What are some Epidemiology & Etiology for COPD?
More than 40 million Americans
4th leading cause of death & illness
Estimated $18 Billion annually in direct care costs
Specific causes are not clearly understood
COPD refers to several disorders affecting airflow, what are the three?
They may occur alone or coexist
What are some risk factors for COPD?
Stimulates excess mucous production
Decreases Ciliary function
Inflames and damages bronchiolar & alveolar walls
CHRONIC RESPIRATORY INFECTIONS
What is the pathophysiology of Bronchitis?
Increased mucous production due to:
- inflammation of bronchi
- Inc size & # of submucousal glands
- Inc number of goblet cells
Impaired ciliary function and dec mucous clearance
Obstruct airway = airway collapse = air trapping
Dec Alveolar ventilation = dec PO2 & inc PCO2 = polycythemia
What is the pathophysiology of Emphysema?
Aveolar walls damaged
Partial airway collapse
Loss of elastic recoil
Formation of blebs and bullae
Inc Ventilatory dead space
(Amt of lungs inflated but not being used for gas exch)
Overdistension of alveoli
What is the pathophysiology for asthma?
Chronic inflammatory response to allergens
Occurs in 2 phases by release of chemical mediators
Lukatrine & Hystamine
Inc Mucosal edema, Inc Mucous secretion, Inc airway inflammation
Leads to airway constriction
Self-sustaining cycle of inflammation and obstruction
Airway responds to antigens and stimuli by constricting
(Exercise, Cold air, dry air, emotional stress, chemical exposure ie paint fumes)
What are some assessments for Bronchitis?
Productive cough with copious amounts of sputum
Dec exercise tolerance
Wheezing in lungs
Short of Breath
Chronic hypoxemia (low oxygen in blood) & hypercapnia (High CO2 in blood)
Inc anteroposterior diameter
What are some assessments for Emphysema?
Progressive DOE = dyspnea at rest
Tachypnea (small volume)
Chest X-Ray=Overinflation & flattened diaphragm
Diminished breath sounds
Clubbing of fingers
Use of accessory muscles
Generally pink color
Inc anteroposterior diameter (Barrel Chest)
What are some assessments for Asthma?
Marked Respiratory Effort during episodes:
-Use of accessory muscles
Wheezing (No wheezing=ominous sign)
Bronchospasm = Almost continuous coughing
Dec Peak expiratory flow rate (PEFR) & forced expiratory volume (FEV)
Dec O2 Sat, Dec PO2, Inc PCO2
What are some complications that occur to the pt body if we fail to treat the primary problem COPD?
Respiratory Failure (Deadly)
(Lungs are no longer effective in meeting your oxygen need or the acid base balance)
(When a hole is generated in the aveoli as a result from excessive coughing)
Status Asthmaticus (Deadly)
(Specific to asthma form of COPD-Bronchoconstriction continues to the point of
(Form of right sided heart failure-Pulmonary artery pumps blood into lungs to pick up oxygen and drains back into left side.)
What are some diagnostic tests for COPD?
-Reveals lungs, calcified casculature & skeletal structure
-Reveals pneumothorax, hemothorax, masses, or parenchymal changes (ie: blebs, bullae, consolidation, infiltrates, etc)
Sputum Culture & Sensitivity
(Bc they are prone to infection-Can identify if there is one there, what it is, and what drug is effective in killing it)
Pulmonary funtion test P.606
(Measures various lung volumes to assess ventilation)
- Peak Expiratory Flowmeter - Measures flow rate
-Peak Expiratory Volume
(Check these on routine basis so they can tell when they are gettin close to have an episode)
Arterial Blood Gases (ABG's)
When you see PO2, it is not the same as O2 or SPO2
- PO2-Measures total volume of oxygen in their arterial blood
What are some Lab work for COPD? (Deals more with complications than with COPD)
Complete Blood Count (CBC)
-Red Blood Cells
Normals for males are slightly higher than females
What is the purpose of Oxygen and what are some considerations pertaining to COPD?
Used cautiously in COPD - Bc their respiratory drive may be prompted by low oxygen levels
Typical Range - 1-3L/min per NC
Can use Venturi mask if higher O2 needed; doesn't promote retention of CO2
May place NC in mouth if mouth breather
Pursed-lip breathing promotes o2/co2 diffusion in alveoli by prolonging expiration
It's unethical to withhold a higher oxygen level when needed even if you are afraid of causing respiratory issues for raising oxygen over 3L.
What do Bronchodilators (Beta2 Agonists-more effective for Chronic Bronchitis or Asthma form) do and what are some considerations, ex, and side effects for COPD pt?
Stimulates beta2 receptors in the lungs
May also enhance mucous clearance by creating a larger airway
Inhaled, parenteral, & oral form
Rapis onset; peak=60-90 mins; duration=3-4 hours
Examples: Albuterol, metaproterenol, levalbuterol
Side Effects: Tachycardia, tremors, nervousness, nausea
These are relief or rescue meds (inhalers)
What are some considerations for Bronchodilators (Anticholinergic Agents)?
Greater effect and fewer side effects
Blocks cholinergic receptors in larger airways
Peak=1-2 hours ; Duration=4-5 hours
Examples: Ipratropium Bromide (Atrovent), Atropine
Side Effects: Dry mouth, nervousness, dizziness, fatigue, headache
What are some considerations for Bronchodilators (Methylxanthines)?
Enhance mucociliary clearance
Stimulate central respiratory drive
(Help pt breath deeper)
Dec pulmonary vascular resistance
Help heart circulate blood through lungs
Increases lung function in sleep
Oral and Parenteral forms
Toxicity may occur; blood levels need to be monitored
Examples: Theophylline, aminophylline
Coffee, chocolate, tea or cola may interact with these meds, and increase blood levels of theyophylline levels (Do these in moderation)
Side Effects: gastric upset, tachycardia, tremors, nervousness, N/V
What are some considerations for Corticosteroids?
Reduce airway inflammation & edema
Inhibits breakdown of epinephrine which creates bronchodilation
Inhaled, Oral and Parenteral forms
Dose should be tapered as clients improve
Chronic use leads to complications such as fat metabolism, immune responses, and changes physical appearance
Examples: Hydrocortisone sodiumsuccinate(Solu-Cortef), methylprednisolone sodium succinate (Solu-Medrol)
Side Effects: hypertension, peptic ulcer, dysphoria, hyperglycemia, cough, oral thrush, fragilie skin, thinning hair, delayed would healing and a hump between scapula
What are mast cell stabilizers used for and what do they do, side efgfects and examples?
Used for asthma
Supppress the release of brochoconstrictive substances during antigen-antibody reactions
Inhaled, oral, nasal & opthalmic forms
Examples: Cormolyn (intal) and Nedocromil (Tilade)
Side Effects: Sneezing, cough, throat & tracheal irritation & nausea
Leuokotriene Recepter Antagonists
Decrease effects of leukotrienes released into the airways
(Leukotrienes cause smooth muscle constriction, Inc vascular permeability, edema of airway mucosa, mucous release, inhibit mucous clearance, and attract eosinophils that promote inflammation) BREAK THE PROCESS AT THE FRONT DOOR (Maintenance med that helps prevent asthma attacks from occuring)
Examples: Montelukast (Singulair) and Zafirlukast (Accolate)
Side Effects: HA, liver failure, fever, muscle aches
What are some nursing interventions for COPD?
HT assess with focused resp assess
Assess VS & Pulse Ox
Provide O2 as needed
-Requires PCP order
BiPAP or CPAP may be used
Continual Postitive Airway Pressure-When they exhale they have to exhale against oxygenated air, helps keep airway open to prolong expiration
Biphasic Airway Pressure-Certain pressure when they breath in and lower pressure when they exhale (Better for Emphysema)
Allow position of comfort; High Fowler's (HOB ^) position is usually best
Instruct in pursed-lip breathing
Proved meds promptly, esp bronchodilators, as ordered
Collect sputum & send for testing; monitor amount, color & consistency
Provide oral care every 2-4 hours
Assess and treat nutritional deficits
Promote clearing of secretions
What are some interventions to promote the clearing of secretions?
Increase fluid intake 2-3L to thin secretions
Humidify Room and or O2
Frequent position changes
The secretions go where gracity takes it so you want to move it around
Instruct in deep breathing and coughing
Huff coughing - Series of small coughs and then one BIG cough - which is better for COPD pt
Give chest physiotherapy
Percussional vibrations to break up mucous
Suction if indicated
What are some O2 safety teaching/health promotion for COPD patients?
No smoking or sources of ignition
No petroleum based products
Conventrator vs. tank-based
Always ground self before touching client
What are some nutritional teaching/health promotions for COPD patients?
Frequent small meals
Inc Calories, Inc fats & proteins, Dec Carbs
Liquids & soft foods easier to handle
If supplements used, use those designed for pulmonary clients
Encourage easy food prep or prepared foods
Work with resources & preferences
What are some Energy/O2 conservation teching/health promotions for COPD pt?
Diary of activity
Help client prioritize
Use inhalers before activities
Plan activites in small steps
Plan frequent rest periods
What are some exercise teaching/health promotions for COPD?
Doesn't improve lung function but can strenthen respiratory muscles
Progressive walking is most common
O2 may be needed
Remind to deep breathe and use pursed-lip breathing
What are some socialization and sexuality teachings/health promotion?
During meals & exercise=good time
Use technology (Email & chat rooms)
Assume passive positions
Use massage as part of foreplay
Have partner play more active role
What are some teachings as to how to minimize infections?
Proper hand hygeine
Identify allergens & avoid (may require lifestyle change)
Avoid contact w/ those who have coughs or fevers
Notify PCP quickly: Changes in sputum, level of dyspnea, fever develops
Encourage influenza and pneumoccoccal vaccinations
What are some teachings for Peak Flow?
Values drop ~24 hrs before acute asthma attack manifests
Monitor daily and record
Follow designated action plan
Use HEPA filter system, esp in sleeping areas
(Very effective in minimizing allergic responses)
What are some inhaler/nebulizer use teachings?
Cleaning of Equipement
Rinse mouth after corticosteroid/anticholinergic use
What is Pneumonia?
An inflammatory process within the lungs, in response to injurty or organism, that results in a marked increase in interstitial and alveolar fluid.
Pneumonia & influenze are the 6th leading cause of death
2nd most common hospital-acquired infection (Highest mortality)
What causes pnemonia (Infectious agents, aspiration, inhalation of toxic or caustic agents) Give examples of each?
Inhalation of toxic or caustic agents:
What are some risk factors for pneumonia?
Changes in anatomy and ability to resist process
Upper Respiratory Infection
Chemotherpy, HIV, etc
Just like foley catheter - Can carry bacteria
This is where you get all essential chemicals for all processes in the body and to help w/ energy to repair
Makes the secretions thick
Resp, Cardiac, Diabetes, Kidney, Cancer
Effect on Nutrition nd Life of tissues round Cancer
Drugs, ETOH, anesthesia, disease, diability
Residence in institution
What are the steps or process of Pnemonia?
Agen or organism produces inflammatory response of lower airways
Dec cough and or ciliary activity leads to colonization; infection develps
Fluid in alveoli consolidates (difficult to expectorate)
O2/CO2 exchange is impaired
What are some signs and symptoms of Pneumonia?
Fever, chills, sweats
Pleuritic chest pain
Blood streaking/tinting in the sputum
Immune system activated and their immune system is focusing on fixing the infection
Altered mental status/confusion & dehydration
(OFTEN 1ST SIGN IN OLDER ADULTS)
Diminished BS, crackles or rhonchi
Tachypnea & Orthopnea
Dec Bowel sounds if resp distress is signifigant
B/c your immune system is focusing on breathing it can cause an ileus
Dec O2 stat possible
What happens to the client if they fail to get treatment, prolong treatment or don't respond to treatment of pnemonia?
Become Hypoxemic; Usually people who have COPD to being with
Coughing too much and too hard
Infection in the blood
(Inflammatory process didn't keep infection and it released into blood)
What are some diagnostics and labs for pneumonia?
Sputum for Gram Stain and a culture & sensitivity
Bronchoscopy (to remove foreign material or for a sample)
Aterial Blood Gases (ABGs)
Level of gas exchange and their pH level
CBC - esp WBC count with differential
When they move from pneu to sepsis -WBC could be normal and there is an absent of fever
What is some pharmacology for Pneumonia?
May or may not be required
Hypoxemia will guide PCP decisions
What are some Antibiotic considerations, examples and nursing implications?
Broad spectrum antibiotics; Does not treat viral
Different types; Some interfere w/ replication of invading organism
IV, IM, and oral form
Examples: Cefazolin Sodium (Ancef), Ceftriaxone Sodium (Rocephin)
- Assess for allergies
- Watch for S&S of nephrotoxicity
- Collect sputum prior to starting, if possible
- Complete dosing regiment
What are some Expectorants considerations, examples and nursing implications?
Reduces adhesiveness and surface tension of secretions; making them easier to cough up
Liquid and tablet form
Example: Guaifenesin (Robitussin or Humibid)
Nausea or Drowsiness
Inc fluid intake to help loosed secretions (at least 2-3L/day)
May interact with Heparin & inc risk of hemorrhage
What are some Antitussives considerations, examples and nursing implications?
Act on cough center of medulla to Dec cough reflex
Not Desirable with pneumonia but may see used if client's cough is non-productive and depriving of sleep
Liquid, capsule, and lozenge
Example: Codeine, dextromorphan hydrobromide (Robitussin DM)
dizziness, drowsiness, N/V, constipation
Insure safety with ambulation
Instruct to cough intentionally every hour to clear secretion
What are some nursing interventions for pneumonia?
HT assess with focuse resp assess
Assess VS & pulse ox
Focus on temp, pulse and Respiration
O2 if needed
Allow position of comfort; High Fowlers is usually best
Pursed-Lip breathing (If COPD is present)
Provide meds promptly, esp bronchodilator, as ordered
Collect sputum & send for testing; monitor amount, color and consistency
Provide oral care
Assess and treat nutritional deficits
No carb restriction if no COPD
Promote clearing of secretions
What are some room assignment considerations with a pneumonia client?
Private room if available
Cohort with similar diagnosis
Keep clients 3-6 feet apart
What are some infection control considerations?
Mask on client if transported
Stay 3-6 feet away from other people until cough has subsided or few days of antibiotics
What are some Bronchoscopy interventions?
IV sedation & topical anesthesia to throat; gag reflex
Aspiration precautions; side-lying position
Observe for Complications:
Stridor from laryngeal edema
Frank bleeding from lungs
What are some teaching and health promotions for pneumonia?
Instruct in infection control:
- Avoid close contact w/ those who have cough/fever
- Cough & sneeze into tissue; dispose promptly
- Proper Hand Hygeine
-Pneumococcal for high-risk clients (q5Years)
Maintain appropriate rest & exercise:
- 6-8 hrs nightly
-30-60 min's aerobic exercise most days/week
Eat balanced diet w/ adequate hydration
Support smoking cessation
What are some alternative therapies for pneumonia?
Apples & Pears
Promotes healthy lining of lung
Dec cough, kills bacteria & viruses, and aids in expectoration
What is tuberculosis and what is the epidemiology?
An infection by the organism, mycobacterium tuberculosis
May occur in lungs (Pulmonary TB) or various other organs
- Estimated 8 mil new cases yearly
- ~3 mil people dying annually
- Cases have been identified in Payne County
- Multiple drug resistant strains now
What is the etiology for TB?
It is caused by inhaled organism that reached the aveoli
Organism very small (1-5mm) and is actively airborne during coughing, talking, laughing, sneezing or singing (Any form of exhalation)
Brief exposure doesn't usually cause infection
Organism must resis body's defenses and penetrate lung issues.
What are some risk factors for TB?
HIC, Cancer tx, malnourished
Poverty, ETOH abuse, drug abuse
Freq contact with medically underserved
low-income, homeless, foreign-born, drug abusers
Close confinement in a residential facility or institution
How does TB develop?
Airnborn TB bacilli are inhaled
Inflammatory process develops pneumonia
WBCs ingest bacilli but don't kill them
Infected WBC carry bacilli to lymph system and other organs
Primary infection site may cause active or dormant TB
Body develops an allergic response(cell mediated immune response) to TB bacilli or their proteins
- Takes 2-6 weeks
-Occurs in all the body's cells
- Inhibits further growth and bacilli and dev of active TB
- Maintained as long as living bacilli is in body
What happens during Active TB?
- Process of necrotic degeneration (caseation) produces cheese-filled cavities of TB bacilli, dead WBCs and necrotic lung tissue
-Liquifies, drains and is coughed up
- Air-filled cavities remain
What happens during dormant TB?
Process of forming scars & calcified lesions (Ghon tubercles) that "wall-off" and contain living bacilli, even for many years
What are some S&S of TB?
Dormant TB may be asymptomatic and only diagnosed by skin testing and chest x-ray
Cough - Productive and nonproductive
Color of sputum
Anorexia and weight loss
Low grade fever
Chills & night sweats
Chest tightness or pleurisy
Crackles or friction rub
What happens if TB is not treated?
Infection of other organs
Brain, liver, kidney's and bone
What are some diagnostic and labs for TB?
Tuberculin Skin Test
Acid-fast bacillus smear and culture
(May see Ghon tubercles or air-filled cavities)
Liver Function Tests
What is and what are some considerations for the TB skin test?
uses purified protein derivative (PPD)
0.1ml injected intradermally on L forearm
Examined in 48-72 hours
Induration >5mm (hardening of tissue), not erythema, = positive (Anergy=Inadequate immune response)
False positive and false negatives can occur
Tuberculin converter = someone with documented neg TB skin test but now shows positive results
What is and what are some considerations for Acid-Fast bacillus smear and culture test for TB?
3 sputum samples collected on 3 consecutive mornings
Acid-fast smear on each sample
Positve results = active TB disease
Culture done on each sample
-Pos for active TB if mycobacterium tuberculosis is grown
What are a couple of the liver function tests for TB?
Liver enzymes released when liver cells are damaged
What is some pharmacology general information for TB?
Drug resistant strains have developed
Multi-drug approach recommended by CDC
- Induction phase: 2 months of 4 meds
- Continuation phase: 4 month-2years of 2 meds
Compliance= MAJOR problem
- Cost and Side Effects
-Various health initiative to address (free meds and follow up, Directly observed therapy= healthcare personnel observe or administer client's meds daily for 6 months
What are 5 first line Antituberculosis Agents?
(Oral form is most common)
(Some inhibit growth and some kill bacteria)
What are some side effects of Antituberculosis Agents for TB?
(Inc liver enzymes, N/V, anorexia, fatigure, jaundice)
May be ototoxic and nephrotoxic
Colors body fluids orange (urine, sweat, salive, aputum & tears), GI upset, renal failure
May cause Gout
May be ocular toxic, causing multiple visual changes
May causeperipheral neuritis (Paresthesias of feet and hands)
What are some nursing interventions for Antituberculosis Agents for TB?
Instruct in importance of completion of drug regimen
May divide RIF dose in half and take twice daily with meals
Monitor liver function tests
INH may cause Vit B6 deficiency; supplementation usually encouraged
What are some things to avoid with INH TB meds?
Thyamine-Containing = Palpitations, flushing & BP
-Beer, wine, processed meats, yeast, aged cheese, smoked fish
Histamine-containing = HA, Inc BP, palpitations, sweating, itching, flushing and diarrhea
-Tuna, Sauerkraut, Yeast
What are some nursing interventions and considerations for TB?
HT assess with focused resp assess
Assess VS & pulse ox
Collect putum & send for testing; 3 samples, 3 consec mornings
Assess and treat nutritional deficits
Room Assignment = PRIVATE
What are some infection control precautions for TB?
- N95 fit-tested respirator for all staff entering room
-Neg airflow room with at least 6 air exchanges/hr
- HEPA filter
-Ultraviolet lights (proven to kill mycobacteria) OPEN WINDOWS
-All close contacts identified and screened with TB skin test
What are some teachings and health promotions for TB?
Emphasize significance of completeing drug regimen as ordered
Promote high calorie, high protein, well balanced diet (Teach regarding thyramin & histamine containing foods)
Encourage yearly TB skin testing for high-risk client group
Teach client with dormant TB when to see PCP
- Review S&S of active TB
-Esp. productive cough of blood-tinged sputum, fever, wt loss & night sweats
What are some cultural considerations for TB?
Certain traditions of native Americans may increase risk for TB (Sharing of ceremonial pipes) and COPD (Smoking)
Chronic, debilitating illnesses (Ie: COPD) may precipitate spiritual distress for some clients (bargaining, blaming, repenting, evaluating life choices)