NURS 444 week 2

Question 1

GERD and asthma

Answer 1

asthma meds. may worsen GERD
treating GERD may reduce nocturnal asthma

Question 2

Asthma triad

Answer 2

nasal polyps
asthma
sensitivity to aspirin or NSAIDs

Question 3

Asthma

Answer 3

a hyperactive inflammatory response

early-phase: 30-60 min response to allergen or irritant, inflammation, and release of kines

Question 4

Asthma late phase

Answer 4

inflammation after 4-6 hrs from initial response
continued release of cell mediators
can last more than 24 hrs
corticosteroids are used

Question 5

Airway Remodeling

Answer 5

due to chronic inflammation include
- fibrosis
- smooth muscle hypertrophy
- mucus hypersecretion
- angiogenesis

progressive loss of lung function not fully reversible results in persistent asthma

Question 6

Early manifestations of asthma attack

Answer 6

! expiratory wheezes
! cough
! dyspnea
! chest tightness

!! worsening- wheezing inspiratory and expiratory
!!! severe- wheezing with forced expiratory or no breath sounds

Question 7

Asthma classifications

Answer 7

• intermittent:
• mild persistent
• moderate persistent
• severe persistent

re-evaluation of treatment efficacy in 2-6 weeks

Question 8

type of impairment criteria for asthma: components of severity

Answer 8

frequency in symptoms
nighttime awakenings
SABA use for symptoms
Interference with normal activity
lung function: FEV1, FVC

Question 9

Intermittent asthma

Answer 9

symptoms less or 2 days/ week
nighttime awakenings less than or 2 times/ month
SABA use less than or 2 days/week
does not interfere with normal activity
Lung function= FEV1 >80%, FEV1 FFVC normal

Question 10

Mild asthma

Answer 10

symptoms occur more than 2 days/week, not daily
nighttime awakening 3-4 times/month
SABA use for symptoms more than 2 days/ week, not daily
minor interference with normal activity
FEV1/ FVC normal

Question 11

Moderate asthma

Answer 11

• symptoms happen daily
• nighttime awakenings more than 1 time/ week, not nightly
• SABA use daily
• some limitation with normal activity
• FEV1 60%- 80% predicted. FEV1/ FVC reduced by 5%

Question 12

severe asthma

Answer 12

! symptoms are continuous
! nighttime awakenings happen often 7/week
! SABA used several times/ day
! extremely limited in normal activity
! FEV1 <60% predicted. FEV1/ FVC reduced by 5%

Question 13

Asthma complications

Answer 13

! pneumonia
! tension pneumothorax
! status asthmaticus
! acute respiratory failure

Question 14

Goals of Asthma treatment

Answer 14

achieve and maintain control
return to optimal functioning

medication guidelines
- go up as symptoms worsen
- go down as symptoms improve

Question 15

Mild to Moderate asthma attacks: symptoms and treatment

Answer 15

symptoms: no more than 2x/week
- minimal ADL interference
- may have some chest tightness
- A&O and speaks in sentences
- increased use of asthma meds.
- o2 sats >90%
- PEFR >50% predicted or personal best

treatment:
*** inhaled bronchodilators and oral corticosteroids
- monitor VS
- monitor as outpatient unless meds. not working
- f/u with HCP

Question 16

Severe asthma attack: symptoms and treatment

Answer 16

symptoms:
! A&O but focused on breathing: frightened/ agitated if hypoxemic
! tachycardia, tachypnea (>30 breaths/min)
! accessory muscle use, sits forward
! wheezing
! symptoms interfere with ADLs
! PEFR < 50% predicted or personal best

treatment:
! ED –> admission
! supp. oxygen and oximetry: PaO2 >60% or O2 >93%
! monitor ABG, PEFR, and VS
! bronchodilators and oral corticosteroids
! silent chest- IMMEDIATELY NOTIFY HCP!!!***

Question 17

Status asthmaticus

Answer 17

• hypoxia –> hypercapnia
• ARF – life-threatening
  chest tightness, increased SOB, sudden inability to speak

without tx leads to:
- hypotension, bradycardia (muscle exhaustion)
- resp./ cardiac arrest
- bronchodilators and corticosteroids not effective

emergent Tx
- intubation and mechanical ventilation
- hemodynamic monitoring
- analgesia and sedation
- IV magnesium sulfate- relaxes bronchial muscles and expands airways

Question 18

RECUE medications for asthma attacks

Answer 18

Short-acting bronchodilators
- inhaled B2-adrenergic agonists (SABAS): albuterol most common
- onset is minutes, duration 4-8 hours
- overuse can result in; tremors, anxiety, tachycardia, palpitations, nausea

Anti-inflammatory drugs
- IV corticosteroids

Question 19

Long-term Asthma medications

Answer 19

used to achieve and maintain control

Bronchodilators
- long-acting inhaled or oral B2- adrenergic agonists (LABAs)
** NEVER used for acute attacks
- methylxanthines- ex. theophyline. less effective and high risks for toxicity
- anticholinergics

Anti-inflammatory drugs
- oral or inhaled corticosteroids (ICS)
- leukotrienes modifiers
- Anti-IgE

Question 20

Anticholinergics in asthma

Answer 20

• promote bronchodilation- preventing muscles around bronchi from tightening
• less effective than SABAs for asthma- used more in COPD
• not routinely used in asthma management unless severe acute attacks

Question 21

non-prescription combinations

Answer 21

bronchodilator (ephedrine) and expectorant (guaifenesin)
- OTC- many SE so should avoid

• epinephrine and ephedrine inhalers- stimulate CNS CV, potentially dangerous
• ephedrine can be used to produce meth.
• reformulated with phenylephrine

Question 22

overall goals for asthma management

Answer 22

• have minimal symptoms during the day and night
• maintain acceptable activity levels (including exercise)
• maintain greater than 80% of personal best PEFR
• few or no adverse effects of therapy
• adequate knowledge to carry out plan

Question 23

Yellow zone

Answer 23

Asthma is getting worse: - symptomatic, limited activity, PEFR 50% - 79% personal best.

Question 24

Red zone

Answer 24

Medical alert
symptomatic
meds. not helping
unable to do usual activities
50% or less PEFR personal best

CALL DOCTOR, AMBULANCE

Question 25

Nursing Acute Care: Asthma

Answer 25

> monitor cardiac and lungs > pulse oximetry, peak flow, ABGs > give meds. > evaluate response to therapy; may take days Decrease patient's anxiety > position Semi-Fowler's > "talking down" to keep calm- used pursed lips > stay with patient > allow rest when attack subsides; get H & P

Question 26

COPD risk factors

Answer 26

-smoking - infection - severe recurring resp. infections in childhood - HIV - asthma - tuberculosis - air pollution - occupational dust and chemicals - aging - genetics- a1 antitrypsin deficiency

Question 27

Pulmonary vascular changes in COPD

Answer 27

- vasoconstriction of small pulmonary arteries due to hypoxia - vascular smooth muscle of pulm. arteries thickens in advanced disease - pressure in pulm. circulation increases - results in pulm. htn resulting in right ventricular hypertrophy and right-sided heart failure

Question 28

COPD classification

Answer 28

FEV forced expiratory volume FEV/ FVC1 of < 70% severity of obstruction- postbronchodilator FEV1 results: -GOLD 1 Mild -GOLD 2 Moderate -GOLD 3 Severe -GOLD 4 Very severe -global initiative for Chronic Obstructive Lung Disease

Question 29

COPD clinical manifestations

Answer 29

^ develops slowly ^ dx considered with chronic cough, sputum production, dyspnea, exposure to irritants ^ symptoms may be ignored ^ dyspnea usually prompts medical attention: occurs with exertion in early stages. present at rest in advanced stages ^ peripheral edema ^ hypoxemia: PaO2 < 60, SaO2 < 88% ^ hypercapnia >45% ^ increased hemoglobin (may reach 20 g/dl, RBC

Question 30

Pulmonary HTN, cor pulmonale

Answer 30

Pulmonary hypertension - Pulmonary vessel vasoconstriction due to alveolar hypoxia - Increased pulmonary vascular resistance - Polycythemia from chronic hypoxia results in increased viscosity Cor pulmonale (right-sided heart failure) - Late manifestation - Pulmonary HTN results in increased right ventricle pressure - Dyspnea most common - Other: S3 and S4, murmurs, distended neck veins, hepatomegaly, peripheral edema, weight gain

Question 31

Dx and Tx for Cor Pulmonale

Answer 31

CXR, US, BNP levels - long-term O2 therapy - diuretics - anticoagulation

Question 32

Specific Tx for COPD

Answer 32

SABAS and corticosteroids - anticholinergic, antibiotics, diuretics Oxygen ***ARF may occur if patient waits too long

Question 33

COPD dx studie

Answer 33

- History and physical exam - Spirometry—confirms diagnosis: FEV1/FVC ratio <70% *** - Chest x-ray - Serum a1-antitrypsin levels - 6-minute walk test: Pulse ox <88% at rest—qualify for supplemental O2 - ABGs - ECG, Echo, MUGA scan - Sputum culture and sensitivity

Question 34

COPD drug management

Answer 34

Bronchodilators relax smooth muscle in the airway, improve lung ventilation, decreased dyspnea and increased FEV1, inhaled route is preferred, include adrenergic agonist, anticholinergics, methylxanthines moderate stage: FEV < 60% -inhaled long-acting anticholinergics -inhaled corticosteroids

Question 35

COPD oxygen therapy

Answer 35

- used to treat hypoxemia - keep O2 sats > 90% during sleep, rest or exertion or PaO2 >60 -low flow delivery is most common -high flow fixed concentration with venturi mask - humidification

Question 36

Miliary TB

Answer 36

TB that travels out of the lungs

Question 37

Acute TB symptoms

Answer 37

generalyzed flu symptoms - high fever - chills - pleuritic pain - productive cough

Question 38

TB complications

Answer 38

! pleural effusion- caused by bacteria in pleural space, inflammatory reaction ! empyema ! TB pneumonia ! miliary TB- other organ involvement: CNS, bone and joint, kidneys, heart

Question 39

Meds. for TB

Answer 39

2 MONTH INITIAL PHASE: 1) Isoniazid (INH) 2) Rifampin 3) pyrazinamide 4) ethambutol INH alone for 6 to 9 months for latent infection (HIV patients should take INK for 9 months)

Question 40

SE of INH

Answer 40

monitor liver function - hepatotoxicity - arthralgias - vomiting - confusion *teach not to drink alcohol