Lewis – Ch 29 – Obstructive Pulmonary Diseases: Nursing Management

question

What is Obstructive Pulmonary Disease?
answer

The most common chronic lung disease, includes diseased characterized by increased resistance to airflow as a result of airway obstruction or airway narrowing.
question

What are the types of Obstructive Pulmonary Disease?
answer

Asthma, COPD, cystic fibrosis, and bronchiectasis.
question

What is Asthma?
answer

Is a chronic inflammatory lung disease that results in variable episodes of airflow obstruction, but is usually reversible.
question

What does chronic inflammation in Asthma lead too?
answer

Recurrent episodes of wheezing, breathlessness, chest tightness, cough, particularly at night or in the early morning.
question

What are the risk factors of Asthma?
answer

Related to the patient (e.g., genetic factors), or the environment. Obesity as well, and gender.
question

What are the gender differences for males with Asthma?
answer

Male gender is a risk factor for asthma in children, but not adults for unclear reasons. Before puberty males are more affected.
question

What are the gender differences for females with Asthma?
answer

After puberty and into adulthood, women are more affected then men. Women who are admitted to the ER are more likely to need hospitalization. Death rates in women are greater then men.
question

What are the cultural and ethnic health disparities in regards to Asthma with African Americans?
answer

Higher prevelance rates over 38%, females have the highest mortality rate.
question

What are the cultural and ethnic health disparities in regards to Obstructive Pulmonary Diseases with Whites?
answer

Highest incidence of COPD, highest incidence of Cystic Fibrosis.
question

What are the cultural and ethnic health disparities in regards to Obstructive Pulmonary Diseases with Puerto Ricans?
answer

Higher asthma prevalence rates and age adjusted death rates than all other racial and ethnic subgroups.
question

What is the Genetic Risk factor with Asthma?
answer

Asthma has a component that is inherited. Numerous genes are involved. Atopy the genetic predisposition to develop an allergic (IgE-mediated) response to common allergies, is a major risk factor.
question

What is the Immune Response Risk factor with Asthma?
answer

Hygiene response hypothesis is thought to play a role in Asthma.
question

How do Allergies effect Asthma?
answer

Indoor and outdoor allergens are well known to trigger asthma. House dust mites, cockroaches, furry animals, fungi and mold can trigger.
question

How does exercise effect Asthma?
answer

Induced or exacerbated asthma. Occurs after vigorous exercise. Symptoms are pronounced during activities where there is exposure to cool, dry air.
question

How do air pollutants effect Asthma?
answer

Cigarette or wood smoke, vehicle exhaust, elevated ozone levels, sulfur dioxide, and nitrogen dioxide can trigger an attack.
question

How does cigarette smoking effect Asthma?
answer

Associated with an accelerated decline of lung function. Increases the severity of the disease, may cause patients to be less responsive to treatment with corticosteroids (systemic or inhaled), and reduces the chance of asthma being controlled.
question

What are occupational factors with Asthma?
answer

Job-related exposures. Irritants cause a change in the responsiveness of the airways. Agricultural workers, painters, plastics manufacturing, and cleaning work are high risk. Arrive at work feeling well but experience gradual development of symptoms towards the end of the day.
question

How do Respiratory Infections effect Asthma?
answer

Major precipitating factors in acute asthma attacks. RSV and rhinovirus are two factors in developing and increasing severity of Asthma. Cause an increase in hyperresponsiveness of the bronchial system.
question

How do nose and sinus problems effect Asthma?
answer

Allergic rhinitis is a major predictor. Treatment of allergic rhinitis may reduce frequency of exacerbation. Chronic sinus problems can cause inflammation of the mucus membranes.
question

What is the Asthma Triad?
answer

Nasal polyps, asthma, and sensitivity to aspirin and NSAIDS.
question

What happens when some asthmatics take aspirin or NSAIDS?
answer

Wheezing will develop within two hours. Usually rhinorrhea, congestion, and tearing occurs. Facial flushing, GI symptoms, and angioedema can occur.
question

How can B-Adrenergic Blockers PO or topical eyedrops effect Asthma?
answer

May trigger asthma because of bronchospasms.
question

How can ACE inhibitors effect Asthma?
answer

May produce cough in susceptible individuals, making symptoms worse.
question

How does tartrazine (yellow dye #5) and sulfating agents effect Asthma?
answer

Used as preservatives and sanitizing agents. Commonly found in fruits, beer, and wine used extensively in salad to prevent oxidation. Can cause asthma exacerbation.
question

How does GERD effect Asthma?
answer

Postulated that reflux of stomach acid into the esophagus can be aspirated into the lungs, causing relfex vagal stimulation and bronchoconstriction.
question

What are the Psychological Factors with Asthma?
answer

Emotional stress, extreme emotions such as crying, laughing, anger and fear can lead to hyperventilation and hypocapnia, which can cause airway narrowing.
question

What is the Pathophysiology of Asthma?
answer

Persistent but variable inflammation of the airway. Airflow is limited because of inflammation results in bronchoconstriction, airway hyperresponsiveness, and edema of the airways.
question

What are the inflammatory cells that are involved with Asthma?
answer

Mast cells, macrophages, eosinophils, neutrophils, T and B lymphocytes, and epithelial cells of the airways.
question

How long does it take for someone to have an early phase response with Asthma?
answer

30 – 60 minutes after exposure to allergen or irritant.
question

How long does it take for someone to have an late phase response with Asthma?
answer

4 – 10 hours after initial attack because of eosinophil and lymphocyte activation and their release of more inflammatory mediators. Epithelial cells also produce cytokines and other inflammatory mediators.. Can persist for 24 hours or more.
question

What is the allergic asthma response?
answer

Triggered when an allergen cross links IgE receptors on Mast cells, which are activated to release histamine and other inflammatory mediators (early-phase response). A late phase response may occur due to further inflammation.
question

What are the clinical manifestations of Asthma?
answer

Wheezing, cough, dyspnea, chest tightness after exposure to a precipitating factor or trigger. Expiration may be prolonged. Expiratory ration may be prolonged to 1:3, or 1:4. Bronchospasm, edema, and mucus in the brochioles, narrowing.
question

What does examination of the person with Asthma reveal?
answer

Hypoxemia, restlessness, increased anxiety, inappropriate behavior, increased pulse and blood pressure, and pulsus paradoxus (a drop in systolic during during the inspiratory cycle greater than 10 mm Hg). Difficulty speaking, increased RR (^30), use of accessory muscles. Hyperresonance on percussion, auscultating with wheezing. Silent chest indicates severe obstruction and impending respiratory failure.
question

How can Asthma be classified?
answer

Intermittent, mild persistent, moderate persistent, or severe persistent.
question

What are the diagnostic studies for Asthma?
answer

H & P, pulmonary function studies including response to bronchodilator therapy, peak expiratory flow rate (PEFR), chest x-ray, measure of oximetry, allergy skin test if indicated, blood level of eosinophil and IgE.
question

What is collaborative therapy for Asthma?
answer

ID and avoidance/elimination triggers, patient and caregiver teaching, drug therapy, asthma action plan, desensitization, assess for control.
question

What does a severe of life-threatening asthma exacerbation indicate?
answer

SaO2, ABGs, inhaled B2-adrenergic agonists, inhaled anticholinergic agents, )2 by mask or nasal prongs, IV or oral corticosteroids, IV fluids, IV magnesium or/and heliox, intubation or assisted ventilation.
question

What do ABG’s reveal with a person with Asthma?
answer

Normal between exacerbation, increase in pH in exacerbation, then decrease if prolonged or severe exacerbation, decrease in PaO2, decrease early in exacerbation of PaCO2 and increase if prolonged severe exacerbation.
question

What is a Chest x-ray reveal with Asthma?
answer

Hyperinflation.
question

What do Pulmonary Function Tests reveal with Asthma?
answer

Total lung capacity is increased, residual volume is increased, FEV1 decreased, FEV1/FVC normal to decreased.
question

What are the goals in collaborative care with Asthma?
answer

To achieve and maintain control of the disease.
question

What anti-inflammatory drugs are used for Long term Control of Asthma?
answer

Anti-inflammatory drugs such as corticosteroids: inhaled (e.g., fluticasone [Floventil]), Oral (e.g., Prednisone). Leukotriene modifiers (e.g., montelukast [Singular]), Anti-IgE (omalizumab [Xolair]).
question

What bronchodilators are used for Long Term Control of Asthma?
answer

Long acting inhaled b2-adrenergic agonists (e.g., salmeterol [Serevent]), Long acting oral b2-adrenergic agonists (e.g., albuteral [VoSpire ER]). Methylxanthines (e.g., theophyline [Uniphyl]), and Anticholinergics (inhaled) (e.g., tiotropium [Spirival]).
question

What bronchodilators are used for Quick Relief of Asthma?
answer

Short-acting inhaled b2-adrenergic agonists (e.g., albuterol [Proventil HFA]), Anticholinergics (inhaled) (e.g., ipratropium [Atrovent]).
question

What antiinflammatory drugs are used for Quick Relief of Asthma?
answer

Corticosteroids (systemic) (e.g., prednisone) – considered quick-relief when used in a short burst 3-10 days at the start of therapy or during a period of gradual deterioration.
question

How do Corticosteroids effect Asthma?
answer

Antiinflammatory medications that reduce bronchial hyperresponsiveness, block the late-phase reaction, and inhibit migration of inflammatory cells. More effective in improving asthma control then any other long term drug.
question

How do Leukotriene Modifiers effect Asthma?
answer

Leukotriene receptor blockers (antagonists) and leukotriene synthesis inhibitors interfere with the synthesis or block the action of leukotrienes – inflammatory mediators produced from arachidionic acid metabolism.
question

How do Anti-IgE medications effect Asthma?
answer

Prevents IgE from attaching to mast cells, thus preventing the release of the chemical mediators.
question

What are the three classes of Bronchodilators?
answer

B2-adrenergic agonists, methylxanthines and derivatives, and anticholinergics.
question

How do B2-Adrenergic Agonists Drug effect Asthma?
answer

Can be short acting or long acting. Act by stimulating b-adrenergic receptors in the bronchioles, thus producing bronchodilation. They also increase mucociliary clearance.
question

How do Methylxanthines effect Asthma?
answer

Bronchodilator with mild antiinflammatory effects, but the exact mechanism is unknown.
question

What is the main problem with Methylxanthines Theophylline?
answer

Relatively high incidence of interaction with other drugs and the occurrence of side effects, which include nausea, headache, insomnia, GI distress, tachcardia, dysrhythmias, and seizures.
question

How do anticholinergic drugs effect Asthma?
answer

Block the bronchoconstricting influence of the parasympathetic nervous system. Less effective than b2-adrenergic agonists.
question

What is a Nursing Assessment with Asthma?
answer

If the patient can speak and is not in acute distress, a detailed health history, including ID of any precipitating factors and what has helped alleviate attacks in the past can be taken. Subjective and objective data. Assess patients asthma control using one of the validated self-questionnaires.
question

What are Nursing Diagnosis for Asthma?
answer

Ineffective Airway Clearance, Anxiety, Deficient Knowledge.
question

What objective data should you look at during a Nursing Assessment of a patient with Asthma in regards to the respiratory system?
answer

Nasal discharge, polyps, swelling, wheezing crackles, diminished or absent breath sounds, rhonchi, hyperressonance, sputum, increase work of breathing, use of accessory muscles, intercostal and supraclavicular retractions, tachypnea with hyperventilation, prolonged expiration.
question

What objective data should you look at during a Nursing Assessment of a patient with Asthma in regards to the Cardiovascular system?
answer

Tachycardia, pulsus paradoxus, JVD, hypertension, or hypotension, premature ventricular contractions.
question

What objective data should you look at during a Nursing Assessment of a patient with Asthma in regards to General data?
answer

Restlessness or exhaustion, confusion, upright or foward leaning body position.
question

What objective data should you look at during a Nursing Assessment of a patient with Asthma in regards to the Integumentary System?
answer

Diaphoresis, cyanosis (circumoral, nail bed), eczema.
question

What overall goals do you plan for the patient with Asthma?
answer

1. minimal symptoms during the day and night. 2. acceptable activity levels. 3. maintenance of greater than 80% of personal best PEFR or FEV. 4. few or no adverse effects of therapy. 5. no recurrent exacerbations of asthma, and 6. adequate knowledge to participate in and carry out management.
question

What do you teach the patient about Asthma with Preventing Asthma Attacks or decreasing the severity?
answer

Identify and avoid known personal triggers, and irritants. Use of special dust covers on mattresses and pillow. Washing bedclothes in hot water or cooler water with detergent and bleach. Avoidance of furred animals. Avoid cold air, dress properly with scares and use masks. Avoid NSAIDS and OTC drugs with asprin. Maintain fluid intake of 2 – 3 L q day, good nutrition and adequat rest.
question

What are life threatening complications of Asthma?
answer

Status asthmaticus.
question

What is Status Asthmaticus?
answer

An acute exacerbation of asthma that does not respond to standard treatments of bronchodilators and steroids.
question

What are symptoms of Status Asthmaticus?
answer

Wheezing may be present, hypoxemia, hypercapnia.
question

What are complications of Status Asthmaticus?
answer

Pneumothorax, pneumomediastinum, cor pulmonale, respiratory arrest.
question

What is Pneumomediastinum?
answer

A condition where air is present in the mediastinum.
question

What is Cor Pulmonale?
answer

Pulmonary heart disease is enlargement of the right ventricle of the heart as a response to increased resistance or high blood pressure in the lungs.
question

What should teaching of patient and caregiver of a patient with Asthma include?
answer

Why use a peak flow meter, info on peak flow meter, what is asthma, what is good asthma control, hindrances to asthma treatment and control, environmental and triggers, medications, correct use of medications, breathing techniques, asthma action plan.
question

What is Chronic Obstructive Pulmonary Disease?
answer

COPD – a preventable and treatable disease state characterized by chronic airflow limitations that is not fully reversible.
question

What are the two types of COPD?
answer

Chronic bronchitis and Emphysema.
question

What is Chronic Bronchitis?
answer

Presence of chronic productive cough for 3 month in each of 2 consecutive years in a patient in whom other causes of chronic cough have been excluded.
question

What is Emphysema?
answer

An abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
question

What are the gender differences for Men with COPD?
answer

More common in men than in women, but trend for men is not increasing. Fewer men are dying from COPD then women.
question

What are the gender differences for Women with COPD?
answer

Number of women with disease is increasing. Increase is probably due to increased number of women smoking cigarettes and increased susceptibility. Lower quality of life, more exacerbations, increased dyspnea, and better response to 02 therapy.
question

What are the signs of Emphysema?
answer

Loss of lung elasticity, proteases break down elastin, hyperinflation o flungs, air trapped in lungs, poor gas exchange, loss of aveolar tissue.
question

What is Chronic Respiratory Acidosis?
answer

A medical condition in which decreased respiration (hypoventilation) causes increased blood carbon dioxide and decreased pH (acidosis).
question

Where is the inflammation located with Chronic Bronchitis?
answer

In the bronchi and bronchioles.
question

How does the inflammatory response to irritants affect Chronic Bronchitis?
answer

Affects small and large airways, hinders airflow and gas exchange.
question

What is the etiology of COPD?
answer

Smoking, AAT deficiency, occupational chemicals and dust, air pollution, infection, genetics, aging.
question

What are the complications of COPD?
answer

Hypoxemia, acidosis, respiratory tract infections, cardiac problems – cardiac failure and dysrhythmias.
question

What are the clinical manifestations of COPD?
answer

Dyspnea with exertion, every day. Late stages dyspnea maybe at rest. Wheezing and chest tightness, vary by time of day. Weight loss and anorexia. Prolonged expiratory phase, decreased breath sounds. Hypoxemia, hypercapnia, polycythemia and cyanosis.
question

What established the diagnosis of COPD?
answer

Spirometry whether or not the patient has chronic symptoms. The FEV1/FEV less than 70% establishes and the severity of obstruction.
question

What are the diagnostic studies for COPD?
answer

H & P, pulmonary function tests, chest x-rays, serum a1-antitrypsin levels, ABGs, 6 minute walk test.
question

What is collaborative therapy for COPD?
answer

Cessation of smoking, treatment of exacerbations, bronchodilator therapy, corticosteroids, airway clearance techniques, breathing exercises and retraining, hydration of 3L qday, patient and caregiver teaching, influenza immunization yearly, pneumovax, longer term 02, progressive plan of exercise, pulmonary rehab program, nutritional supplement if low BMI, surgery.
question

What does a nursing assessment for a patient with COPD involve?
answer

Subjective health information past health history and medications, functional health patterns, general objective data with integumentary, respiratory, cardiovascular, gastrointestinal, musculoskeletal and diagnostic findings.
question

What should the health history contain of a patient with COPD during an assessment?
answer

Long term exposure to chemical pollution, respiratory irritants, occupation fumes, dust, recurrent respiratory infections, previous hospitalizations.
question

What general objective data do you look at during a nursing assessment with COPD?
answer

Debilitation, restlessness, assumption of upright position.
question

What integumentary objective data do you look at during a nursing assessment with COPD?
answer

Cyanosis (bronchitis), pallor or ruddy color, poor skin turgur, thin skin, digital clubbing, easy bruising, peripheral edema.
question

What respiratory objective data do you look at during a nursing assessment with COPD?
answer

Rapid, shallow breathing, inability to speak, prolonged expiratory phase, pursed-lip breahting, wheezing, rhonchi, crackles, diminished or bronchial breath sounds, decreased chest excursion and diaphragm movement, use of accessory muscles, hyperresonant or dull chest sounds on percussion.
question

What cardiovascular objective data do you look at during a nursing assessment with COPD?
answer

Tachycardia, dysrhythmias, JVD, distant heart tones, right sided S2 (cor pulmonale), edema (esp in feet).
question

What Gastrointestinal objective data do you look at during a nursing assessment with COPD?
answer

Ascites, hepatomegaly (cor pulmonale).
question

What Musculoskeletal objective data do you look at during a nursing assessment with COPD?
answer

Muscule atrophy, increased anterior-posterior diameter (barrel chest).
question

What Possible Diagnostic findings do you look with a patient with COPD?
answer

Abnormal ABGs (compensated respiratory acidosis), decreased PaO2 and SaO2, increased PaCO2, polycythemia, pulmonary function tests showing expiratory airflow obstruction (low FEV1, low FEV1/FVC, large RV), chest x ray showing flattened diaphragm and hyperinflation or infiltrates.
question

What are the main aspects of the psychosocial assessment with COPD?
answer

Smoking (pack years), anxiety, depression.
question

What are diagnosis with COPD?
answer

Ineffective breathing patterns, ineffective breathing clearance.
question

What are nursing goals with planning of a patient with COPD?
answer

1. prevention of disease progression. 2. ability to perform ADLs and improved exercise tolerance. 3. relief of symptoms. 4. no complications related to COPD. 5. knowledge and ability to implement a long-term treatment regimen, and 6. overall improved quality of life.
question

What are the teaching subjects for the patient and caregiver with COPD?
answer

Overall guide, what is COPD, breathing and airway clearance exercises, energy conservation techniques, medications, correct use of medications, psychosocial/emotional issues, management plan, health nutrition.
question

What are the surgical options for a patient with COPD?
answer

LVRS, Lung transplantation.
question

What is LVRS?
answer

Lung volume reduction surgery. Reduce the size of the lungs by removing the most disease lung tissue so the remaining healthy lung tissue can perform better.
question

What is the benefits of a Lung Transplant?
answer

For carefully selected patients with advanced COPD. Single-lung transplant is most commonly used technique because of shortage of donors, bilateral transplantation can be performed.
question

What are the obstacles of lung transplant?
answer

Organ rejection, effects of immunosuppressive therapy, and the high cost of surgery.
question

What are the different breahting techniques for COPD?
answer

Pursed lip breathing, positioning, energy conservation.
question

What is the purpose of Pursed-Lip Breathing?
answer

Prolongs exhalation and thereby prevent bronchiolar collapse and air trapping.

Get instant access to
all materials

Become a Member