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Flashcards in Respiratory problems Deck (69):
1

Bronchodilators

1. Beta 2 agonists
2.Cholinergic antagonists (anticholinergics): ipratropium (Atrovent)
3. Methylxanthines: theophylline (Theo-Dur)

2

Albuterol (Proventil)

short-acting beta 2 agonist (SABA) : rapid but short-term relief; causes bronchodilation by relaxing bronchiolar smooth muscles .
Inhaler

3

Albuterol : use

primary - fast acting rescue drug to be used either during an asthma attack or just before engaging in activity that usually triggers an attack

4

Albuterol: nursing interventions

1. carry at all times;
2. monitor HR: can cause tachycardia
3. use 5 min before the other inhaled drug

5

Anti-Inflammatory Agents

1. Corticosteroids
2. NSAIDs
3. Leukotriene antagonist
4. Immunomodulator

6

Fluticasone (Flovent)

inhaled corticosteroid; disrupts all known production pathways of inflammatory mediators.
MDI or DPI inhalers

7

Flovent : use

The main purpose is to prevent an asthma attack caused by inflammation or allergies.

8

Flovent: nursing interventions

1. Use daily , even if no symptoms are present
2. Perform good mouth care and check mouth daily for lesions or drainage (drug reduced local immunity - risk for local infection - Candida albicans - yeast)
3. not to use with onset of asthma symptoms ( drug has slow onset of action and does not relieve symptoms)

9

Prednisone ( Deltasone)

oral corticosteroid; not recommended unless asthma symptoms cannot be controlled with any other therapy; rescue drug .

10

Prednisone side effects:

1. GI ulceration
2. fat redistribution
3. weight gain
4.hyperglycemia

11

Prednisone: nursing interventions

1. avoid anyone who has upper respiratory infection (drug reduces all protective inflammatory responses)
2. avoid activities that lead to injury ( blood vessels become more fragile , leading to bruising and petenchie)
3. take drug with food ( to reduce the risk for GI ulceration)
4. do not suddenly stop taking the drug ( if vomiting - receive the drug parenterally) - drug suppresses adrenal production of corticosteroids.

12

Ipratropium (Atrovent)

cholinergic antagonist : both rescue and prevent asthma; used in place of SABA by patients who cannot tolerate side effects of beta 2 agonists: tachycardia, nausea, nervousness.
Mouth dryness - drink 4 L of fluid daily

13

Asthma and exercise

regular exercise (aerobic ) recommended: assist in maintaining cardiac health, enhancing skeletal muscle strength and promoting ventilation and perfusion.

14

Asthma and oxygen therapy

delivered by mask, NC, or endotracheal tube;
Heliox ( 50 % helium + 50 % of oxygen) can help improve oxygen delivery to the alveoli.

15

Status Asthmaticus

severe, life-threatening acute episode of airway obstruction that intensifies once it begins.
S/S: extremely labored breathing and wheezing - if not reversed - pneumothorax and cardiac or respiratory arrest !!!
TX: IV fluids, systemic bronchodilators, steroids ( decrease inflammation), epinephrine, oxygen.

16

Asthma S/s:

1. Dyspnea (SOB)
2. Chest tightness
3, Coughing
4. Wheezing
5. Increased mucus production
6. Use of accessory muscles (muscle retraction)
7. Possible barrel chest
8. Cyanosis of oral mucosa and nail beds

17

FVC

forced vital capacity : volume of air exhaled from full inhalation to full exhalation.

18

FEV1

forced expiratory volume in the first second

19

PEF

peak expiratory flow : fastest airflow rate reached at any time during exhalation

20

Asthma - inflammation

obstructs lumen (inside) ;can be caused by allergens attaching to antibodies which are
attached to mast cells and basophils (WBC)
-can also be cause by general inflammatory triggers not related to allergic responses.

21

Inflammation triggers:

cold air
dry air
fine airborne particles
microorganisms
aspirin (increase in leukotrienes)

22

Asthma - airway hyperresponsiveness

twitchy airways; obstructs airways ( outside) constricting bronchial muscles

23

Airway hyperresponsiveness triggers

exercise
upper respiratory illness
inflammation
unknown

24

Asthma labs:

1. ABGs : decrease in PaO2
early : decrease in PaCO2 ( increase in RR)
later: increase in PaCO2 (poor gas exchange; CO2 retention)
2. Allergic asthma: increase in serum eosinophil count
increase in IgE levels (immunoglobulin E)
3. PFT: pulmonary function test

25

The Step System

• 1 – Mild Intermittent
• 2 – Mild Persistent
• 3 – Moderate Persistent
• 4 – Severe Persistent
• 5 – Severe Persistent Not Responsive to Previous Step
• 6 – Severe Persistent Not Responsive to Previous Step

26

Asthma : Goal

increase symptom-free periods, less hospital stays

27

Asthma: patient education

• Avoid environmental triggers
• Avoid trigger meds (ASA, NSAID’s, beta-blockers)
• Proper use and compliance with medications and metered dose inhalers (teach
patient to always carry the rescue drug inhaler with them)
• Monitor peak expiratory flow rates with a peak flow meter at least twice daily
• When to seek emergency care

28

Emphysema classic symptoms:

1 – loss of lung elasticity
2 – hyperinflation of the lungs
• Air becomes trapped in the lungs
• Loss of recoil in alveolar walls
• Overstretched and enlarged alveoli - bullae
• Use of accessory muscles for breathing

29

Emphysema: "air hunger"

need for oxygen ; Inhalation starts before exhalation is completed - uncoordinated patter of breathing

30

Proteases

enzymes that destroy and eliminate protein-based particulate matter and organisms inhaled during breathing;
if present in higher than normal levels: damage the alveoli and small airways by breaking down elastin ( alveolar sacs loose their elasticity).

31

Emphysema classification :

• An alveolar problem (loss of alveolar tissue)
• Classified as panlobular, centrilobular, or paraseptal depending on the pattern of destruction and dilation of the gas-exchanging units - acini

32

Chronic bronchitis

• Inflammation of the bronchi and bronchioles
• Affects only the airways and not the alveoli
The irritant triggers inflammation, with vasodilation, congestion, mucosal edema, and bronchospasm

33

Chronic bronchitis: causes

- increase in number of mucous glands
- increase in size of mucous glands
- thickened bronchial walls
- increased and excessive mucus production
- mucous plug formation
- PaO2 decreases - hypoxemia
- PaCO2 increases - respiratory acidosis

34

COPD and cigarette smoking

Most important risk factor !!!
8-pack-year history : obstructive lung changes;
20-pack-year history : early -stage COPD
Inhaled smoke triggers the release of excessive amounts of the proteases from cells in the lungs: break down elastin; impairing the action of cilia ( from clearing bronchi of mucus, cellular debris, and fluid).

35

COPD and AAT

Alpha 1-antitrypsin - Protease Inhibitor;
• Enzyme made by the liver to function in lungs - regulates proteases (which break down pollutants)
• Prevents proteases from breaking down lung structures
- depends on the inheritance of a pair of normal gene alleles for this protein .

36

COPD complications:

• Hypoxemia
• Acidosis
• Respiratory infection
• Cardiac failure (esp. cor pulmonale: right sided heart failure caused by pulmonary disease)
• Cardiac dysrhythmias

37

Obtain smoking history

1. length of time the patient has smoked ;
2. the number of packs smoked daily
to determine the pack - year smoking history

38

COPD: assessment

• Smoking history
• Description of breathing difficulties: wheezing, SOB, difficulty with breathing with speaking, cough/cough pattern, orthopnea
• Appearance: thin with loss of muscle mass in extremities
• Person usually sits in a forward-bending posture (tri-pod)
• L ABS  ABG’s; sputum samples; Hgb and Hct
• Chest X-ray
• PFT

39

Orthopnea

breathlessness is worse when lying down ( many patients sleep in semi-sitting position

40

COPD: nursing diagnosis

• Impaired Gas Exchange
• Ineffective Breathing Problems
• Ineffective Airway Clearance
• Activity Intolerance
• Fatigue
• Imbalanced Nutrition
• Anxiety
• Sleep Deprivation
• Impaired Thought Processes
• Knowledge Deficit
• Sexual Dysfunction
• Ineffective Coping

41

COPD: interventions

• Airway maintenance and monitoring• Mucolytics to thin mucus secretions
• Expectorants
• Corticosteriods
• Couch enhancement
• Oxygen therapy (2-4L)
• Energy conservation (space out ADL’s/take breaks)
• Surgery: lung transplantation
• Homecare management: O2; pulmonary rehabilitation
programs

42

Expectorants:

mycolytics which thin secretions, making them easier to expectorate

43

Breathing techniques :

- diaphragmatic/abdominal breathing: use abd mucles to blow out as much air as can
- pursed-lip breathing: breath in through nose then purse lips when
breathing out as if whistling
- planned/controlled coughing especially in morning and at mealtimes

44

Chest physiotherapy:

- postural drainage
- suctioning prn
- positioning and hydration

45

Pneumonia :

• Inflammatory process resulting in excess fluid in the lungs
• Inflammation can be in interstitial spaces, alveoli and bronchioles
• Triggered by infective/irritating organisms (many different kinds)
• Results in reduced oxygenation and tissue perfusion
• Can be nosocomial (HAP) or community (CAP)

46

HAP: risk factors

• Older adult
• Has chronic lung disease
• Altered LOC
• Poor nutritional status
• Immunocompromised
• Receiving mechanical ventilation
• Has NG, endotracheal or tracheostomy tube

47

CAP: risk factors

• Older adult
• Never received pneumonia vaccine or received more than 6 years ago
• Tobacco or alcohol use
• Has chronic health problem or other coexisting conditions

48

Pneumonia: S/s

• Flushed cheeks, bright eyes, anxious expression
• Chest or pleuritic pain or discomfort
• Hemoptysis; increased fatigue; cyanosis
• Headache; fever; chills; cough; sputum production
• Tachycardia; dyspnea; tachypnea
• Crackles - fluid
• Wheezing - inflammation and exudate in airways (narrowing)
• Tactile fremitus is increased over pneumonia consolidated areas; dulled percussion over these areas

49

Pneumonia: DX

• Diminished chest expansion and/or unequal on inspiration
• May be hypotensive with orthostatice changes
• Rapid weak pulse (dehydration)
• LABS: CBC (inc WBC); hypernatremia and inc BUN may be result of dehydration
• Chest x-rays (shows changes only until 2 or more days after manifestations are present): appears as area of increased density
• Thoracentesis if accompanying pleural effusion

50

Pneumonia: nursing diagnoses and intervention

• Similar and comparable to those symptoms of COPD
• Pts have potential for sepsis - eradication of the organism causing the infection
• Meds similar
• Antibiotics : Ampicillin/sulbactam (Unasyn); Azithromax (Zithromax); Levofloxacin (Levaquin); Vancomycin (Vancocin)

51

Pulmonary Tuberculosis (TB)

• Highly communicable; caused by Mycobacterium tuberculosis
• Airborne transmission

52

TB: assessment

• Has a slow onset and often symptoms not significantly recognizable until further
advancement – can be several months
• S/S:
1. persistent cough (mucopurulent with possible blood streaks)
2. fatigue
3. lethargy
4. nausea
5. anorexia; weight loss
6. irregular menses
7. low grade fever; night sweats

53

TB: labs

• Positive smear for acid-fast bacillus (AFB)
• Tuberculin test (mantoux test)
• Chest X-ray confirms diagnosis following a positive TB skin test

54

TB: nursing diagnosis

• Impaired gas exchange• Fatigue
• Imbalanced nutrition
• Social isolation
• Deficient knowledge

55

TB: interventions

• Drug therapy: Isoniazid (INH); Rifampin
• Additional drug therapy: Pyrazinamide; Ethambutol; (antiemetics for nausea
possibly caused by above TB drugs)
• Pt put on airborne precautions in hospital – room with ventilation of 6 exchanges of
fresh air per minute
• Health care workers must wear special mask/respirator
• Can be managed at home

56

Rifampin (RIF) : action

kills slower-growing organisms, even those that reside in macrophages and caseating granulomas

57

Rifampin : nursing interventions

1. Expect the drug to stain the skin and urine and other secretions - reddish-orange tinge; + soft contact lenses will become permanently stained. ( harmless)
2. Women using oral contraceptives - use additional protection while taking this drug + 1 month after.
3. Avoid drinking alcoholic beverages while on this drug ( can cause liver damage).
4. Risk for liver toxicity or failure : darkening of the urine, yellow skin or whites of the eyes; increase tendency to bruise or bleed.
5. Ask patient about all other drugs in use ( interacts with many drugs).

58

Guaifenesin

expectorant - thin secretions

59

Bactericidal

Bacteria killing

60

Acetylcysteine ( Mucomyst)

mycolytic - destroys or dissolves mucus

61

Bacteriostatic

Inhibiting growth or multiplication of bacteria

62

Chronic bronchitis and hypoxia

Large amount of thick mucus ( impaired gas exchange )

63

Pneumonia, pulmonary embolus

altered alveolar capillary diffusion

64

Step 1 : Mild intermittent asthma

symptoms less the once/week ; night symptoms less than 2/month; no daily drugs; rescue drug - SABA inhaler : Albuterol

65

Step 2 : Mild persistent asthma

symptoms more than 1/week ( but not daily); night symptoms more than 2/month; daily ICS low dose: Flovent; rescue inhaler

66

Step 3 : Moderate persistent asthma

symptoms daily; night symptoms more than 1/week; low dose ICS + LABA : Salmeterol (Serevent) or ICS alone - medium dose range

67

Step 4: Severe persistent asthma

symptoms daily; night symptoms frequently; limited activity; ICS (medium) + LABA

68

Step 5: Severe persistent asthma not responsive to previous step

ICS ( high) + LABA

69

Step 6: Severe persistent asthma not responsive to previous step

ICS (high) + oral corticosteroids: Prednisone (Deltasone ) + LABA