Gas Exchange
Cromolyn sodium
an inhaled nonsteroidal antiallergy agent and a mast cell stabilizer. Undesirable effects associated with inhalation therapy are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritus, nausea, diarrhea, and myalgia.
Asthma Severe spasm or obstruction:
Breath sounds and wheezing cannot be heard (silent chest), and cough is ineffective (represents a lack of air movement).
Asthma diagnosis
Diagnosis is made on the basis of the child's symptoms, history and physical examination, chest radiograph, and laboratory tests.
Asthma Assessment
Pt has episodes of dyspnea, wheezing, breathlessness, chest tightness, and cough, particularly at night or in the early morning or both.
A 50-year-old client is diagnosed with chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100 beats/min, a blood pressure of 138/82 mm Hg, a respiratory rate of 32 breaths/min, a tympanic temperature 98.2°F (36.8°C), and an oxygen saturation of 80%. Which vital signs obtained by the nurse indicates a positive outcome?
The respiratory rate ranges in older adults from 12 to 20 breaths/min, and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus a rate decrease to 14 breaths/min indicates a positive outcome. COPD may also cause high blood pressure. Thus a blood pressure of 110/70 mm Hg obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95% to 100%. An oxygen saturation increase from 88% to 92% indicates a positive outcome of the therapy. The radial pulse indicates a positive outcome of the therapy if the client has a history of heart disease. A body temperature reading of 98.2°F (36.8°C), is considered normal and not a sign of COPD.
Asthma Classification and management
classified on the basis of disease severity; management includes medications, environmental control of allergens, and child and family education.
Gradual weaning from prednisone
is necessary to prevent adrenal insufficiency or adrenal crisis; depresses the immune system, thereby increasing susceptibility to infection. The medication usually suppresses growth. A moon face may occur, but it is not a critical, life-threatening side effect.
Name the position of comfort for clients with COPD?
orthopnea position
Who should receive the pneumococcal vaccine?
patients 65 or older or those who are immunocompromised
Status asthmaticus
the most severe form of an asthma attack that is unresponsive to repeated courses of beta-agonist therapy; this is a medical emergency that can result in respiratory failure and death if not recognized and vigorously treated.
peak expiratory flow meter (PEFM)
used to measure the amount of air being exhaled. To adequately measure this, the client must blow out fast and hard. The client should use the PEFM while in a standing position to permit better expansion of the lungs. The highest of three readings, not the average, is recorded. The readings should be obtained close to the same time each day to ensure consistency.
Quick-Relief Medications (Rescue Medications)
▪ Short-acting β2 agonists (for bronchodilation) ▪ Anticholinergics (for relief of acute bronchospasm) ▪ Systemic corticosteroids (for antiinflammatory action to treat reversible airflow obstruction)
Name 3 characteristics found on assessment (RSV)?
-Listless and not interested in feeding -Cyanosis -Air hungry -Tachypnea -Sternal retractions -Accessory muscle use -Grunting -Periods of apnea -Coughing or wheezing
Mild intermittent asthma
-S/S less than 1 per week -Nocturnal s/s less than 2x month -PEFR < 20% variability -FEV1 > 80% predicted, PFT > 20% variability -Normal between attacks -Exacerbation brief with variable intensity -No daily medication needed -Inhaled *SABA or cromolyn before exercise or allergen exposure
mild persistent asthma
-S/S no more than 2x week, but less than 1x daily -Nocturnal s/s more than 2x month -May affect activity and sleep -PEFR 20% - 30% variability -FEV1 > 80% predicted, PFT 20%-30% variability -Exacerbation may or may not affect ADLs -One medication daily (low-dose corticosteroid or -slow-release theophylline), cromolyn/nedocromil, leukotriene modifiers, Inhaled SABA as needed
List the 3 primary symptoms of COPD
1.Chronic cough 2.Sputum production 3.Dyspnea
Which rationale would the nurse use when teaching a client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing?
Decrease air trapping Pursed-lip breathing prolongs the expiratory phase and increases airway positive pressure, leading to more complete expiration and reduced air trapping. Bronchi and bronchioles stay open longer and are expanded during pursed-lip breathing. Pursed-lip breathing does not strengthen the intercostal muscles or reduce diaphragmatic excursion.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute pneumonia. The client is in moderate respiratory distress. The nurse would place the client in which position to enhance comfort?
The high-Fowler position elevates the clavicles and helps the lungs expand, thus easing respirations. The side-lying, Sims, and semi-Fowler positions do not promote more comfortable breathing.
Mast cell release of histamine (Asthma)
leads to a bronchoconstrictive process, bronchospasm, and obstruction.
Precipitants
may trigger an asthma attack
What is the treatment for TEF?
surgery to close the fistula
nursing interventions for pneumonia?
-Encourage hydration (2 L/day) -Encourage coughing and deep breathing with an IS -Chest physiotherapy -administer and titrate O2 therapy -Place in semi-fowlers position -small frequent meals -ongoing monitoring for signs of respiratory failure -In older adults monitor for delirium
the difference between viral and bacterial pneumonia treatments?
1.Bacterial: treated with antibiotics 2.Supportive treatment with hydration, antipyretics, etc.
List the 4 types of pneumonia
1.CAP - community acquired 2.HCAP - healthcare acquired 3.HAP - hospital acquired 4.VAP - ventilator acquired
Which information is needed to determine oxygen administration for a client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 87%?
Arterial blood gases Clients with COPD who have low oxygen levels respond to oxygen administration. However, some clients with COPD have a respiratory drive that stimulates breathing that is dependent on carbon dioxide. The administration of too much oxygen in these clients lowers respiratory drive and decreases breathing. Therefore, the nurse would assess the client's arterial blood gases to determine how much oxygen to administer. Level of orientation shows the amount of hypoxia the client is experiencing. Clients may have abnormal lung sounds that can impede oxygenation, but this is not the basis for determining oxygen administration. A complete blood count assesses red blood cells, hemoglobin, and hematocrit; these values can be diminished in clients with COPD, but they do not determine oxygen needs. Pulmonary function tests are used to diagnose pulmonary disorders
A client is receiving dexamethasone to treat acute exacerbation of asthma. For which side effect would the nurse monitor the client?
Increased blood glucose Dexamethasone increases gluconeogenesis, which may cause hyperglycemia. Hypokalemia, not hyperkalemia, is a side effect. Liver dysfunction is not a side effect. Hypertension, not hypotension, is a side effect.
The nurse is providing hygiene care to a immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is correct when the client becomes short of breath during the care?
Put the client in a high Fowler position Putting the client in the high Fowler position will help expand the lungs and decrease the severity of shortness of breath. Leaving the client to obtain a pulse oximeter while the client is experiencing shortness of breath places the client in danger. Providing a rest period of at least 15 minutes may be appropriate but is not the priority. The nurse needs to acknowledge the change in the client's condition, such as shortness of breath, and take care of this immediate client need before continuing the hygiene activities.
A client with chronic obstructive pulmonary disease (COPD) is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take?
Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula Sitting facilitates breathing by increasing lung expansion; 2 L of oxygen promotes respirations while preventing carbon dioxide narcosis. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen higher than 2 L. More research is needed before this theory is applied clinically. Five liters of oxygen may cause respiratory depression and carbon dioxide narcosis in a client with COPD. Chest physiotherapy (postural drainage) may be done later after the client's condition improves. Delaying intervention is likely to worsen the respiratory distress.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care?
Restores negative pressure in the pleural space Negative pressure is exerted by gravity drainage or by suction through the closed system. Though the discomfort may be lessened as a result of the insertion of the chest tube, this is not the primary purpose. There is an accumulation of air, not fluid, when a pneumothorax occurs in a client with COPD. Subcutaneous emphysema in the chest wall is associated most commonly with clients receiving air under pressure, such as that received from a ventilator; subcutaneous emphysema can also occur with a chest tube
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco 2 of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition?
The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO 2, and the acceptable range of arterial Pco 2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO 3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis
Which action by a client with asthma indicates that the client teaching about use of a peak flow meter has been effective?
Uses a quick relief inhaled medication when peak flow is in the yellow zone. Peak flows in the yellow zone are between 50% and 80% of personal best and indicate a need to use a quick relief inhaler such as albuterol to improve breathing. There is no need to call a provider when peak flows are in the green zone, which is 80% to 100% of the personal best. Peak flows in the red zone indicate that peak flows are less than 50% of personal best. The client should use a quick relief inhaled medication, then call the health care provider or go to the hospital when peak flows are this low. The client would continue the usual long-term control medications such as inhaled corticosteroids when peak flows are in the yellow zone while adding a quick relief inhaler such as albuterol to improve peak flow.
The nurse provides teaching to a client who is being discharged after an acute exacerbation of chronic obstructive pulmonary disease (COPD). The nurse would instruct the client to monitor for which indication of right-sided heart failure?
weight gain The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites. Clubbing is indicative of hypoxemia. Hypertension is associated with left-sided heart failure.
severe persistent asthma
-S/S continuous -Nocturnal s/s frequent -PEFR > 30% variability -FEV1 less than or equal to 60% predicted, PFT variability > 30% -Exacerbations frequent -Exacerbations affect and limit ADLs -Physical activity limited by asthma -Inhaled SABA as needed; Multiple daily controller meds, high-dose inhaled corticosteroid, LABA, cromolyn/nedocromil, leukotriene modifiers, may need long-term corticosteroids
moderate persistent asthma
-S/S daily but not continual -Nocturnal s/s more than 1x week, but not every night -PEFR > 30% variability -FEV1 60%-80% predicted, PFT > 30% -Exacerbations affect ADLs, Affect activity and sleep -Daily controller medications; combination inhaled medium-dose corticosteroid and LABA, especially for nighttime symptoms, cromolyn/nedocromil, leukotriene modifiers, Inhaled SABA as needed
Gas Exchange Med List
-Short acting Beta agonist- Albuterol -Long acting Beta agonist- Salmeterol -corticosteroid- methylprednisolone, mometasone furoate, Fluticasone diskus, Prednisone -glucocorticosteroid- Budesonide -anticholinergic- Ipratropium Bromide -Leukotriene antagonist- Montelukast Sodium -RSV agent - Palivizumab -Methylxanthine- Theophylline
Oxygen given to clients during stage 4 of chronic obstructive pulmonary disease (COPD) would be administered in which manner?
1 to 2 L via nasal cannula to keep SaO 2 above 90% Oxygen therapy usually is delayed until stage 4, which is very severe COPD. Usually it is administered at 1 to 2 L per minute to maintain SaO 2 at or above 90%. One to 2 L to maintain the SaO 2 above 95% is not necessary. Oxygen administration may not be necessary. Three liters of oxygen via a mask is unnecessary, and a level of 95% may suppress the hypoxic drive in clients who are chronic CO 2 retainers. Oxygen should not be given unless the chronic saturation level is less than 88%.
Asthma medications
1. Quick-relief medications (rescue medications): Used to treat symptoms and exacerbations 2. Long-term control medications (preventer medications): Used to achieve and maintain control of inflammation Certain long-term control medications, such as long-acting beta-adrenergic agonists (LABAs), should not be given without an inhaled corticosteroid because of the risk for rebound bronchoconstriction. 3. Nebulizer, metered-dose inhaler (MDI): May be used to administer medications; if the child has difficulty using the MDI, medication can be administered by nebulization (medication is mixed with saline and then nebulized with compressed air by a machine). 4. If an MDI is used to administer a corticosteroid, a spacer should be used to prevent yeast infections in the child's mouth; the spacer prevents the medication being sprayed directly into the mouth, which can lead to irritation and possibly infection (thrush) in the mouth. 5. The child's growth patterns need to be monitored when corticosteroids are prescribed.
Give an example that demonstrates that an acute attack asthma client is declining?
1. decreased or absence of wheezing 2. decreased LOC 3. decreased SaO2 levels
A client with chronic asthma is being cared for in the inpatient care unit. Which health care team member would be delegated to assess the client on a regular basis?
The RN is a licensed nursing professional and is responsible for assessing the asthmatic symptoms of the client and providing care. The charge nurse is responsible for the coordination and assignment of tasks for the client's care. PCAs are unlicensed assistive personnel whose scope of practice is limited. The LPN does not assess the client's condition, but is responsible for providing treatment prescribed by the health care provider and delegated by the RN.
recovering from status asthmaticus
The high-Fowler position decreases pressure on the diaphragm and promotes lung expansion. Fluids should not be restricted. Adequate fluid intake should be maintained to promote hydration. Droplet precautions are not required. Asthma is not an infectious disease, and there are no data to indicate an accompanying infection. If the practitioner prescribes an antibiotic, it is to treat a concurrent infection; prophylactic antibiotic therapy is not required for children with status asthmaticus.
Albuterol
produces sympathetic nervous system side effects such as tachycardia and hypertension. Pallor, not flushing, is a common side effect. Dyspnea is not a common side effect; this medication is given to decrease respiratory difficulty. Hypertension, not hypotension, is a common side effect.
Which recommendation from the school nurse to the parent of an older child reflects the safest plan for managing the child's asthma in the school setting?
"I need your permission for your child to carry the inhaler at all times." With parental permission, older children with asthma can carry their inhalers with them at all times in case of an emergency. Locking the inhaler in the health center or telling a parent that a nurse or teacher will always be available to supervise the child may not be realistic, because they may not be immediately present if the child requires the inhaler, which would delay treatment and risk an asthma exacerbation.
After the home health nurse has taught a client with asthma how to use a peak flow meter, which statement by the client needs correction?
"I will repeat the test in 15 minutes if the reading is in the red zone." A red zone reading is a serious situation; the client should be instructed to use airway reliever medications and seek immediate medical care. Clients need to conduct a peak flow test 3 times and record the highest reading. Clients should use the peak flow meter while standing independently without leaning. Correct use of the peak flow meter begins with the client taking a deep breath before blowing into the meter.
Priority Nursing Actions: Acute Asthma Attack
1. Assess airway patency and respiratory status. 2. Administer humidified oxygen by nasal cannula or face mask. 3. Administer quick-relief (rescue) medications. 4. Initiate an intravenous (IV) line. 5. Prepare the child for a chest radiograph and fiberoptic nasal laryngectomy if prescribed. 6. Prepare to obtain a blood sample for determining arterial blood gas levels if prescribed.
List the 3 most common symptoms of Asthma
1. Cough 2. Dyspnea 3. Wheezing
example that demonstrates disease progression in COPD?
1. Decreased ability to perform ADL's from baseline 2. New cardiac symptoms
What is needed for follow up care following surgery for TEF?
1. TPN 2. Antibiotics 3. Close assessment during all feedings
What are the 3 C"s of TEF?
1.Coughing 2.Choking 3.Cyanosis
A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon awakening in the morning. To address the concern, the nurse would make which suggestion?
A humidifier will help liquefy secretions and promote their expectoration. Sleeping on pillows facilitates breathing; it does not relieve chest congestion. Nonproductive coughing should be avoided because it is irritating and exhausting. Deep breathing and coughing at night will not help relieve early-morning congestion.
Describe a written action plan using peak flow monitoring
A treatment plan that is developed between the MD and the patient. The patient will complete their peak flow monitoring every morning and then based on the results activate their written action plan accordingly.
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia?
Arterial Blood Gas Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.
Asthma Exercise-induced attack:
Cough, shortness of breath, chest pain or tightness, wheezing, and endurance problems occur during exercise.
The nurse teaches a client with chronic obstructive pulmonary disease (COPD) and cor pulmonale about nutrition. Which instruction would the nurse include?
Eat small meals six times a day to limit oxygen needs Eating small meals will decrease the amount of oxygen necessary for ingestion and digestion at any one time; a small volume of food in the stomach will not impede the downward movement of the diaphragm during inhalation. Although fluids can help liquefy secretions, they should not be encouraged for a client with heart failure. Lying down increases intra-abdominal pressure, pushing a full stomach against the diaphragm and limiting respiratory excursion. Protein maintains or increases hydrostatic pressure; it does not decrease it.
The nurse is teaching pursed-lip breathing to a client with chronic obstructive pulmonary disease (COPD). The client asks about the benefit of the exercises. Which explanation would the nurse give?
Pursed-lip breathing keeps the airway open longer to decrease the work that goes into breathing. Clients with COPD are taught to breathe out through pursed lips to help keep the air passages open until exhalation is complete. Pursed-lip breathing does not prevent COPD complications. Pursed-lip breathing may relieve shortness of breath by decreasing the breath rate. Pursed-lip breathing does not increase the amount of air taken in during inspiration.
The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?
RSV is a highly communicable disorder and is transmitted via droplets and direct contact with respiratory secretions. Use of contact, droplet, and standard precautions during care is necessary. Using good hand-washing technique and wearing gloves, gown, and a mask should be done to prevent transmission. An infant with RSV should be placed in a private room to prevent transmission.
The most common viral pathogen that causes bronchiolitis?
Respiratory Syncytial Virus
When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears moist rumbling sounds that improve after the client coughs. How will the nurse document the lung sounds?
Rhonchi Rhonchi are coarse and moist sounds caused by obstruction of the airway with thick mucus, and they usually clear or change with coughing as the mucus moves or is expectorated. Wheezes are high-pitched, continuous sounds. Fine crackles are high-pitched popping noises. Vesicular sounds are the normal breath sounds.
The primary risk factor for COPD?
SMOKING
Which med first?
Salmeterol is an adrenergic type of bronchodilator, and beclomethasone dipropionate is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective.
A client is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). Which action would the nurse take to prevent client fatigue?
Schedule nursing activities to allow for rest. Rest limits muscle contractions, which diminishes oxygen needs and decreases fatigue. Although small, frequent meals may decrease pressure on the diaphragm and facilitate breathing, this precaution does not address the client's fatigue. Although pursed-lip breathing facilitates gas exchange, it does not reduce the metabolic demand for oxygen. Bed rest promotes pooling of pulmonary secretions, which may aggravate the client's respiratory status.
What is the first line of treatment (medication)during an acute asthma exacerbation?
Short acting beta2 andronergic agonist:albuterol
Which diagnostic testing is most useful in evaluating the effectiveness of treatment for asthma?
The most useful test when evaluating the effectiveness of asthma treatment is pulmonary function testing, which measures airflow. A chest x-ray might be used to check for complications of asthma such as respiratory infection, but is not used to evaluate the effectiveness of asthma treatment. Serum eosinophil counts might be used to determine whether a client's asthma was caused by allergies, but eosinophil counts will not be commonly used to check for effectiveness of treatment. Immunoglobulin E levels might be checked to determine if a client had allergic asthma, but would not be used to check for whether treatment was effective.
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO 2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing?
The pH indicates acidosis; the PCO 2 level is the parameter for respiratory function. The expected PCO 2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.
Omalizumab
an anti-inflammatory and monoclonal antibody used for long-term control of asthma. Anaphylactic reactions can occur with the administration of this med. The nurse administering the medication should monitor for adverse reactions of the medication. Swelling of the lips and tongue are an indication of an anaphylaxis.
The abnormal communication occurs where in the body for Tracheoesophageal fistula (TEF)?
between the trachea and the esophagus.
Asthma allergic reaction in the airways
caused by the precipitant can result in an immediate reaction with obstruction occurring, and it can result in a late bronchial obstructive reaction several hours after the initial exposure to the precipitant. Mast cell release of histamine leads to a bronchoconstrictive process, bronchospasm, and obstruction.
Prednisone
corticosteroid; reduces the child's resistance to certain infectious processes and, as an anti-inflammatory medication, masks infection. The child will self-limit activity depending on respiratory status. The eosinophil count is often consistently increased in children with asthma. The child will need adequate hydration to help loosen and expel mucus.
What is the Priority nursing intervention while admitting a child diagnosed with RSV to the unit?
initiate contact precautions
Long-Term Control (Medications to Prevent Attacks)
▪ Inhaled corticosteroids (for antiinflammatory action) ▪ Antiallergy medications (to prevent an adverse response on exposure to an allergen) ▪ Long-acting β2 agonists (for long-acting bronchodilation) ▪ Leukotriene modifiers (to prevent bronchospasm and inflammatory cell infiltration) ▪ Monoclonal antibody (blocks binding of immunoglobulin E [IgE] to mast cells to inhibit inflammation)
Allergens
-Outdoor: Trees, shrubs, weeds, grasses, molds, pollen, air pollution, sand dust, spores -Indoor: Dust, dust mites, mold, cockroach antigen -Irritants: Tobacco smoke, wood smoke, odors, sprays -Exposure to Occupational Irritants -Exercise -Cold Air -Changes in Weather or Temperature -Environmental Change: Moving to a new home, starting a new school -Colds and Infections -Animals: Cats, dogs, rodents, horses -Medications: Aspirin, nonsteroidal antiinflammatory drugs, antibiotics, beta blockers -Strong Emotions: Fear, anger, laughing, crying -Conditions: Gastroesophageal reflux disease, tracheoesophageal fistula -Food Additives: Sulfite preservatives -Foods: Nuts, milk, other dairy products -Endocrine Factors: Menses, pregnancy, thyroid disease
A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO 2 intoxication (CO 2 narcosis), which would the nurse do?
Administer oxygen at a low concentration to maintain respiratory drive With chronically high levels of carbon dioxide, it is believed that decreased oxygen levels become the stimulus to breathe; high oxygen administration negates this mechanism. Initiating pulmonary hygiene to clear air passages of trapped mucus is an appropriate intervention but is not directly related to CO 2 intoxication (CO 2 narcosis). Encouraging continuous rapid panting to promote respiratory exchange will not bring oxygen into the alveoli for exchange, nor will it adequately remove carbon dioxide because it will increase bronchiolar obstruction. Inhalation should be of regular depth and expiration should be prolonged to prevent carbon dioxide trapping (air trapping).
When the nurse is evaluating a client with an acute asthma attack who has just received a nebulized bronchodilator treatment, which finding requires the most rapid action?
Absent breath sounds and labored appearing respirations indicate that the client has extremely limited airflow and is at risk for respiratory arrest. The nurse would notify the health care provider immediately and anticipate interventions such as intubation, systemic bronchodilators, and mechanical ventilation. Continued high-pitched respiratory wheezes indicate that further treatment is needed, but the client would not be at risk for respiratory arrest. Pursed-lip breathing is frequently used by clients with obstructive airway disease to help improve expiratory effort. Hyperresonance to percussion indicates air trapping in the lungs, but is not an uncommon finding in clients with asthma
When caring for a client with chronic obstructive pulmonary disease (COPD) exacerbation and an oxygen saturation of 87% (0.87), which prescribed action by the health care provider would the nurse question?
Administer oxygen at no more than 3 L/minute. Because the client is hypoxemic, oxygen would be given at the flow rate and method needed to increase the oxygen saturation to a level of at least 89% to 90%. Some (but not all) clients with COPD do have a decreased respiratory drive when oxygen saturations are in the high normal range, but this client needs a high FiO 2 to correct the current hypoxemia. The nurse would carefully monitor oxygen saturation and titrate oxygen flow rate down as the client's oxygen saturation improves. Intravenous fluids are likely needed to help liquefy respiratory secretions. Sitting up for meals will expand the thoracic cavity and improve respiratory effort as well as decreased risk for venous thrombosis. Ibuprofen is an appropriate treatment for pain or fever.
Priority of an acute asthma attack
Albuterol relaxes smooth muscles in the respiratory tract, resulting in bronchodilation. The priority is to facilitate respiration, and this intervention follows the ABCs of emergency care—airway-breathing-circulation. The use of an incentive spirometer may be taught after the acute episode of respiratory distress has been resolved. It will take time to obtain the device and teach the child about its use, and it should be used after the airway has been opened. Obtaining a blood specimen is not the priority. The results will not influence the priority intervention. Notifying the respiratory therapist is not the priority. Chest physical therapy is performed after the airway has been opened.
A client is admitted to the hospital with chronic asthma. Which complication would the nurse monitor in this client?
Atelectasis As a result of narrowed airways, adequate ventilation of lung tissue is compromised, and alveoli may collapse (atelectasis). Pneumothorax is not a common complication of asthma; a collapsed lung is referred to as a pneumothorax. Pulmonary edema is not a common complication of asthma; pulmonary edema is caused by left-sided heart failure. Respiratory alkalosis is not a common complication of asthma; with narrowed air passages, the client with asthma is at risk for hypoxia and respiratory acidosis.
When a client with chronic obstructive pulmonary disease (COPD) is receiving oxygen, which assessment findings indicate increasing carbon dioxide (CO 2) retention?
Because high oxygen saturation and high PaO 2 levels can depress respiratory drive in some (but not all) clients with COPD, the nurse will plan to assess for clinical manifestations of CO 2 retention when clients are receiving supplemental oxygen. CO 2 retention depresses the central nervous system, leading to drowsiness, confusion, and decreased respiratory depth and rate. CO 2 retention also affects cardiac function, leading to dysrhythmias. Lethargy, rather than anxiety, is seen with CO 2 retention because of central nervous system depression. Respiratory rate will decrease with CO 2 retention because of central nervous system depression.
theophylline
For it to be effective, therapeutic serum levels must be maintained by taking the medication at the prescribed time. If the medication is not taken at the prescribed time, the level may drop below the therapeutic range. The medication will not be effective if it drops below the therapeutic range. It should be given after a meal and with a full glass of water to decrease gastric irritability. Giving it 2 hours after a meal (on an empty stomach) can result in gastric discomfort. It should not be taken at night, because it can cause central nervous system stimulation resulting in insomnia, restlessness, irritability, etc. It is used for long-term medication therapy.
In which position would the nurse place an 8-year-old child with asthma who is short of breath?
High-Fowler Clients find it easier to breathe while sitting up than lying down. Helping them get into a comfortable sitting position is crucial. The high-Fowler position gives the lungs more room to expand, thereby promoting respiration and affording more comfort. The supine, left lateral, and Trendelenburg positions will all increase dyspnea; they do not permit chest expansion.
A child admitted to the hospital with a diagnosis of status asthmaticus appears to be improving. Which is the most objective way for the nurse to evaluate the child's response to therapy?
Evaluating the child's peak expiratory flow rate A peak expiratory flow meter (PEFM) is used to obtain the peak expiratory flow rate (PEFR). The PEFM provides an objective measure of the maximal flow of air that can be forcefully exhaled in 1 second. The PEFM individualizes data for the child because after a personal best value is established, this baseline can be compared with current values to determine progress or lack of progress regarding the child's respiratory status. Although breath sounds may be auscultated, the child's respiratory pattern may be monitored, and the color of the lips may be assessed, none is as objective a measure as a PEFR result.
Which response provides evidence that a client with chronic obstructive pulmonary disease (COPD) understands the nurse's instructions about an appropriate breathing technique?
Holding each breath for a second at the end of inspiration allows added time for gaseous exchange at alveolar capillary beds. Inhalation should occur through the nose to moisten, filter, and warm the air. Increasing the respiratory rate does not allow for prolonged expirations, thus decreasing the effectiveness of respirations. The expiratory phase should be lengthened, and exhalation should occur through pursed lips to prevent alveolar collapse.
A client is experiencing an acute episode of bronchial asthma. The nurse would focus on which goal when creating the client's plan of care?
In addition to dilation of bronchi, treatment is aimed at expectoration of mucus. Mucus interferes with gas exchange in the lungs. Curing the condition permanently is an unrealistic goal; asthma is a chronic illness. Increased fluid intake helps liquefy secretions. Asthma has a psychogenic factor, but this is not the only cause; it may occur as an allergic response to an antigen, such as dust.
What are two qualifiers for a patient to receive Palivizumab (Synagis)?
In those less than 2 years old: 1.Prematurity 2.Chronic lung disease 3.Certain congenital heart diseases 4.Certain neuromuscular disorders
A client with chronic obstructive pulmonary disease (COPD) receives information about a rehabilitation plan. To decrease hospital admissions and to live a more active life, which instruction would the nurse provide to the client?
Incorporate humidification into the home environment Humidification of the environment helps prevent thickened secretions. Liquefied secretions are easier to expectorate. Measures to prevent infection are essential; however, infections are impossible to eliminate. Exhaling requires less energy than inhaling; therefore, movements that use energy should be done during exhalation. The use of abdominal muscles rather than thoracic muscles improves the client's breathing.
A client with a chronic obstructive pulmonary disease (COPD) exacerbation is receiving oxygen at 2 L/minute per nasal cannula and has an oxygen saturation of 88% (0.88). Which action would the nurse anticipate taking next?
Increasing oxygen flow rate to 3 L/minute Because the client's oxygen saturation indicates hypoxemia, a higher flow rate of oxygen is needed. The nurse will continue to monitor the oxygen saturation and respiratory rate and depth, because some (but not all) clients with COPD will have a decrease in respiratory drive when oxygen saturation is in the 95% to 100% (0.95-1.00) range. Intubation and assisted ventilation is not indicated now, although it may be needed if higher oxygen flows fail to improve the client's oxygen saturation. Inhaled bronchodilators help open airways and are frequently used for clients with COPD exacerbation, but do not directly increase oxygen saturation. The nurse will continue to monitor the client, but a change in treatment is indicated because the client is hypoxemic.
A client presenting with an acute asthma attack is being assessed in the emergency department. The client's spouse reports that the client currently is undergoing treatment for an upper respiratory infection. The nurse would understand that the client most likely has which type of asthma?
Intrinsic asthma is triggered by an internal factor such as a cold. Intrinsic asthma does not have an identifiable allergen. Asthma related to emotions is considered to be extrinsic asthma. Extrinsic asthma includes allergens such as pet dander, dust mites, mold, dust, and others
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client's arterial blood gases deteriorate, and respiratory failure is impending. Which clinical indicator is consistent with the client's condition?
Mental confusion Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema)
Asthma Severity Classification System
Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent
The nurse is teaching a child with asthma breathing exercises using techniques in play situation, and the child performs a repeat demonstration for the nurse. Which technique indicates the child needs further teaching?
Moving a cotton ball when inhaling The goal for teaching a child with asthma breathing exercises is to lengthen expiratory time and expiratory pressure. This activity focuses on inhalation, not exhalation. Singing songs with long phrases forces the child to exhale until each phrase is completed. Activities such as puffing through a straw or blowing through a pipe encourage exhalation.
What diet is ordered for a newborn withTEF?
NPO
The medication indicated for prevention of severe disease (RSV) for those who are most susceptible.
Palivizumab (Synagis)
When preparing a child with asthma for discharge, which instructions would the nurse emphasize to the family?
Parents should be taught to limit allergens in the home that can precipitate asthma attacks (e.g., no carpets, no down pillows, no scented products; wet-mopping floors, vacuuming when the child is not in the home). Medications to control inflammation, including inhaled corticosteroids and long-acting β 2-agonists, must be continued to suppress exacerbations of asthma. Environmental moisture is necessary for these children; in addition, cold environments should be avoided. Consistent limits should be placed on the child's behavior, regardless of the illness; a chronic illness does not eliminate the need for limit setting. The child should return to school and continue to interact with schoolmates and friends.
RSV Interventions
RSV is a highly communicable disorder and is transmitted via droplets or contact with respiratory secretions. Use of contact, droplet, and standard precautions during care (wearing gloves, mask, and a gown) reduces nosocomial transmission of RSV. In addition, it is important to ensure that nurses caring for a child with RSV do not care for other high-risk children to prevent the transmission of the infection. An infant with RSV should be placed in a private room. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.
Which type of acid-base imbalance would the nurse expect in a child admitted with a severe asthma exacerbation?
Respiratory acidosis caused by impaired respirations and increased formation of carbonic acid The restricted ventilation accompanying an asthma attack limits the body's ability to blow off carbon dioxide. As carbon dioxide accumulates in the body fluids, it reacts with water to produce carbonic acid; the result is respiratory acidosis. The problem basic to asthma is respiratory, not metabolic. Respiratory alkalosis is caused by the exhalation of large amounts of carbon dioxide; asthma attacks cause carbon dioxide retention. Asthma is a respiratory problem, not a metabolic one; metabolic acidosis can result from an increase of nonvolatile acids or from a loss of base bicarbonate.
Asthma Ventilatory failure and asphyxia:
Shortness of breath, with air movement in the chest restricted to the point of absent breath sounds, is noted; this is accompanied by a sudden increase in the respiratory rate.
When a client is newly diagnosed with chronic obstructive pulmonary disease (COPD), which action by the nurse has the highest priority?
Smoking cessation slows the progression of COPD and is the most important action that the client can take to help maintain lung function. Although many clients may not be ready to stop smoking, the nurse will assess the client's interest in smoking cessation at every encounter. Teaching correct inhaler use is important, but inhaled medications only treat the symptoms of COPD and do not slow disease progression. The client will be educated on the progression of COPD, but education alone does not change the progression of the disease. Pulmonary rehabilitation programs are helpful in improving ability to do activities of daily living and also will assist the client with tobacco cessation, but assessment of readiness to quit smoking is done before developing a plan to quit
A client is prescribed albuterol to relieve severe asthma. Which adverse effects will the nurse instruct the client to anticipate?
Tremors and palpitations Albuterol's sympathomimetic effect causes central nervous system (CNS) stimulation, precipitating tremors, tachycardia, and palpitations. Lethargy is an adverse effect of medications that cause CNS depression, not CNS stimulation. Albuterol causes bronchodilation, not bronchoconstriction. Albuterol will cause tachycardia, not bradycardia.
Terbutaline
a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures. The medication may increase blood glucose levels.
Asthma
a chronic inflammatory disease of the airways
Albuterol/ipratropium
a combination agent—one is a β2-adrenergic agonist and the other is an anticholinergic medication, and in combination they produce an overall bronchodilation effect. Common side and adverse effects include headache, dizziness, dry mouth, tremors, nervousness, and tachycardia.
Zafirlukast- (like Montelukast)
a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Is used with caution in clients with impaired hepatic function. Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication. It is not necessary to perform the other laboratory tests before administration of the medication.
Theophylline
a methylxanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, cola, and chocolate.
Fluticasone
a steroid commonly administered by way of inhalation for long-term control of asthma symptoms. Oral thrush is a side effect that manifests as white patches. Administered via inhalation so food or milk is not needed before administration. Dry mouth is not a side effect.
Acute asthma attacks assessment
a.Episodes include progressively worsening shortness of breath, cough, wheezing, chest tightness, decreases in expiratory airflow secondary to bronchospasm, mucosal edema, and mucus plugging; air is trapped behind occluded or narrow airways, and hypoxemia can occur. b. The attack begins with irritability, restlessness, headache, feeling tired, or chest tightness; just before the attack, the child may present with itching localized at the front of the neck or over the upper part of the back. c. Respiratory symptoms include a hacking, irritable, nonproductive cough caused by bronchial edema. d. Accumulated secretions stimulate the cough; the cough becomes rattling, and there is production of frothy, clear, gelatinous sputum. e. The child experiences retractions. f. Hyperresonance on percussion of the chest is noted. g. Breath sounds become coarse and loud, with crackles, coarse rhonchi, and inspiratory and expiratory wheezing; expiration is prolonged. h. Child may be pale or flushed, and the lips may have a deep, dark-red color that may progress to cyanosis (also observed in the nail beds and skin, especially around the mouth). i. Restlessness, apprehension, and diaphoresis occur. j. Child speaks in short, broken phrases. k. Younger children assume the tripod sitting position; older children sit upright, with the shoulders in a hunched-over position, the hands on the bed or a chair, and the arms braced to facilitate the use of the accessory muscles of breathing (child avoids a lying-down position). l. Exercise-induced attack m. Severe spasm or obstruction n. Ventilatory failure and asphyxia
When a client with chronic obstructive pulmonary disease (COPD) reports a 5-lb (2.3-kg) weight gain in 1 week, the nurse will assess for other signs and symptoms of which complication?
cor pulmonale Fluid retention and weight gain caused by right ventricular failure is a clinical manifestation of cor pulmonale, or right ventricular failure caused by pulmonary hypertension associated with COPD. Polycythemia may be caused by COPD, but it does not cause weight gain. Compensated respiratory acidosis is caused by COPD, but it would not lead to weight gain. Left ventricular failure may lead to weight gain, but it is not a complication of COPD.
peak flow meters (PFMs)
used to measure the maximal amount of exhalation. In doing this, it can identify when airway obstruction is occurring before the obstruction is sufficient to cause symptoms. PFMs are used to measure exhalation, not inhalation. PFMs are not used for medication administration. The use of a PFM should not be preceded by administration of a bronchodilator.
