often and how long PD & P should be done.

A newly admitted client is suspected to have influenza due to increasing dyspnea and dehydration. Which of these prescribed actions will the nurse implement first?

1) Start oxygen using a non- rebreather mask 2,3,4 should be implemented after addressing the clients respiratory problem 2) Give first dose of oseltamivir (tamiflu) 3) Infuse 5% dextrose in water at 100ml/hr 4) Collect blood sputum specimens for testing

An adult was admitted to the respiratory floor with COPD. The nurse finds him extremely restless, incoherent, and showing signs of acute respiratory distress. He is using accessory muscles for breathing and is diaphoretic and cyanotic. What is the nurse's best initial action? (Select all that apply)

1. Administer oxygen as ordered. 2. Obtain a pulse oximetry reading. 3. Assess vital signs and neural vital signs Should be done in this ORDER Rationale: The patient's symptoms are indicative of hypoxemia. A pulse oximetry should be measured, followed by oxygen administration, and then followed by vital signs. Eventually the ABGs can be requested, but not before administration of the O₂.

Acute Laryngotracheobronchitis LTB (Croup)

14-month-old child is admitted to the hospital with laryngotracheobronchitis (LTB -croup). On assessment the nurse would expect to find: barking, coughing and inspiratory stridor The two primary symptoms of croup include: stridor and barky cough Croup: Harsh cough No antibiotics - why? Treat with humidified air/oxygen Take out in cool air Which intervention for treating croup at home should be taught to parents? have decongestant available to give the child when an attack occurs have the child sleep in a dry room take the child outside Give the child an antibiotic at bedtime.

CHEMICAL CLASS Alpha 1 Adrenergic Blockers · Prazosin (Minipres) · Terazosin (Antihypertensive) Peripheral acting

ACTION · Blocks stimulation of alpha 1 receptors in vasculature → inhibits vasconstriction → dilates veins and arteries & ¯ BP ·↓ serum levels of LDL ADVERSE EFFECTS · Orthostatic Hypotensionand reflex tachycardia · Na & H2O retention & edema · Sedation, headaches, impotence · Dry mouth NURSING INTERVENTIONS · Monitor VS, wt., peripheral edema · Watch UO - not used with renal disease · 1st dose at night to minimize risk of fainting (1st dose syncope) · Rise slowly from supine to standing · Give one-hour ac unless GI upset · Hard candy ·Decrease salt intake

CHEMICAL CLASS Nitrates · Nitroglycerine - SL, IV, patch, paste · Isosorbide (Antianginals, antihypertensives)

ACTION · Decreases cardiac workload and myocardial 02 demands by relaxing peripheral veins and arterioles · Reduces venous return (preload) and peripheral vascular resistance (afterload) ·Dilates nonsclerosed coronary arteries ADVERSE EFFECTS Dizziness, faintness, headache, hypotension Tolerance may occur NURSING INTERVENTIONS · Obtain baseline BP · Sl - give H20 a to enhance absorption; may take 3 doses up to 5 minutes apart. Keep bottle dry and away from light. If no relief p 5 min call 911. Spray should tingle. · Patch/paste - rotate on chest, thighs, arms. Avoid hair. Use gloves - med can be absorbed. · Acetaminophen for headache · Teach patient to sit or stand slowly. · Nitrate free period 8-10 hrs/day (at noc) · IV form also available

CHEMICAL CLASS Alpha 2 Agonists · Clonidine (Catapres) · Methyldopa (Antihypertensive) Central acting- works directly on alpha 2 receptors in CNS

ACTION · Decrease sympathetic response to peripheral vessels. · Stimulate alpha 2 receptors to ¯ sympathetic activity and ¯ serum epinephrine, norepinephrine, & renin release →vasodilation · ¯ Peripheral resistance & afterload ADVERSE EFFECTS · Drowsiness, dry mouth, dizziness, HA, postural hypotension · NA & H2O retention NURSING INTERVENTIONS · Monitor BP & P, weight, peripheral edema, I&O · Monitor serum enzymes · Do not D/C abruptly- severe reflex HTN · Do not take during pregnancy · Sip water or chew sugarless gum for dry mouth

The nurse is caring for a client with a diagnosis of COPD. Auscultation reveals wheezing and his O2 saturation is 85%. Four hours ago his O2 sat was 88%. It is most important for the nurse to do which of the following?

Administer albuterol 2 puffs per MDI Beclomethasone is a steroid anti-inflammatory. It should be used after administering the bronchodilator (albuterol)

Which medication would be most appropriate to administer to a patient experiencing an acute asthma attack ?

Albuterol (proventil HFA) Ipratropium (atrovent HFA) . Both bronchodilators) Salmeterol (serevent) is an anti inflammatory) Montelukast (singulair) is an anti inflammatory and bronchodilator

which of the following actions should be included in the plan of care regarding oxygen use?

Anticipate the need for humidification Adjust the flow rate to keep the reservoir bag inflated 2/3 full during inspiration

INH treatment is associated with the development of peripheral neuropathies. Which of the following interventions would the nurse teach the client to help prevent this complication ?

Avoid excessive sun exposure

Bronchoscopy

Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Because the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway patency. An adult has undergone a bronchoscopy. Which assessment findings indicate to the nurse that he is ready for discharge? Stable vital signs, return of gag and cough reflex. Vital signs are taken frequently. Nothing is given by mouth until the cough and swallow reflexed have returned. Both are important criteria for discharge What nursing care/teaching is required before and after this procedure? NPO 4-8 hours prior to procedure. There is a possibility of laryngeal spasm. Report any difficulty breathing after the test. Check the gag, cough, and swallow reflexed before offering food or fluids. Before Obtain signed consent. After Check breath sounds q4hr for 24 hr and report any respiratory distress. Check incision site for bleeding. A chest x-ray should be done after to check for pneumothorax. After a chest tube may be placed post procedure until the lung has re-expanded, Monitor breath sounds to follow chest re-expansion. Encourage deep breathing for lung re-inflation after Bronchoscopy Keep the patient NPO until the gag reflex returns. Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is used to suppress the gag and cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler's position.

The nurse is caring for a child who had a tonsillectomy performed 4 hours ago. Which of the following is an abnormal finding and a cause for concern?

Increased swallowing Rationale: Increased swallowing could be a sign of hemorrhage from the surgical site.

Describe the basics of supportive treatment for lower respiratory disorders.

Humidity/ Hydration, Antipyretics, Rest, Oxygen, Antibiotic therapy, coughing and deep breathing, incentive spirometry.

Otitis Media

Pediatric Respiratory Problems Otitis Medica-Effusion and infection or blockage of the middle ear. Bacterial or viral Risk factors-allergies, day care, pacifiers, bottle feeding, smoke exposure Earache, pulling ears, bulging, opaque tympanic membrane, irritability, fever 80% resolve spontaneously Pain relief Treat under age 2 The fever indicates that the infection may not be resolved, and the patient might need further antibiotic therapy. A feeling of fullness, "popping" of the ear, decreased hearing, and fluid in the middle ear are indications of otitis media with effusion. These symptoms are normal for weeks to months after an episode of acute otitis media and usually resolve without treatment. A bluish-tinged tympanum can occur with acute otitis media, which requires immediate care to prevent perforation of the tympanum Insertion of instruments such as cotton-tipped applicators into the ear should be avoided Otitis Media: Caused by straighter, narrower Eustachian tube Bottle fed babies have increased risk MD may allow to resolve on its own rather than use ABX right away When would HCP prescribe antibiotics Repeat infections may cause scarring/ loss of hearing Surgical treatment: tubes in the ear drum the nurse is teaching the parents of a child who is being treated in clinic for otitis media. Which of the following statements is essential to include in the teaching? ****Take all of the medication as ordered. _______ is a risk factor for ear infections in infants Bottle feeding (B) Breastfeeding passes immunity to the child that helps prevent acute otitis media. The position of the breastfeeding child is better than the bottle feeding position for the eustachian tube function Which of the following instructions should nurse Cheryl include in her teaching plan for the parents of Reggie with otitis media? Avoid contact with people who have upper respiratory tract infection (Otitis media is commonly precipitated by an upper respiratory tract infection. Therefore, children prone to otitis media should avoid people know to have an upper respiratory infection) An 8-month-old child in your clinic is being seen for otitis media. The baby is pulling on his ears, is irritable and crying, and has a fever of 102°F. What treatment would you anticipate the physician ordering for this child and why?I would anticipate the physician ordering Tylenol for the pain and fever, watchful waiting for48-72 hours, and amoxicillin 80-90 mg/kg/day

Guaifenesin: Ther. Class.allergy, coldand coughremediesexpectorant

Purpose Action: increase production of respiratory tract fluids to help liquefy and decrease viscosity of secretions Use: to loosen and promote elimination of bronchial secretions Mobilization and subsequent expectoration of mucus. Reduces viscosity of tenacious secretions by increasing respiratory tract fluid Teaching Instruct patient to cough effectively. Patient should sit upright and take several deep breaths before attempting to cough. Advise patient that guiafenesin is a drug with known abuse potential. Protect it from theft, and never give to anyone other than the individual for whom it was recommended Inform patient that drug may occasionally cause dizziness. Avoid driving or other activities requiring alertness until response to drug is known. Advise patient to limit talking, stop smoking, maintain moisture in environmental air, and take some sugarless gum or hard candy to help alleviatethe discomfort caused by a chronic non productive cough. Instruct patient to contact health care professional if cough persists longer than 1 wk or is accompanied by fever, rash, or persistent headache or sore throat.

Theo-dur : Theophylline Ther. Class.bronchodilatorsPharm. Class.xanthines

Purpose Bronchodilator It can treat asthma and other lung problems, such as emphysema, COPD and chronic bronchitis. Long-term control of reversible airway obstruction caused by asthma or COPD Teaching Encourage the patient to drink adequate liquids(2000 mL/day minimum) to decrease the viscosity of the airway secretions Encourage patients not to smoke. Advise patient to minimize intake of xanthine-containing foods or beverages (colas, coffee, chocolate) and not to eat charcoal-broiled foodsdaily. Emphasize the importance of having serum levels routinely tested every 6-12 mo. Emphasize the importance of taking only the prescribed dose at the prescribed time intervals. Take missed doses as soon as possible or omit if close to next dose.

Ceftriaxone: Ther. Class.anti-infectivesPharm. Class.third generationcephalosporins

Purpose Skin and skin structure infections, Bone and joint infections, Complicated and uncomplicated urinary tract infections, Uncomplicated gynecological infections including gonorrhea, Lower respiratory tract infections, Intra-abdominal infections, Septicemia, Meningitis, Otitis media. Perioperative prophylaxis. Teaching Advise patient to report signs of super infection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy. Instruct patient to notify health care professional if fever and diarrhea develop, especially if diarrhea contains blood, mucus, or pus. Advise patient not to treat diarrhea without consulting health care professional.

Prednisone: Ther. Class.anti-inflammatories(steroidal)(intermediateacting)immunemodifiers

Purpose Suppresses the inflammatory process and suppresses the action of the adrenal gland. Suppression of the inflammatory and immune responses in autoimmune disorders, allergic reactions, and neoplasms. Management of symptoms in adrenalinsufficiency.•Inflammatory,•Allergic,•Hematologic,•Neoplastic,•Autoimmunedisorders.•Suitable for alternate-day dosing in the management of chronic illnes Teaching Shake inhaler well, and allow at least 1 minbetween inhalations of aerosol medication.Prime the inhaler before first use by releasing 4test sprays into the air away from the face.Caution patient also to avoid smoking and otherrespiratory irritants.Inform patient that albuterolmay cause an unusual or bad taste. Advisepatient to rinse mouth with water after eachinhalation dose to minimize dry mouth andclean the mouthpiece with water at least once awk

Anti-inflammatory Drugs - ¯ inflammation Sx of asthma triggered by allergic and env. stim (release of eos) Glucorticoids ¯ inflammation & bronchoconstriction Used in combination with bronchodilators ¯ edema Blocks late phase response & ¯hyperresponsiveness Inhibits release of mediators

SIDE EFFECTS 1st line controller medicine for persistent asthma Oral fungal infections, hoarseness, dry cough with MDI use PO or IV- many side effects-osteoporosis, muscle and skin breakdown, ↑ BS, Immunosuppression, GI distress, edema, wt gain AGENTS MDIs- triamcinolone (Azmacort) beclomethasone (Vanceril) fluticasone (Flovent) PO - prednisone, prednisolone (Orapred) IV- methylprednisolone (Solu-medrol) ROUTE/ DOSE P.O. (chewable) MDI IV- Rescue med Inhalers have less systemic SEs NURSING IMPLICATIONS · P.O. take with food/milk. · PO or IV- Many SE, S.E. p several weeks · MDI- rinse out mouth, Use after bronchodilator , not helpful with an acute asthma attack · PO - Wean-Never DC abruptly · Takes 1-3 weeks to reach full effectiveness · Better delivery with spacer * MDI beclomethasone and ciclesonide have smaller particle size so more med deposited in airways

Leukotriene Receptor Antagonists Inhibits leukotriene formation ¯ inflammation, ¯ bronchoconstriction (leukotrienes stimulate aggregation of neutrophils, monocytes, smooth muscle contraction, and capillary permeability which further lead to b constriction, inflam & edema)

SIDE EFFECTS Generally few - dizzy, fatigue, HA, GI, cough, nasal congestion AGENTS montelukast (singulair) zafirlukast (Accolate) ROUTE/ DOSE PO NURSING IMPLICATIONS · Not for acute episodes · Used for prophylaxis -chronic asthma or exercise induced · Safe for children Need to monitor liver enzymes

Sympathomimetic - (Beta adrenergic agonists) Bronchodilators Cause dilatation of the bronchi Non-selective vs selective - act only on lung receptors Short-acting and long-acting

SIDE EFFECTS MDI®mouth dryness throat irritation Systemic - tremor, HA nervousness, HR , cough, insomnia, palpitations, increased blood sugar, angina, dysrhythmias AGENTS -metaproterenol (Alupent) -albuterol (Proventil) -levalbuterol (Xopenex)- short acting -salmeterol (Serevent)-prevent exercise induced asthma, bronchospasm in COPD (long-acting) -Vilanteral - LABA ROUTE/ DOSE Freq admin by MDI (1-2-puffs) NURSING IMPLICATIONS · Don't use with angina or other cardiac disorders · DM-monitor glucose · Proper use of MDI · Monitor B/P & HR · Do not exceed dose Works in 1-3 minutes; · Reassess 15-20 minutes after short-acting

Home Oxygen Use

home oxygen use: the company that provides the prescribed O2 therapy equipment will instruct the patient on equipment care. The following are some general instructions that you may include when teaching the patient and caregiver about the used of home O2 • Decreasing risk for infection • Brush teeth or use mouthwash several times a day • Wash nasal cannula (prongs) with liquid soap and thoroughly rinse one or twice a week • Replace cannula every 2-4 weeks •If you have a cold replace the cannula after you symptoms pass • Always remove secretions that are coughed out •If you use an O2 concentrator every day unplug the unit and wipe down the cabinet with a damp cloth and dry it .• Ask the company providing the equipment how often to change the filter SAFETY ISSUES Post No smoking warning signs outside the home • O2 will not blow up but it will increase the rate of burning, since it is a fuel for the fire. • Do not allow smoking in the home, and do not smoke yourself while wearing O2. Nasal cannulas and masks can catch fire and cause serious burns to face and airways. • Do not use flammable liquids such as paint thinners, cleaning fluids, gasoline, kerosene, oil based paints, or aerosol sprays while using O2 • Do not use blankets or fabrics that carry a static charge such as wool or synthetics •Inform the staff at your electric company if you are using a concentrator, In case of a power failure, they will know the medical urgency of restoring your power. • Encourage the patient who uses home O2 to remain active and travel normally. •If traveling by bus, train or airplane, the patient should inform the appropriate people when reservations are made that O2 will be needed for travel. The patient should contact the air line to determine the particular accommodations and policies for in flight O2

respiratory assessment of an infant. what signs and symptoms of respiratory distress should you monitor

increase respiratory rate greater than 30, Nasal flaring, Retractions, Grunting, Inspiratory stridor, Coughing, decreased pulse oximetry , feeding difficulties, and adventitious breath sounds

Chronic Bronchitis

is an inflammation of the bronchi and bronchioles due to chronic exposure to irritants 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. CAUSES Chronic irritation by inhaled irritants (esp. cigarette smoking) and repeated infections are the primary risk factors. Chronic bronchitis is four to ten times more common in heavy smokers; cigarette smoke interferes with the movement of cilia and inhibits the activity of white blood cells in the bronchi and alveoli. Some patients also have hyperreactive airways with widespread inflammation, narrowing and distortion. The changes in the respiratory epithelium may increase the risk of lung cancer. SYMPTOMS AND SIGNS A chronic cough producing copious amounts of sputum occurs early, and patients have frequent respiratory problems, often as a result of acute broncho pulmonary infections. Dyspnea is generally moderate and occurs relatively late in the disease process. Over time, right-sided heart failure (cor pulmonale) develops, marked by dependent edema, distended neck veins, pulmonary hypertension, and an enlarged right ventricle. DIAGNOSIS chest x-ray, pulmonary function or peak flow testing, arterial blood gas studies, and an electrocardiogram. TREATMENT Bronchodilators, inhaled steroids, and other drugs are used to prevent bronchospasm, improve airflow, and aid in the removal of secretions. Increased fluid intake (about 3 L/day), ultrasonic or mechanical nebulizer treatments, and chest physiotherapy may be needed to help thin, loosen and remove secretions. Acute respiratory infections are treated with empirical antibiotics such as azithromycin or trimethoprim/sulfamethoxazole, among others. Patients with underlying chronic bronchitis should receive pneumococcal and influenza vaccines. Other treatments are symptom based. Cessation of smoking is an important part of the overall treatment. Oxygen therapy is frequently needed. PATIENT CARE The initial history and assessment cover the use of tobacco, the presence of other known respiratory irritants and allergens, the degree of dyspnea, the use of accessory muscles for breathing, the presence of wheezes or rhonchi, the color and characteristics of sputum, nutritional status, and the effect of the disease on desired activity. Patients who smoke are referred to a smoking cessation program. The patient's lungs are auscultated before and after aerosol therapy to assess the effectiveness of bronchodilators. The respiratory therapist delivers bronchodilators and other inhaled medications, e.g., steroids, as indicated by the presence of wheezing or evidence of retained airway secretions. Chest physical therapy may prove useful when the patient cannot easily cough up the secretions. Oxygen therapy is administered based on evidence of hypoxemia, inadequate perfusion of vital organs, or cor pulmonale.

acute respiratory distress syndrome (ARDS)

pantoprazole (Protonix) 40 mg IV sucralfate (Carafate) 1 g per nasogastric tube methylprednisolone (Solu-Medrol) 60 mg IV Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications that PEEP should be reduced. "PEEP prevents the lung air sacs from collapsing during exhalation." By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient. The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2. The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS. important to report to HCP : The FIO2 of 80% increases the risk for O2 toxicity. Because the patient's O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The nasogastric drainage indicates possible gastrointestinal bleeding or stress ulcer and should be reported.

Supplemental low-flow oxygen therapy is prescribed for a man with emphysema. Which is the most essential action for the nurse to initiate

schedule frequent pulse oximeter checks. RATIONAL: The pathophysiology of emphysema is directly related to airway obstruction. The end result of deterioration is respiratory acidosis from airway obstruction. Assess vital signs every 2 hours including O2 saturations and ABG results. The acuity of the onset and severity of respiratory failure depend on baseline pulmonary function, pulse oximetry or arterial blood gas values, comorbid conditions, and the severity of other complications of COPD

what must the nurse need to consider in planning discharge arrangements for a patient with TB?

• Advise the patient to quit smoking, avoid excess alcohol intake, maintain adequate nutrition, and avoid exposure to crowds and others with upper respiratory infections • Teach appropriate preventive measures. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. •Instruct the patient to abstain from alcohol while on INH and refer for eye examination after starting and then every month while taking ethambutol. • Teach the patient to recognize symptoms such as fever, difficulty breathing, hearing loss, and chest pain that should be reported to healthcare personnel. • Discuss the patient's living condition and the number of people in the household. Give the patient a list of referrals if she or he is homeless or economically at risk. • Teach patients to cover the nose and mouth with paper tissues every time they cough, sneeze,or produce sputum. The tissues should be thrown into a paper bag and disposed of with thetrash or flushed down the toilet. • Emphasize careful hand washing after handling sputum and soiled tissues • Homes should be well ventilated, especially the areas where the infected person spends a lot of time. • While still infectious, the patient should sleep alone, • spend as much time as possible outdoors, • minimize time in congregate settings or on public transportation. • Teach the patient and caregiver about adherence with the prescribed regimen. This isimportant, since most treatment failures occur because the patient neglects to take the drug,discontinues it prematurely, or takes it irregularly

Why is it necessary to monitor the client's ABGs that have acute respiratory distress syndrome

• Obtain ABGs to determine baseline oxygenation and ventilation status. ABG values are reviewed and used to guide oxygenation and ventilation changes. Continuous pulse oximetry provides data regarding arterial oxygenation and end-tidal CO2 monitoring provides data related to ventilation. • Periodic ABGs and continuous SpO2 provide objective data regarding oxygenation. • ABGs determine the levels of PaCO2, PaO2, bicarbonate, and pH. In respiratory failure, • Assess ABGs for evidence of excess O2. O2 toxicity: frequently monitor and evaluate the ABG values, and take measures to maintain the levels within prescribed or acceptable parameters • ABGs indicate inadequate oxygenation or ventilation, endotracheal intubation or tracheostomy and mechanical ventilation are needed

what age is Cystic Fibrosis usually diagnosed? What symptoms lead to the diagnosis? What is the diagnostic test for CF?

• The median age at diagnosis of CF is 5 months of age • 72% are diagnosed in the first year of life. • Currently every state has mandatory newborn screening for CF which has allowed for early intervention. • An initial finding of meconium ileus in the newborn infant prompts the diagnosis in20% of people with CF Other signs that suggest a CF diagnosis are acute or persistent respiratory symptoms (wheezing, coughing, frequent pneumonia), failure to thrive or malnutrition, steatorrhea (large protuberant abdomen may develop with an emaciate appearance of the extremities • Diagnostic criteria for CF include a combination of clinical presentation, family history, laboratory testing and genetic testing. The sweat glands of CF patients secrete normal volumes of sweat but sodium chloride cannot be absorbed from sweat as it moves through the sweet duct. Therefore four times the normal amount of sodium and chloride is excreted in sweat. This abnormality usually does not directly affect the persons general health, but it is the main diagnostic test for CF. The sweat chloride test is considered the gold standard for the diagnosis of CF and is performed with the pilocarpine iontophoresis method

what Potential Complications's are possible with mechanical ventilation

•Infection (artificial airway (breathing tube) may allow germs to enter the lung. • Lung damage. Injury to the alveolar-capillary membrane. Lung damage caused by eitherover inflation or repetitive opening and collapsing of the small air sacs alveoli of thelungs. • Ventilator Associated Pneumonia (VAP)• Volutrauma • Barotrauma•collapsed lungs. • Alveolar Hypoventilation • Alveolar Hyperventilation