Unit 1: RSV

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Risk Factors for RSV
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infants and toddlers who are not breastfed, secondary smoke exposure, day care, live in crowded conditions, socioeconomically disadvantaged
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Tobacco Smoke
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increases mucus production and reduces action of the cilia within the airway passages.
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RSV season
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Annual epidemics from October to March.
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RSV is transmitted…
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through direct contact with respiratory secretions or indirectly through contaminated surfaces.
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Infants at risk for severe RSV
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Under 24 mos. w/ chronic luing disease who have required med. therapy w/ in 6 mos. of RSV season onset. Those w/ congentail heart disease, and preterm infants> reduced immunity
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Risk factors for RSV
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Infants and toddlers who are not breastfed, live w/ second smoke, attend daycare, live in crowded conditions, and are socioeconomically disadvantaged.
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Adult RSV risk factors
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Older adults. Chronic pulmonary disease, and CHF
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Early signs of (mild) RSV
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Rhinorrhea (drainable mucus from nose), cough, irritability, low grade fever for 1-3 days
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Signs of serious RSV
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Irratibility, excessive coughing, wheezing, and observable retractions of the ribcage. Nasal flaring, rapid resp. rate, blue skin, listlessness, and periods w/out breathing.
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RSV Plan of care
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Monitoring breathing patterns, maintain patent airway, adequate fluid and caloric intake, support appropriate developmental behavior.
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Meds. to treat RSV
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Ribavirin-controversial-reserved for severe; bronchodialtors-controversial; antipyretics; antiboitics-only if bacteria infection
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Clinical Therapy for RSV
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Isolation. Humidified oxygen using a hood, face tent, mask, or nasal cannula to maintain pulse ox. of greater than 90%. CPAP maybe used w/ moderate-severe.
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Indication of severe illness in children?
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Lack of play. Most children continue to play despite illness.
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Signs of life-threatening illness
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Central cyanosis, resp. rate greater than 70, listlessness, and apneic episodes. The chest is hyperinflated and air exchange is so poor that breath sounds are very diminished on auscultation.
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Priority nursing care for RSV?
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Maintaining a clear airway and promoting oxygenation.
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Dealing w/ parents?
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Include them in providing care, teach interventions-helps reduce their anxiety
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Stance that indicates resp. distress?
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Tripod stance
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Ineffective Airway Clearance?
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Monitor temp, pulse, resp., bp, pulse ox; Auscultate lung sounds; Encourage oral fluids (thin secretions); Suction mouth and nose; Teach parents to suction (bulb syringe), and signs and symptoms, not to smoke; Admin. meds as ordered
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Ineffective Breathing Pattern?
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Monitor breathing pattern-rate, rhythm, and quality; Teach parents to observe breathing patterns; Inspect and palpate chest for use of accessory muscles; Assess for tripod stance; Admin. bronchiodilators and oxygen as ordered
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Impaired Gas Exchange?
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Monitor temp. pulse, resp., bp, and pulse ox; monitor breathing patterns; Assess for bluish skin; Collect sputum specimen; collect ABG, CBC and chem. levels; Admin. oxygen as ordered
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May indicate increased need for oxygen?
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Use of accessory muscles to breath.
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Bronchiolitis
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Lower resp. tract illness that occurs when an infecting agent (virus or bacterium) causes inflammation and obstruction of the small airways (bronchioles)> RSV is most common cause!
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RSV incubation period
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2-8 days. The virus is shed by the infected child for 3-8 days.
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Atelectasis
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Collaspse of alveoli or section of alveoli
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RSV infects….
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the squamous epithelial cells of the bronchioles and alveoli.
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Syncytia
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Large masses of cells created by infected cells merging w/ adjacent cells. Syncytia-burst and die-clogging the minute airways of the lower resp. tract.
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Wheezing and crackles created by?
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Partially obstructed airways allow air in, but the mucus and airway swelling block expulsion of air.
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RSV Diagnostic Tests
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nasopharyngeal culture, chest x-ray
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Lack of Play
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an indication of severe illness in children
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Signs of life threatening illness in the infant with bronchiolitis include
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central cyanosis, RR > 70, listlessness, apneic episodes (periods without breathing), hyperinflated chest, very diminished lung sounds
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Atelectasis
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collapse of alveoli
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Apnea
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absence of respirations
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The nurse working with a client with Ineffective Airway Clearance should
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Monitor vitals, auscultate lung sounds, encourage fluids, suction mouth and nose, teach parents suctioning, teach parents signs ans symptoms, teach parents not to smoke around infant, administer meds
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The nurse working with a client with an Ineffective Breathing Pattern should
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Monitor rate, rhythm and quality of breathing pattern, teach parents how to observe breathing pattern, inspect chest for use of accessory breathing muscles, assess for self posturing, administer bronchodilators and O2 therapy as ordered
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The nurse working with a patient with Impaired Gas Exchange should
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Monitor vitals, monitor breathing patterns, assess for bluish skin color, collect a sputum specimen to i.d. causative agent, collect ABG, CBG, and chemistry levels, admin. O2 as ordered
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The nurse working with a client with Impaired Nutrition: Less Than Body Requirements should
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Monitor dietary intake, take daily weight, offer preferred foods, offer small frequent feedings, encourage parents to feed child as normal
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Nursing interventions for Fluid Volume Deficit related to fever and poor oral intake include
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Assess for poor skin elasticity, dry mucous membranes, and decreased urinary output, weigh each diaper for accurate output, teach parents to count diapers per day, encourage oral intake, monitor IV fluid rate
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Nursing Interventions for Activity Intolerance include
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assessing capacity to play, organize care to allow for rest periods
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What is the treatment for RSV?
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There is no treatment for RSV just it’s symptoms
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What are the treatments for RSV’s Symptoms?
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Hospitalization, IV fluids, humidified oxygen, bronchodilators, corticosteroids, thin chest secretions, reduce fever
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How to prevent RSV
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cover mouth when cough or sneeze, frequent hand washing with soap and water, avoid sharing cups and utensils, refrain from kissing on the mouth
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What is the priority of nursing care when taking care of a client with RSV?
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Maintaining a patent airway and promoting oxygenation
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A child in the early stages of impaired gas exchange often experiences which of the following diagnoses as well?
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Anxiety related to hypoxia
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The parents of an infant with bronchiolitis ask the nurse why their baby’s room has a sign on the door that says “Contact Precautions” and why all the nurses wear gowns and gloves when they hold him. What is the nurse’s best response?
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“The virus that usually causes bronchiolitis can spread to other babies if extra precautions are not taken.”
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Which of the following would be a priority nursing intervention for the child with bronchiolitis?
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Maintain strict intake and output.
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The nurse wears gloves when examining a child with respiratory syncytial virus (RSV) infection. After removing the gloves, what should the nurse do next?
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Wash hands.
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A client with hypertension asks the nurse what can be done to relieve the symptoms associated with respiratory syncytial virus (RSV). The nurse recommends which of the following?
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Use an over-the-counter nasal spray for no more than 3 days to relieve congestion.
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The nurse is caring for a 75-year-old client with respiratory syncytial virus (RSV). The nurse monitors this client closely for which of the following?
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Pneumonitis
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The nurse selects Ineffective Airway Clearance for a premature infant who is in the hospital with respiratory syncytial virus (RSV) based on which of the following?
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The infant does not have the energy to cough effectively.
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The nurse is preparing to discharge a frail infant from the nursery to home in October. Which of the following instructions to the parents is a priority? (Select all that apply.)
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Keep anyone with a cold away from the infant. Insist that anyone handling the infant use good handwashing. Have the child vaccinated with palivizumab monthly.
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RSV/Respiratory Syncytial Virus
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Respiratory virus that infects the lungs and breathing passages by invading the cells of the bronchial mucosa causing the cells to rupture. This ruptured cell debris irritates the airway leading to increased secretions and airway obstruction.
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What 2 common illnesses can RSV cause?
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Bronchiolitis and Pneumonia
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What time of year are RSV cases most prevalent?
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Fall, Winter, and early Spring
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Is RSV contagious?
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Yes!
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What precautions level is RSV?
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Droplet precautions
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The most severe cases are in what age group?
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Children six months or younger
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What is the recovery time?
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1-2 weeks
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Can reinfection occur?
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Yes!
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What are the INITIAL symptoms of RSV?
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nasal stuffiness, fever, cough, sneeze, decreased appetite, decreased play
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What are the PROGRESSIVE symptoms of RSV?
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deep cough, rapid labored breathing, and respiratory distress such as use of accessory muscles, posturing, sternal retractions, and nasal flaring
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RSV Assessment Findings
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wheezing/crackles upon auscultation, diminished breath sounds upon auscultation, impaired gas exchange, and eventually respiratory failure
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Who is at risk?
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Children <2 with congenital heart disease, premature infants, adults 65 years and older, children and adults with weakend immune systems
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How is RSV spread?
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Droplets (cough or sneeze), Direct (kiss), Indirect (virus on surfaces)
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What are some common nursing diagnosis for RSV?
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Ineffective Airway Clearance, Ineffective Breathing Pattern, Impaired Gas Exchange, Fluid Volume Deficit, Activity Intolerance
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Chronic Airflow limitation results from these 4 factors?
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*Loss of Elasticity, Constricted Airways, Increased (mucous) secretions, Inflammation
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These 3 common respiratory disorders are characterized by Chronic Airflow Limitation?
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*Chronic Bronchitis, Emphysema, Asthma
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These 5 kinds of medications can be used to treat diseases of limited airflow?
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*Bronchodilators, Mucolytics, Antihistamines, Antitussives, Antinflammatories
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These Liquify and remove secretions?
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*Mucolytics
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Nursing Interventions for clients taking respiratory drugs?
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*#1 MAINTAIN AIRWAY, Establish clients baseline respiratory function before admin of meds, Assess clients understanding of meds, expected effects, and safe home useage.
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Nursing Interventions, Establishing Respiratory Baseline includes assessing?
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*Rate, Quality and Auscultation of Breath Sounds, Color of skin and mucous membranes, Activity Tolerance
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These relax smooth muscle of the bronchi and open narrowed airways (ex:)?
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*Bronchodilators such as Albuterol (Proventil), Serevent
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Expected outcomes after using a Bronchodilator include?
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*Decreased Wheezing, Relief of Coughing, Increase in breathing and Increased Activity Tolerance
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Client teaching for Bronchodilators-seek care IMMEDIATELY if any of these adverse reactions occur?
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*Cyanosis, Inability to walk or talk, Lethargy or Confusion, Shortness of Breath, Irregular Heart Rate
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The action of Anticolinergic Drugs is to?
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*Block Acetylcholine (Parasympathetic Neurotransmitter) at the receptor sites
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This is the most commonly used Anticholinergic/Bronchodilator and can be used in conjunction with Albuterol?
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*Atrovent (Ipratropium Bromide)
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These interrupt the inflammatory process by inhibiting the release of histamine and reduction of edema?
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*Glucocorticoids. Some examples are: Prednisone derivitives like Prelone & Deltasone. Others are Flovent, Beclavent, Decadron, Aerobid
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Glucocorticoids have these 3 important actions?
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*Anti-inflammatory, Anti-stress, Anti-allergic
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Discharge instructions for short term Glucocorticoids should include patient teaching on how to?
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Taper off of the drug. Abruptly discontinuing can cause Adrenal Crisis (N&V, Diarrhea, Decreasing LOC, Low BP, Dehydration)
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These prevent inflammation, edema, brochoconstriction and the release of histamine?
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*Mast Cell Stabilizers. The drug of choice for Asthmatics, long term therapy with less side effects than glucocorticoids
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This is released when the body encounters a foreign agent?
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Histamine. Use an Antihistamine (Benedryl) for treatment
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These thin secretions by changing the molecular composition of mucous, making it thinner, and easily removable?
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*Mucolytics (Mucomyst) for treatment of Emphysema and Bronchitis
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These decrease the adhesiveness of secretions so they can be mobilized and removed from the respiratory tract?
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*Expectorants, an example is Robitussin (guaifenesin)*Always give with a full glass of H2O to aid in removal of secretions
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These suppress coughing in order to promote rest and healing?
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*Antitussives, and example is Dextromorphan (Suppress), Tessalon, or Delsym.
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Chronic Bronchitis
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inflammation of the main airways in the lungs.
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Diaphragmatic/Abdominal breathing
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Place one hand on Abdomen and other on chest Inhale concentrating on pushing abdomen out while chest remains still Exhale slowly abdomen moves inward while chest remains still
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Controlled Coughing Technique
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Inhale bronchodilator treatment Cough twice, first to loosen mucus, then to expel it Inhale by sniffing to prevent mucus from moving back to deep airways
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Huff Coughing
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Inhale deeply while leaning forward Exhale sharply with a “huff” sound to help keep airways open while mobilizing secretions
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Bronchodilators
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Relax the smooth muscle of the bronchi and open narrowed airways
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After administration of Bronchodilators, the nurse expects to see:
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Decreased wheezing, Relief of coughing, increased ease in breathing, increase activity tolerance
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Types of Bronchodilators
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Beta-adrenergic agonists, Anticholinergics, Xanthines
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Beta-adrenergic agonists
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cause a sympathetic response (use with caution in pregnant, elderly, clients with: renal dysfunction, hyperthyroidism, prostatic hypertrophy, hypertension, and Glaucoma) Do NOT take any over the counter drugs without consulting physician
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Examples of Short-acting Beta-adrenergic agonists
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Metaproterenol, Albuterol, Terbutaline, Pirbuterol
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Examples of Long-acting Beta-adrenergic agonists
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Serevent, Formoterol
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Side Effects of Beta-adrenergic agonists
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Increased HR, Hyperglycemia, Anxiety, Nervousness/restlessness, and muscle tremors
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Because of their cardiac effect, Beta-adrenergic agonists would be used with extreme caution in a client with a cardiac disorder. What other disease might contraindicate their use?
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Diabetes mellitus
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The nurse should instruct the client to seek care immediately if any of the following occur while on Beta-adrenergic agonists …
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Cyanosis, increased SHOB, inability to walk or talk, lethargy or confusion, irregular HR
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Anticholinergics
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block parasympathetic response which blocks bronchoconstriction and inflammatory mediators
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The most common anticholinergic bronchodilator is :
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Impratropium bromide (Atrovent)
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Atrovent
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is used in pt.s who do not respond well to beta-a agonists and/or is used along side beta-a agonists. Not useful in treating emergencies, and has greatest therapeutic effect if taken consistently.
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Anticholinergic Side Effects
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Dizziness, headaches, excitemnt, cough, urinary retention, dry mouth, irritability, delayed GI motility
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Nsg. Interventions for clients on Atrovent therapy
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frequent oral care to relieve dry mouth and bitter taste, monitor urinary retention
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Xanthines
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Chemically related to caffeine. Dilate the bronchi by relaxing smooth muscle, have long half life and can cause toxicity because of build up in body. React with many other drugs!
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Most common Xanthines
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Truphylline, Theophylline
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Manifestations of Xanthine Toxicity are:
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CNS stimulation: tremors, headache, agitation, seizures GI distress: nausea, vomiting, anorexia Cardiac stimulation: palpitations, tachycardia, dysrhythmias Hyperglycemia and hypokalemia
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Effective client teaching for Xanthines should include:
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Take the medication at the same time every day Drink plenty of fluids to thin secretions Limit caffeine and smoking Learn the manifestations of toxicity Report any manifestations of theophylline toxicity to the health-careprovider immediately
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Xanthine Side Effects (like that of caffeine)
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tachycardia, insomnia, diuresis, restlessness, epigastric pain, nausea, anorexia
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What is a safe range for Xanthine levels in the blood?
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10-20 mcg/ml
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Severe Xanthine Toxicity
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Seizures, Ventricular fibrillation
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Types of Anti-inflammatories
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Glucorticoids and Mast Cell Stabilizers
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Glucorticoids
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hormones produced by the adrenal cortex that reduce edema and the release of histamines in the respiratory system by interrupting the inflammatory process.
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Common Glucorticoids
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Prednisolone (Prelone), Prednisone (Deltasone), Fluticasone (Flovent)
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3 Important Actions of Glucorticoids
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Ant-inflammatory Anti-allergic Anti-stress
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Contraindications for Glucorticoids
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Peptic ulcer disease, severe infections, hepatic dysfunction
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Glucorticoids Caution
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May stunt growth in children if taken long term and may cause osteoporosis in elderly. Long term therapy may cause Cushingoid appearance
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Side Effects of Glucorticoids
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Hypertension: d/t Na+ and H20 retention Peptic Ulcer: decreased gastric mucous Pancreatitis: d/t increased blood glucose levels Osteoporosis: increased excretion of Ca+ Potassium excretion: r/t Na+ retention Hirsutism: d/t hormonal effect Impaired healing: r/t protein catabolism Ecchymoses: r/t capillary fragillity Muscle wasting: d/t protein catabolism………..and much more!
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Nursing interventions for clients using glucocorticoids include monitoring for:
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Hyperglycemia Hypokalemia Emotional changes Muscle weakness Hypertension
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If glucocorticoids decrease the inflammatory process and also decrease the immune response, what clinical manifestations will the nurse see in the client?
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Absence of manifestations of infection
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Abruptly stopping If glucocorticoids therapy can cause:
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An Adrenal crisis!
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Nurse care plan for glucocorticoids should include teaching the client to
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Regulate activity and control stress Avoid aspirin (Bayer) and other medications unless directed by a physician Wear a MedicAlert bracelet Take oral preparations in the morning Restrict foods high in sodium and eat foods high in potassium Take antacids as prescribed Rinse mouth after use
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If a client is using both a bronchodilator inhaler and a glucocorticoid inhaler, which inhaler should the nurse tell the client to use first?
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Bronchodilator because the bronchi need to be open for the anti-inflammatory to enter and be most effective
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Mast Cell Stabilizers
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Prevents edema, inflammation, and bronchoconstriction. Drug of choice for long term therapy because it lacks side effects of glucorticoids.
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Common Mast Cell Stabilizer
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Cromolyn
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Clients taking mast cell stabilizers should be taught to:
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-Recognize that most cell stabilers are not for acute attacks. -Use 15-30 minutes prior to exercise or exposure to cold because this may reduce an ensuing attack. -Recognize manifestations of a worsening asthma attack and call a health-care provider if respiratory distress occurs.
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Which instruction is appropriate for the nurse to give the client on cromolyn sodium (Intal)?
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Use the medication before exercising to avoid an asthma attack.

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