Chapter 24: Management of Patients with Chronic Pulmonary Disease

What is histamine, a mediator that supports the inflammatory process in asthma, secreted by?

Mast cells Mast cells, neutrophils, eosinophils, and lymphocytes play key roles in the inflammation associated with asthma. When activated, mast cells release several chemicals called mediators. One of these chemicals is called histamine.

A physician orders a beta2 adrenergic-agonist agent (bronchodilator) that is short-acting and administered only by inhaler. What drug would the nurse know to administer to the client?

Albuterol Short-acting beta2-adrenergic agonists include albuterol, levalbuterol, and pirbuterol. They are the medications of choice for relief of acute symptoms and prevention of exercise-induced asthma. They are used to relax smooth muscle.

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

Anxiety In a client with a respiratory disorder, anxiety worsens such problems as dyspnea and bronchospasm. Therefore, Anxiety is a likely nursing diagnosis. This client may have inadequate nutrition, making Imbalanced nutrition: More than body requirements an unlikely nursing diagnosis. Impaired swallowing may occur in a client with an acute respiratory disorder, such as upper airway obstruction, but not in one with a chronic respiratory disorder. Unilateral neglect may be an appropriate nursing diagnosis when neurologic illness or trauma causes a lack of awareness of a body part; however, this diagnosis doesn't occur in a chronic respiratory disorder.

Which is the most important risk factor for development of COPD?

Cigarette smoking Risk factors for COPD include environmental exposures and host factors. The most important environmental risk factor for COPD worldwide is cigarette smoking. A dose-response relationship exists between the intensity of smoking (pack-year history) and the decline in pulmonary function. Other environmental risk factors include smoking pipes, cigars, and other types of tobacco. Passive smoking (i.e., second-hand smoke) also contributes to respiratory symptoms and COPD. Air pollution and genetic abnormalities are risk factors for development of COPD, but neither is the most important.

Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply.

Compromised gas exchange Decreased airflow Wheezes Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions, and infection. Bronchospasm can sometimes be detected on auscultation with a stethoscope when wheezing or diminished breath sounds are heard. Increased mucus production, along with decreased mucociliary action, contributes to further reduction in the caliber of the bronchi and results in decreased airflow and decreased gas exchange. This is further aggravated by the loss of lung elasticity that occurs with COPD (GOLD, 2015).

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

High-protein Breathing is more difficult for clients with COPD, and increased metabolic demand puts them at risk for nutritional deficiencies. These clients must have a high intake of protein for increased calorie consumption. Full liquids, 1,800-calorie ADA, and low-fat diets aren't appropriate for a client with COPD.

Asthma is cause by which type of response?

IgE mediated responce Atopy, the genetic predisposition for the development of an IgE-mediated response to allergens, is the most common identifiable predisposing factor for asthma. Chronic exposure to airway allergens may sensitize IgE antibodies and the cells of the airway.

The classification of grade I COPD is defined as

Mild COPD Grade I is mild COPD. Grade II is moderate COPD. Grade III is severe COPD. Grade IV is very severe COPD.

The classification of Stage II of COPD is defined as

Moderate COPD

Bullectomy

surgically removing a lungs air pocket. the surgical removal of a bulla, which is a dilated air space in the lung parenchyma measuring more than 1 cm. These are caused by a lung rub or friction as the lungs rub together.

A nurse has just completed teaching with a client who has been prescribed a meter-dosed inhaler for the first time. Which statement if made by the client would indicate to the nurse that further teaching and follow-up care is necessary?

"I do not need to rinse my mouth after I use this inhaler" Mouth-washing and spitting are effective in reducing the amount of drug swallowed and absorbed systemically. Actuation during a slow (30 L/min or 3 to 5 seconds) and deep inhalation should be followed by 10 seconds of holding the breath. The client should actuate only once. Simple tubes do not obviate the spacer/VHC per inhalation.

The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least ______ mm Hg and an arterial oxygen saturation (SaO2) of at least ___%.

60 mm Hg; 90% The goal is a PaO2 of at least 60 mm Hg and an SaO2 of 90%.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for?

Atelectasis In bronchiectasis, the retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

Atelectasis In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.

Which statement is true about both lung transplant and bullectomy?

Both procedures improve the patients quality of life. bullectomy is used to treat clients with bullous emphysema.

A home health nurse sees a client with end-stage chronic obstructive pulmonary disease. An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met?

Decreased oxygen requirements A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements.

Which exposure accounts for most cases of COPD?

Exposure to tobacco smoke Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases. Occupational exposure, passive smoking, and ambient air pollution are risk factors, but they do not account for most cases.

Which of the following is not a primary symptom of COPD?

Weight gain COPD is characterized by three primary symptoms: cough, sputum production, and dyspnea upon exertion. Weight loss is common with COPD.

As status asthmaticus worsens, the nurse would expect which acid-base imbalance?

Respiratory acidosis As status asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis.

To help prevent infections in clients with COPD, the nurse should recommend vaccinations against two bacterial organisms. Which of the following are the two vaccinations?

Streptococcus pneumonia and Haemophilus influenzae Clients with COPD are more susceptible to respiratory infections, so they should be encouraged to receive the influenza and pneumococcal vaccines. Clients with COPD aren't at high risk for varicella or hepatitis B. The HPV vaccine is to guard against cervical cancer and is recommended only for females ages 9 to 26 years.

pleural effusion

abnormal accumulation of fluid in the pleural space. The build-up of excess fluid between the layers of the pleura outside the lungs.

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

the airways are so swollen that no air can get through. During an acute asthma attack, wheezing may stop and breath sounds become inaudible because the airways are so swollen that air can't get through. If the attack is over and swelling has decreased, there would be no more wheezing and less emergent concern. Crackles don't replace wheezes during an acute asthma attack.

A junior-level nursing class has just finished learning about the management of clients with chronic pulmonary diseases. They learned that a new definition of COPD leaves only one disorder within its classification. Which of the following is that disorder?

Emphysema COPD may include diseases that cause airflow obstruction (eg, emphysema, chronic bronchitis) or any combination of these disorders. Other diseases such as cystic fibrosis, bronchiectasis, and asthma that were previously classified as types of COPD are now classified as chronic pulmonary disorders. Asthma is now considered a distinct, separate disorder and is classified as an abnormal airway condition characterized primarily by reversible inflammation.

A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs?

Administer the salmeterol and then administer the triamcinolone. Always administer bronchodilators before other medications because ABCs are top priority always. Bronchodilators end in (ol) and corticosteroids end in (alone). Just a way to remember which is which. A client with asthma typically takes bronchodilators and uses corticosteroid inhalers to prevent acute episodes. Triamcinolone (Azmacort) is a corticosteroid; Salmeterol (Serevent) is an adrenergic stimulant (bronchodilator). If the client is ordered a bronchodilator and another inhaled medication, the bronchodilator should be administered first to dilate the airways and to enhance the effectiveness of the second medication. The client may not choose the order in which these drugs are administered because they must be administered in a particular order. Monitoring the client's theophylline level isn't necessary before administering these drugs because neither drug contains theophylline.

A patient is being treated for status asthmaticus. What danger sign does the nurse observe that can indicate impending respiratory failure?

Respiratory acidosis In status asthmaticus, increasing PaCO2 (to normal levels or levels indicating respiratory acidosis) is a danger sign signifying impending respiratory failure. Understanding the sequence of the pathophysiologic processes in status asthmaticus is important for understanding assessment findings. Respiratory alkalosis occurs initially because the patient hyperventilates and PaCO2 decreases. As the condition continues, air becomes trapped in the narrowed airways and carbon dioxide is retained, leading to respiratory acidosis.

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances?

Respiratory acidosis Increased carbon dioxide tension in arterial blood leads to respiratory acidosis and chronic respiratory failure. In acute illness, worsening hypercapnia can lead to acute respiratory failure. The other acid-base imbalances would not correlate with COPD.

A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments?

a. Oxygen through nasal cannula at 2 L/minute b. Intravenous methylprednisolone (Solu-Medrol) 120 mg c. Ipratropium bromide (Alupent) by metered-dose inhaler d. Vancomycin 1 gram intravenously over 1 hour When a client presents in the emergency department with an exacerbation of COPD, the nurse should first administer oxygen therapy and perform a rapid assessment of whether the exacerbation is potentially life threatening.

Which statement describes emphysema?

disease of the airways characterized by destruction of the walls of overdistended alveoli Emphysema is a category of COPD. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.