Nursing Assessment & Interventions For the Respiratory System

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Primary Purpose of the Respiratory System
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Gas exchange
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Two parts of the respiratory system
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Upper respiratory tract and Lower respiratory tract
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Structures of the Respiratory System
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Upper respiratory tract, lower respiratory tract, lung lobes
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Upper Respiratory Tract Structures
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Nose, Mouth, Pharynx, Larynx, Trachea
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Lower Respiratory Tract
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Bronchi, Bronchioles, Alveolar ducts, Alveoli
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Structures and Functions of the Respiratory System: Blood Supply
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Pulmonary and Bronchial
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Structures and Functions of the Respiratory System: Chest Wall
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Ribs, Pleura, and Diaphragm
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Pulmonary System
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Airways and lungs; ventilation; respiration
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Pulmonary System: Ventilation
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Movement of air into/out of the lungs
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Pulmonary System: Respiration
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Exchange of oxygen/carbon dioxide; Alveolar capillary/capillary cell membrane
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Structures and Functions of the Respiratory System: Respiratory System
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Filtration of air; Mucociliary clearance system; Cough reflex; Reflex bronchconstriction; Alveolar macrophages.
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Factors That Influence Pulmonary Function
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Life span and development (e.g. respiratory distress syndrome, upper respiratory infection (URIs), adolescent smoking, cardiac insufficiency); Environment (e.g. allergies, stress); Lifestyle (e.g. nutrition, exercise, substance abuse); Medications; Smoking; Pulmonary system abnormalities (structure, airway inflammation/obstruction, alveolar-capillary membrane disorder, atelectasis); Pulmonary circulation abnormalities; Central nervous system abnormalities; Neuromuscular abnormalities.
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Gerontologic Considerations: Effects of Aging on Respiratory System: Alterations in: Structure
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Decreased deep breathing; decreased breath sounds; barrel chest; kyphotic posture
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Gerontologic Considerations: Effects of Aging on Respiratory System: Alterations in: Defense Mechanisms
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Decreased cough effectiveness and secretion clearance; increase of aspiration, infection, influenza, PNA
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Gerontologic Considerations: Effects of Aging on Respiratory System: Alterations in: Respiratory Control
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Decreased ability to maintain acid-base balance
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Assessment of Respiratory System:
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History, subjective, objective data
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Assessment of Respiratory System: Subjective Data
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What questions can you ask the patient related to how their illness has affected their functional patterns? Health perception, nutrition, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception-self-concept, role-relationship, sexuality-reproduction, coping-stress tolerance, values-belief
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Assessment of Respiratory System: Objective Data
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Physical examination, Lab/diagnostic procedures
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Assessment of Respiratory System: Objective Data: Lab/diagnostic procedures
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ABGs, Sputum Studies, Skin Tests, CBC, Pulmonary Function Tests, Radiologic Studies
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Arterial Blood Gases (ABGs): Evaluates gas exchange in the lungs by measuring
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pH; partial pressure of arterial CO2(PaCO2): reflects adequacy of lungs’ ventilation and CO2 elimination; respiratory parameter; Partial pressure of arterial oxygen (PaO2): reflects body’s ability to pick up oxygen from the lungs; Bicarbonate (HCO3); Apply pressure for 5 minutes after specimen is obtained
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Sputum Studies
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Best obtained after a heavy cough, usually in the morning or after performing oral care; Checking for: culture and sensitivity (C&S), cytology, gram stain
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Skin testing
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Positive result indicates exposure to antigen, not that the disease is currently active; ensure the test is administered ID not SQ
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CBC
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Can reveal information about conditions that may be contributing to respiratory symptoms. WBC (differential), RBC, Hgb
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Pulse Oximetry
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Monitor oxygen saturation; May attach probe to finger, earlobe, nose, forehead (finger application); Normals: 93-100%, individual situation
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CXR (Chest Xray)
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Screen, diagnose, evaluate change; PA and Lateral views, Remove metal between neck and waist.
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Computed Tomography (CT) Scan
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Diagnose lesions difficult to assess by conventional x-ray studies; Cross sections; Contrast media; Evaluation of BUN/Creatinine; Allergy to shellfish or iodine? Sedation possible; Avoid metformin per protocol for Type II M
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Magnetic Resonance Imaging (MRI)
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Diagnose lesions difficult to assess by CT scan; Contrast media not iodine based; Sedation possible; Metal objects must be removed; No pacemakers or internal defibrillators
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Pulmonary Angiogram
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Xray image using contrast dye (usually via catheter fed through groin) that looks at blood vessels of the lungs; Can show PE, aneurysm, AVM, congenital problems, stenosis; Patient may experience flushing sensation, metallic taste, N/V, HA; Risks: allergy to iodine, kidney problems, bleeding (anticoagulant), aspiration
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Pet Scan
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Uses a radioactive material called a tracer which is given IV and collects in organs/tissues; Positron Emission Tomography scanner detects tracer signal, converts to 3D images; Screen diagnose cancer, how far cancer has spread or how well cancer has responded to treatment; Can be done in combination with CT scan to find exact tumor location; Diabetics: follow specific instructions.
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VQ Scan
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Uses inhaled and injected radioisotopes to identify areas of the lung not receiving air flow (ventilation) or blood flow (perfusion); Probable problem-blood clots (embolus)
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Diagnostic Procedures of the Respiratory System
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Endoscopic examinations (bronchoscopy); Lung biopsy; Thoracentesis; Pulmonary function tests; Exercise testing
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Lung Biopsy
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Sample can be obtained via endoscopy or during surgery; Endoscopy precautions: monitor site for bleeding, respiratory stress may indicate pneumothorax (PTX); Surgical: chest tube care, C/DB
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Thoracentesis
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Pleural fluid specimen collection through needle cather; Diagnose, removal of fluid, or instill medication
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Pulmonary Function Tests
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Evaluate lung volumes and airflow; Air movement is measured; Diagnose, monitor disease progression, evaluate disability, evaluate response to bronchodilators
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Exercise Testing
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Treadmill exercise; Diagnose, exercise capacity, and disability evaluation; Pulse oximetry monitored during exercising
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Nursing Interventions for Oxygenation
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Oxygen delivery and maintenance; Teaching/assisting with IS; Chest physiotherapy; Positioning; Suctioning; Turn, cough, deep breath (TCDB); Promote venous return; Immunization/Prevent URIs; Increase fluid intake
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Interventions for Optimal Oxygenation
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Use of a mechanical ventilator; use of chest tube drainage systems; administering respiratory medications; using artificial airways
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Do you need a doctor’s order for O2?
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Yes
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Delivery of Oxygen:Goals
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Reduce the work of breathing; Maintain sats; Reduce the workload of the heart; Maximize the O2 carrying capability of the blood.
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What percent of oxygen is room air?
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21% oxygen
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What percent oxygen is 1 liter oxygen?
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4% oxygen
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Low-Flow Oxygen Delivery Systems
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Nasal cannula, Simple face mask, Partial rebreather mask, Non-rebreather mask
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Nasal Cannula (nasal prongs)
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Most common; 1-6 L; Chronic lung disease; no more than 2-3 L/min
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Simple Face Mask
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5-10 L/min; 40-60%; for short term or in an emergency; minimum is 5-6L/min to prevent rebreathing of exhaled air
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Partial Rebreather
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6-11 L/min; Reservoir bag contains first part of exhaled air as the remaining escapes through vents; Patient rebreathes about one third of the expired air and the oxygen that is mixed in the bag.
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Non Rebreather Mask
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6-15 L/min; Highest concentration via mask; Patient only breathes full oxygen; A valve prevents patient from rebreathing exhaled air; Flow rate must be sufficient to keep bag from collapsing during inspiration
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High-Flow O2 Delivery Systems
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Venturi mask; Face tent; Aerosol mask; Tracheostomy collar
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Ambu Bag
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A manual resuscitation bag; Delivers breaths; Emergency situations
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Noninvasive Positive-Pressure Ventilation
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BiPAP cycling machine delivers a set of inspiratory positive airway pressure each time the client begins to inspire. At exhalation, it delivers a lower set end-expiratory pressure. Together the two pressures improve tidal volume.
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Continuous Nasal Positive Airway Pressure
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Effect is to open collapsed alveoli; Clients who may benefit include those with atelectasis after surgery or cardiac induced pulmonary edema; it may be used for sleep apnea
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Hazards and Complications of Oxygen Therapy
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Combustion; Oxygen-induced hypoventilation; Drying of mucous membranes; Infection; Contents under pressure
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Home Oxygen Use
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Skin cleansing and massage; use water based lip and nose moisturizers; provide frequent oral hygiene; humidify O2 to prevent drying; cleanse mask with water 2x daily; change equipment; no smoking in the home
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Incentive Spirometer (IS)
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Encourages patient to take deep breaths; facilitates increased lung volume; Promotes coughing; Prevention
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Chest Physiotherapy (CPT): What is it?
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Moving secretions; Goal-Expectoration and/or suctioning
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Chest Physiotherapy (CPT): What is involved?
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Postural drainage, Chest percussion, Chest vibration
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CPT: Postural Drainage
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Uses gravity; Place affected area in uppermost position (Example: LLL pneumonia. Place patient on right sie and elevate foot of bed)
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CPT: Chest Percussion and Vibration
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Used in conjunction with postural drainage; Position for 10-15 minutes; Goal: loosen and mobilize secretions
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CPT: Chest Percussion and Vibration: Percussion
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Clapping on chest wall with cupped hands
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CPT: Chest Percussion and Vibration: Vibration
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Vibration on chest wall with palms of hands while patient exhales
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Positioning
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Upright and elevated-promotes maximum lung expansion; aspiration precautions
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Suctioning
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Gurgling during respiration; Restlessness; Labored breathing; Decreased oxygen saturation; Adventitious breath sounds; O2 levels decrease quickly; Irritation to airway; Potential for infection
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Suctioning Oral Secretions Only
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Yankauer
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Suctioning Airways: Nasal Trumpet (NPA)
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Use with suction catheter kit; Prepackage nasopharyngeal airway
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Turn/Cough/Deep Breathe (TCDB)
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Deep breathing promotes ventilation and gas exchange; Coughing after DB mobilizes secretions; Keeps alveoli and airways open; Greater surface area for gas exchange
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Promoting Venous Return
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Elevate legs; Early and frequent ambulation; No crossing legs; ROM exercises; Compression devices: TED hose, SCDs
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Antihistamines (H1-Receptor Antagonists)
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Selectively block histamine from reaching its H1 receptors & alleviating allergic symptoms; Relieve sneezing, runny nose, itching of eyes/throat; Often combined with decongestants and antitussives; Has anticholinergic effects (drying mucous membranes, urinary hesitancy); Drowsiness is a SE, especially (dyring mucous membranes, urinary hesitancy); Drowsiness is a SE, especially with 1st generation; Most are PO; IV, intranasal, and opthalmic available; Diphrenhydramine (benadyl): 1st generation; Fexofenadine (allegra), Loratidine (Claritin), levocetirizine (Xyzal): 2nd generation
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Intranasal Corticosteroids
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Decrease the secretion of inflammatory mediators, reduce tissue edema, and cause mild vasoconstriction; Takes 1-3 weeks for peak response; May experience burning sensation or epistaxis due to drying; Fluticasone (Flonase); Contraindicated with know bacterial, viral, fungal, or parasitic infections as steroids can mask these infections; Mainly given for allergic rhinitis
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Decongestants:
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Sympathomimetic, PO, Intranasal
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Decongestants: Sympathomimetic
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Activates alpha-adrenergic receptors causing arterioles in the nasal passages to constrict
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Decongestants: PO:
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Pseudophedrine (Sudafed); adverse effects: HTN and CNS stimulates (insomnia, anxiety)
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Decongestants: Intranasal:
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Oxymetazoline (Afrin 12hour); phenylephrine (Afrin); Adverse effects: rebound congestion, CNS excitation, tremors, dysrhythmias, tachycardia, difficulty voiding; Do not use more than 3-5 days.
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Antitussives
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Dampen the cough reflex; Opioids: raise the cough threshold in the CNS: Codeine & hydrocodone, low dose=low risk for dependece; Nonopioids
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Antitussives: Nonopioids
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Dextromethorphan (Robitussin DM): Chemically similar to opioids but less potential for abuse; high doses: hallucinations, slurred speech, dizziness, drowsiness, euphoria, decreased motor coordination; Benzonate (Tessalon): anesthetizes stretch receptors in lungs
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Expectorants
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Reduce thickness of bronchial secretions, increase mucous flow and allowing mucous to be removed easily by coughing
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Guaifenesin (Mucinex)
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Most common expectorant. Side effects are drowsiness, HA, GI upset; no serious adverse effects
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Mucolytics
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Directly loosen thick, viscous bronchial secretions by breaking down the chemical structure of mucus molecules
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Acetylcysteine (Mucomyst)
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Mucolytic delivered by inhalation (not OTC); malodorous, resembling rotten eggs; adverse effects: severe N/V, bronchospasm
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Assessment-Prior to administration
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Health history, length of symptoms, pregnant/breast feeding, fever, allergies, current drug use, nicotine; vital signs; labs
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Assessment: Throughout administration
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Assess for desired effects; Vital signs, especially in patients with cardiac disease; Assess for adverse effects
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Diagnosis
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Ineffective airway clearance; Ineffective breathing pattern; Disturbed sleep pattern r/t adverse drug effects; Deficient knowledge (drug therapy); risk for injury r/t adverse drug effects; risk for falls r/t adverse drug effects
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Planning: The patient will:
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Experience therapeutic effects (specific); Be free from or experience minimal adverse effects; Verbalize an understanding of the drug’s use, adverse effects, and required precautions; Demonstrate proper self-administration of the medication
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Interventions: Ensuring therapeutic effects
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Incorporate non-pharmacologic measures (i.e. fluid intake); Ongoing assessment; instruct patient to contact HCP if worsens
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Interventions: Minimizing adverse effects
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Monitor VS and potential adverse effects of meds (i.e. dizziness); assess color/consistency of sputum. Notify for any changes; Assess for changes in visual acuity; Monitor for anticholinergic effects; Teach patient proper administration techniques; Teach med safety to avoid OD; Teach med timing.
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Evaluate
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Refer to the planning slide; Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met.

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