Exam 4: Week 14
Methylxanthine indication
(Aminophyline, theophylline) Dilates the bronchioles
Nursing considerations for methylxanthines
(Aminophylline, theophylline) Monitor for AE: GI distress, sleeplessness, hyperactivity, tachycardia Administer with food, avoid caffeine, check HR, crosses placenta
Adrenergic and sympathomimetics indication
(Epinephrine, albuterol, salbutamol) Dilates the bronchioles
Nursing implications of adrenergic and sympathomimetics
(Epinephrine, albuterol, salbutamol) Monitor for AE: tachycardia, anxiety, urine retention Instruct proper inhaler use, sleep disturbances
Anticholinergic indication for COPD
(Ipratropium) Dilates the bronchioles
Nursing considerations for anticholinergics
(Ipratropium) Monitor AE: Dry mouth, blurred vision, cough Do not exceed 12 doses in 24 hours
Indication for corticosteroids in COPD
(Prednisone, solu-medrol, beclomethasone, budesonide) Anti-inflammatory.
Nursing considerations for corticosteroids
(Prednisone, solumedrol, beclomethasone, budesonide) Monitor AE: Cardiac dysrhythmias, insomnia, hyperglycemia Instruct proper inhaler use, endocrine issues, encourage oral care after use
Asthma pt teaching
- Identify and avoid triggers - Proper inhalation technique - Perform peak flow monitoring - Create action plan - Learn when and how to seek assistance
Normal PaO2
80-100 mmHg
Optimum SpO2 for COPD
88-92%
Asthma nursing interventions
Administer bronchodilators, administer fluids and humidification, education, ABGs, ventilator patterns, CPAP, BiPAP
What COPD medications should you closely monitor for tachycardia?
Adrenergic- Epinephrine, albuterol, salbutamol Methylxanthine- Aminophyline, theophylline
Short acting beta agonist
Albuterol
At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-Medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer: albuterol (Proventil). morphine. alprazolam (Xanax). propranolol (Inderal).
Albuterol (Proventil)
Common triggers for asthma
Allergens, exercise, foods/drinks, beta blockers, infection, allergic reaction, emotional stress, reflex esophagitis
What genetic abnormality leads to COPD?
Alpha1-antitrypsin deficiency
The nurse at the beginning of the evening shift receives a report at 1900 on the following patients. Which patient would the nurse assess first? An 85 year old with COPD with wheezing and an O2 saturation of 89% on 2 L of oxygen A 74 year old with chronic bronchitis who has BP 128/58, HR 104, and R 26 An 86 year old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office A 62 year old with emphysema who has 300 mL of intravenous fluid remaining
An 86 year old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office
Corticosteroids MOA and considerations
Anti-inflammatory Monitor glucose
Budesonide MOA
Anti-inflammatory. Used long term to prevent and reverse symptoms of inflammation.
What COPD medication can cause dry mouth, blurry vision and a cough?
Anticholinergic- Ipratropium.
A 55-year-old client is scheduled for spirometry testing for evaluation of chronic obstructive pulmonary disease (COPD). The nurse Tells the client that arterial blood gas is performed after spirometry testing States that various blood tests must also be done Asks the client, "What are your allergies?" Explains to the client not to eat or drink before the spirometry test
Asks the client, "What are your allergies?"
Airways affected: Asthma Emphysema Bronchitis CF
Asthma: upper Emphysema: lower Bronchitis: upper CF: all
A client's spouse states that she is worried about her husband because he appears to be breathing "really hard." The nurse performs a respiratory assessment. What findings would indicate a need for further interventions? Pale, paper-thin skin, O2 at 2L/min via nasal cannula BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 °F (38.5 °C) BP 122/82, HR 102, R 24, noted barrel chest, temperature 98.4 °F (36.9 °C) Client states, "It always seems like I just can't catch my breath."
BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 °F (38.5 °C)
Examples of inhaled corticosteroids
Beclomethasone, budesonide, fluticasone
What type of COPD leads to Cor pulmonale?
Both bronchitis and emphysema can lead to cor pulmonale. More common in chronic bronchitis.
Which of the following occupy space in the thorax, but do not contribute to ventilation? Lung parenchyma Bullae Alveoli Mast cells
Bullae
Respiratory drive is triggered by changes in levels of ___.
CO2. This is called a hypercapnic response.
Pulmonary bleb
Cavity in the lung much like a balloon; may rupture to create a pneumothorax Caused by emphysema
CF treatment
Chest physical therapy Pulmonary rehab PAP with PEP Avoid crowds Nutritional counseling Oxygen Feeding tube Transplant Pharm regimen
COPD
Chronic Obstructive Pulmonary Disease Slowly progressive inflammatory respiratory disease of airflow obstruction
What condition is this: A form of COPD that does not struggle due to loss of hypercarbic drive
Chronic bronchitis
What condition is this: Chronic hypoxia leads to a dusky or cyanotic color.
Chronic bronchitis
What condition is this: Diagnosis made if chronic sputum with cough daily for >3 months for 2 consecutive years
Chronic bronchitis
Two types of COPD
Chronic bronchitis and emphysema
What condition is this: A condition in which the lungs are constantly swollen, inflamed and clogged with mucus. The excess mucus causes a chronic cough.
Chronic bronchitis.
Emphysema ABGs
Compensated respiratory acidosis
A nurse is caring for a client with COPD. While reviewing breathing exercises, the nurse instructs the client to breathe in slowly through the nose, taking in a normal breath. Then the nurse asks the client to pucker his lips as if preparing to whistle. Finally, the client is told to exhale slowly and gently through the puckered lips. The nurse teaches the client this breathing exercise to accomplish which goals? Select all that apply. Control the rate and depth of respirations Prevent airway collapse Condition the inspiratory muscles Strengthen the diaphragm Release air trapped in the lungs
Control the rate and depth of respirations Prevent airway collapse Release air trapped in the lungs
COPD meds
Corticosteroids MDIs: Bronchodilators, anticholinergics, combination agents
Chronic bronchitis diagnosis
Cough and sputum production for at least 3 months in each of 2 consecutive years
Asthma signs and symptoms
Cough, night cough, dyspnea, wheezing, generalized chest tightness, expiration requires effort, hypoxemia, diaphoresis, tachycardia
A client has asthma. Which of the following medications is a commonly prescribed mast cell stabilizer used for asthma? Albuterol Budesonide Cromolyn sodium Theophylline
Cromolyn sodium
A client is being admitted to the medical-surgical unit for the treatment of an exacerbation of acute asthma. Which medication is contraindicated in the treatment of asthma exacerbations? Levalbuterol HFA Albuterol Ipratropium Cromolyn sodium
Cromolyn sodium
When to use asthma controllers
Daily basis to prevent and control bronchospasm
Respiratory rate in COPD patients is controlled by
Decrease in O2 Not increase in CO2
Goal of pharmacologic therapy for COPD
Decrease inflammation and dilate the airway
A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath and fatigue for 1 hour after awakening in the morning. Which of the following statements by the nurse would best help with the client's shortness of breath and fatigue? "Drink fluids upon arising from bed." "Raise your arms over your head." "Delay self-care activities for 1 hour." "Sit in a chair whenever doing an activity."
Delay self-care activities for 1 hour
Lung sounds with COPD
Diminished sounds or wheezes.
CF medications
Dornase alfa (cough medicine), CFTR modulators, pancreatic enzymes, bronchodilators, antibiotics as needed for infections
The diagnosis of pulmonary hypertension associated with chronic obstructive pulmonary disease (COPD) is suspected when which of the following is noted? Select all that apply. Left ventricular hypertrophy Elevated plasma brain natriuretic peptide (BNP) Enlargement of central pulmonary arteries Right ventricular enlargement Dyspnea and fatigue disproportionate to pulmonary function abnormalities
Elevated plasma brain natriuretic peptide (BNP) Enlargement of central pulmonary arteries Right ventricular enlargement Dyspnea and fatigue disproportionate to pulmonary function abnormalities
What condition is this: Relies on pursed lip breathing to blow off CO2
Emphysema
What condition is this: Struggles due to strong hypercarbic drive
Emphysema
What condition is this: Deflated, damaged alveoli leads to blebs and bullae.
Emphysema.
The nurse has instructed the client to use a peak flow meter. The nurse evaluates client learning as satisfactory when the client Inhales deeply and holds the breath Records in a diary the number achieved after one breath Exhales hard and fast with a single blow Sits in a straight-back chair and leans forward
Exhales hard and fast with a single blow
What is the primary cause of COPD in the US?
Exposure to tobacco smoke (80-90%)
Stage 1 COPD
FEV-1 >80% You may have no symptoms. You might be short of breath when walking fast on level ground or climbing a slight hill
Stage 3 COPD
FEV1 30-49% You may be too short of breath to leave the house. You might get breathless doing something as simple as dressing and undressing.
Stage 2 COPD
FEV1 50-79% If you're walking on level ground, you might have to stop every few minutes to catch your breath
Stage 4 COPD
FEV1 <30% You might have lung or heart failure. This can make it hard to catch your breath even when you're resting. You might hear this called end-stage COPD.
A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client Has a respiratory rate of 28 breaths/minute Reports shortness of breath Has wheezes in the right lung lobes Cannot perform activities of daily living
Has wheezes in the right lung lobes
Nutrition for CF
High fat, high protein Extra salt intake Pancreatic enzymes taken with every meal
Patho results of asthma
Hyperresponsiveness Mucosal edema Mucus production
A physician orders metaproterenol by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication? "I need to call the physician right away if I feel my heart beating fast after using the drug." "I need to hold my breath as long as possible after I take a deep inhalation." "I should use this inhaler whenever I get short of breath." "I can stop using this drug when I begin to feel better."
I need to hold my breath as long as possible after I take a deep inhalation
A nurse notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 65% for a patient with COPD. What stage should the nurse document the patient is in? IV II III I
II
When to use humidification
If administering greater than 4L/min
A nurse is assisting a client with mild chronic obstructive pulmonary disease (COPD) to set a goal related to the condition. Which of the following is an appropriate goal for this client? Relieve shortness of breath to a level as close as possible to tolerable. Continue with current level of mobility at home. Increase walking distance around a city block without shortness of breath. Maintain activity level of walking to the mailbox.
Increase walking distance around a city block without shortness of breath
Which measure may increase complications for a client with COPD? Increased oxygen supply Administration of antitussive agents Decreased oxygen supply Administration of antibiotics
Increased oxygen supply
Asthma preventers
Inhaled corticosteroids: Prednisone, solu-medrol, beclomethasone, budesonide Leukotriene receptor agonist: Montelukast
Roflumilast AE
Insomnia, weight loss, depression
A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should: administer pain medication as ordered. instruct the client to drink at least 2 L of fluid daily. maintain the client on bed rest. administer anxiolytics, as ordered, to control anxiety.
Instruct the client to drink at least 2 L of fluid daily
A nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? It increases inspiratory muscle strength. It decreases use of accessory breathing muscles. It helps prevent early airway collapse. It prolongs the inspiratory phase of respiration.
It helps prevent early airway collapse
Pink puffers vs. blue bloaters
PP: Barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe. Person works harder to breathe but the oxygen taken in is adequate to oxygenate the tissues. BB: Insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart failure (Cor Pulmonale)
Signs and symptoms of emphysema
Pink puffers, CO2 retention, dyspnea, pursed lip breathers, distant/quiet breath sounds, wheezes, barrel chest, pulmonary blebs on radiograph, orthopnea, prolonged expiratory time, anxious, thin, use of accessory muscles
If Bullae rupture, it can cause a ___
Pneumothorax
The client is prescribed albuterol 2 puffs as a metered-dose inhaler. Which action by the client demonstrates understanding of administration for this medication? Holds the breath for 5 seconds after administering the medication Carefully holds the inhaler upright without shaking it Positions the inhaler 2 finger widths away from the lips Immediately repeats the second puff after the first puff
Positions inhaler 2 finger widths away from the lips
Goals of CF treatment
Preventing and controlling infections in the lungs Removing and loosening mucus Treating and preventing intestinal blockage Providing adequate nutrition
PFT (pulmonary function test)
Purpose: Assesses respiratory function & determine extent of dysfunction. (FEV1) During: Uses mouthpiece to blow as hard as they can for 8 seconds
Pathophysiology of emphysema
Reduced gas exchange surface area Increased air trapping (increased AP diameter) Decreased capillary network Increased O2 consumption
Diaphragmatic breathing indication
Reduces RR, increases alveolar ventilation and expels more air during expiration
Asthma preventers MOA
Reduces inflammation and prevents issues
Roflumilast indication
Reduces lung inflammation in severe COPD
pH: 7.37 CO2: 63 PO2: 58 HCO3: 35 SaO2: 89%
Respiratory acidosis fully compensated.
Chronic bronchitis can lead to
Right-sided heart failure (Bilateral pedal edema, increased JVD)
Why should you rinse your mouth after corticosteroid use?
Rinse mouth to avoid thrush.
Asthma relievers
SABAs: Beta2 adrenergic agonists like albuterol and salbutamol Anticholinergic: Ipratropium
Long acting beta agonist
Salmeterol
Cor pulmonale
Serious cardiac disease associated with chronic lung disorders. Right ventricular hypertrophy. Increased pressure in the pulmonary artery.
COPD PaO2
Should be at least 60 mmHg
Pursed lip breathing is beneficial to
Slow expiration, prevent collapse of small airways, control rate and depth of respiration
80-90% of COPD is caused by ___
Smoking tobacco
Risk factors of emphysema
Smoking, environmental/occupational exposure, genetics
Stages of COPD
Stage 1: Mild. FEV1 >80% Stage 2: Moderate. FEV 50-79% Stage 3: Severe. FEV 30-49% Stage 4: Very severe. FEV <30%
Bullae tx
Surgically treated with a resection, chest tube
Typical posture of a person with COPD
Tend to lean forward using accessory muscles to breathe May be a result of bronchospasm
A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. This change occurred because:
The airways are so swollen that no air can get through
A client is receiving theophylline for long-term control and prevention of asthma symptoms. Client education related to this medication will include 1- the importance of blood tests to monitor serum concentrations. 2- taking the medication at least 1 hour prior to meals. 3- monitoring liver function studies as prescribed. 4- development of hyperkalemia.
The importance of blood tests to monitor serum concentrations
A commonly prescribed methylxanthine used as a bronchodilator is which of the following? Levalbuterol Albuterol Terbutaline Theophylline
Theophylline
What asthma medication do you need to monitor serum values?
Theophylline
Causes of COPD
Tobacco smoke (80-90% of COPD) Passive smoking Occupational exposure (firefighter, coalminers) Air pollution Genetic abnormalities (Alpha1-antitrypsin deficiency)
COPD positioning
Tripoding: Sitting in chair with feet spread shoulder width apart and leaning forward with elbows on knees. Arms and hands are relaxed. Leaning forward
T or F: Bronchoconstriction can be reversed in asthma
True.
A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when he: wants the head of the bed raised to a 90-degree level. has a pulse oximetry reading of 93%. uses the sternocleidomastoid muscles. sits in tripod position.
Uses the sternocleidomastoid muscles
Forced expiratory volume
Volume of air expired in 1 second during maximal expiration
CF pharmacology indications
- Target gene mutation - Abx to treat lung infections - Anti-inflammatory to lessen airway swelling - Mucus thinning drugs - Bronchodilators to keep airway open - Oral pancreatic enzymes for nutrition - Stool softeners - Acid reducing medications - Specific drugs for diabetes and liver disease
Chronic bronchitis
-A condition in which the bronchi in the lungs are constantly swollen and clogged with mucus -Alveoli become damaged, fibroses, and alveolar macrophage function diminishes.
Emphysema
-Abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli -Decreased elasticity in the alveoli. Scar tissue formation over time, narrowing airways. -Decreased alveolar surface area increases in "dead space," impaired oxygen diffusion. Air trapping.
Asthma Action Plan: Yellow Zone
-Peak flow 50%-79% predicted -Add quick-relief medicine (albuterol) and oral corticosteroid (beclomethasone)
Asthma Action Plan: Red Zone
-Peak flow <50% predicted -Take SABAs and oral corticosteroid -Call 911
Asthma action plan: green zone
-Peak flow >80% predicted -Take long term control medicine and anti-inflammatory medicine daily
If a patient is prescribed montelukast, when should they take the medication?
1 hr before meals or 2 hrs after
MDI administration (9 steps)
1. Remove the cap, hold inhaler upright 2. Shake the inhaler 3. Tilt head back slightly and breathe out slowly 4. Position inhaler 1-2 inches from mouth 5. Breathe in slowly 6. Hold breath for 10 seconds 7. Repeat puffs. 15-30 seconds between puffs. 8. Apply cap 9. Rinse mouth after inhalation when using corticosteroid MDI
What condition is this: Overinflated airways lead to loss of elasticity. Inflammation narrows airways and air sacs eventually collapse.
Emphysema.
Barrel chest is associated with
Emphysema. Pink puffers
T or F: Clear breath sounds means adequate oxygenation
False.
T or F: Blebs usually have intense symptoms
False. They usually have no symptoms.
Risk factors for asthma
Family history Exposure to pollution
Common inhaler combinations
Fluticasone + salmeterol Ipratropium + albuterol
When to use asthma relievers
For acute attacks. Quickly dilates bronchial airway.
Hypoxic drive
Form of respiratory drive in which the body uses oxygen chemoreceptors instead of carbon dioxide receptors to regulate the respiratory cycle. Seen in patients with COPD.
COPD interventions
Fowlers Respiratory tx: beta agonists, anticholinergics, adrenergic, sympathomimetics Mech. soft diet Hydrate (3L/day) Smoking cessation Lowest FiO2 to prevent CO2 retention (O2: 88-92%) Monitor s/s FVE Maintain a PaO2 between 55-60 Baseline ABGs Teach pursed lip breathing and diaphragmatic breathing and tripoding Administer bronchodilators and anti-inflammatory agents
Chronic bronchitis signs and symptoms
Generalized cyanosis, "blue bloaters", right sided heart failure, JVD, crackles, expiratory wheezes, cool dusty to cyanotic, sputum production, respiratory acidosis, hypercapnia, tachypnea, clubbing, cough, use of accessory muscles to breath
CF pathophysiology
Genetic mutation of a gene causing dysfunction in the CFTR which normally transports chloride ions. Impacts the cells that create mucus, sweat and digestive juices. This causes thick secretions in the lungs, pancreas, liver, intestine and reproductive tract. Thick mucus leads to bronchial mucus plugs, inflammation and damaged bronchioles.
A client with chronic obstructive pulmonary disease tells a nurse that he feels short of breath. The client's respiratory rate is 36 breaths/minute and the nurse auscultates diffuse wheezes. His arterial oxygen saturation is 84%. The nurse calls the assigned respiratory therapist to administer an ordered nebulizer treatment. The therapist says, "I have several more nebulizer treatments to do on the unit where I am now. As soon as I'm finished, I'll come and assess the client." The nurse's most appropriate action is to: administer the treatment by metered-dose inhaler. give the nebulizer treatment herself. notify the primary physician immediately. stay with the client until the therapist arrives.
Give the nebulizer treatment herself
Chest physical therapy (CPT)
Gravity-assisted bronchial drainage with techniques for secretion removal and breathing techniques.
Bronchodilators for COPD
Key for symptom management.
Normal vs. COPD AP diameter
Normal- 1:2 Emphysema- 1:1
In COPD, the chemoreceptors are chronically exposed to carbon dioxide. Instead of having hypercapnic response driving respiratory effort, ___ drives respiratory effort.
O2. This is called hypoxic drive.
Symptoms of CF
Chronic cough and sputum production. Wheezing, crackles, rattling, rales or stridor. GI abnormalities, sinusitis, salty sweat
Three primary symptoms of COPD
Chronic cough, sputum production and dyspnea
Chronic bronchitis pathophysiology
Chronic hypoxemia, cor pulmonale Increased bronchial wall thickness (obstructs air flow) and increased mucus production
Asthma pathophysiology
Chronic inflammatory disease of the airways Hyperresponsive bronchoconstrictor and inflammatory response to different stimuli
A client has chronic obstructive pulmonary disease (COPD) and is exhibiting shallow respirations of 32 breaths per minute and a pulse oximetry of 93% despite receiving nasal oxygen at 2 L/minute. What action should the nurse take? Encourage the client to take deep breaths. Increase the flow of oxygen. Teach the client to perform upper chest breaths. Encourage the client to exhale slowly against pursed lips
Encourage the client to exhale slowly against pursed lips
Peak flow meter zones
Green 80-100%: asthma under control Yellow 60-79%: asthma caution Red <60%: medical emergency
Cystic fibrosis manifestations
Growth failure, vitamin deficiency Hepatic steatosis Cholelithiasis, cirrhosis Osteoporosis, arthritis Meconium ileus, meconium peritonitis Bronchiectasis, PNA, atelectasis, cor pulmonale, excess mucus productive, reactive airway disease Pancreatitis Hypersplenism Infertility
Asthma controllers
LABAs: Salmetrol
Bullae
Large blebs formed together
Why would a client with COPD report feeling fatigued? Select all that apply. Lung function gradually decreases over time in clients with COPD. The client is using all expendable energy for activities of daily living (ADLs). The client is using all expendable energy just to breathe. Muscle function gradually decreases over time in clients with COPD.
Lung function gradually decreases over time in clients with COPD. The client is using all expendable energy just to breathe.
A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess? Heart rate Lung sounds Respiratory rate Skin color
Lung sounds
What medication should you ensure proper oral care after use in COPD patients?
MDIs with corticosteroids should always be proceeded with good oral care.
Cromolyn sodium moa
Mast cell stabilizer. Prevents the release of mast cells that would normally attract inflammatory cells
COPD diet
Mechanical soft, high-calorie, low-carbohydrate, high-fat, small frequent feedings
A nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Choose all that apply. Mucus secretions that block airways Inflamed airways that obstruct airflow Decreased numbers of goblet cells Overinflated alveoli that impair gas exchange Dry airways that obstruct airflow
Mucus secretions that block airways Inflamed airways that obstruct airflow Overinflated alveoli that impair gas exchange
Qualifications for long term oxygen therapy
Reserved for those who have a PaO2 <55 mmHg or evidence of tissue hypoxia, RHF, decreased LOC, or edema
For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? Keeping the client in semi-Fowler's position Encouraging the client to drink three glasses of fluid daily Using a Venturi mask to deliver oxygen as ordered Administering a sedative as ordered
Using a venture mask to deliver oxygen as ordered
A client with cystic fibrosis is admitted to the hospital with pneumonia. When should the nurse administer the pancreatic enzymes that the client has been prescribed? Three times a day regardless of meal time After meals and at bedtime With meals Before meals
With meals