Presentation on theme: "Care of the Chronic Respiratory Client"— Presentation transcript:
1Care of the Chronic Respiratory Client Keith Rischer RN, MA, CEN
2Todays ObjectivesCompare & contrast pathophysiology and clinical manifestations of asthma, emphysema, bronchitis & lung cancer.Identify the diagnostic tests, nursing priorities, and client education with asthma, emphysema, bronchitis, & lung cancer.Describe the mechanism of action, side effects and nursing responsibilities with pharmacologic management of asthma, emphysema & bronchitis.Contrast and compare medical vs. surgical management for treatment of lung cancer.Identify nursing priorities and care of the client with a chest tube.Identify nursing priorities and care of the client on a mechanical ventilator.
4Obstructive Airway Disorders Increase resistance to airflowBronchi smooth muscle innervated by autonomic nervous systemParasympathetic stimulationSympathetic stimulationInflammatory mediator responseCOPDChronic-recurrent obstructionEmphysemabronchitisCOPDCOPD
5Obstructive Disorders:Asthma PathoIntermittent & reversible airway obstructionINFLAMMATION-ChronicAntibody molecules (IgE)Mast cells>histamine>WBCPhysiological response to inflammationVessel dilation>capillary leakage>tissue swelling>incr. secretionsAirway hyper-responsivenessChildhoodAllergenssmokingCold/dry airBacteriaBronchospasmedema & mucousImpacts over 20 million in USPathophysiology-Clinical syndrome characterized by increased responsiveness of the tracheobronchial tree/airways NOT ALVEOLI to a variety of stimuli-Chronic inflammationairways become hyperresponsive to specific antigens and other stimuli such as physical exertion or breathing cold airASTHMA IS REVERSIBLE AIRFLOW OBSTRUCTION WHILE EMPHYSEMA AND COPD ARE IRREVERSIBLEALLERGENS BIND TO IgE molecules on mast cells chemicals released that cause inflammatory responseBlood vessel dilation-cap leak which leads to tissue swelling…increased secretions-mucous production…MOST COMMON CAUSE OF ASTHMA
6What is a Mast Cell? Bag of Granules Located in connective tissue close to blood vesselsHistamine releasedIncrease blood flowIncrease vascular permeabilityBinds to H1, H2 receptorsMost important activator of inflammationCellular bags of granules that includes histamineLocated in loose connective tissue, close to blood vessels such as under the skin, GI track and the Respiratory TrackHistamine is stored here until released during an inflammatory responseWhen something stimulates/agitates the mast cell, out tumbles the histamine as a mediator of inflammation. (Basophils are similar to mast cells but are found in the blood – for me )Histamine Inflammation begins with degranulation of mast cells and ends with healing - p154)H1-H2 receptors parietal cells stomach-increase gastric secretion
7Etiology of asthma Intrinsic etiologies uncertain causes physical or psychological stressexercise-inducedExtrinsic etiologiesantigen-antibody (allergic) reaction to specific irritantsair pollutantssinusitiscold and dry airMeds-ASAfood additiveshormonal influencesGE refluxCan occur at any ageHalf of adults who have-had as a childMore common in urban than rural settingsResponsible for 5000 deaths in US annually
8Clinical manifestations of Asthma Severe dyspneawheezing with expiration or inspirationWhich is worse…TachypneaCoughFeelings of chest tightnessProlonged expirationDiminished breath soundsIncreased heart rate and blood pressureRestlessness, anxiety, agitationSeverity and duration of symptoms are unpredictableThe progressive airway obstruction unresponsive to treatment leads to status asthmaticus, and emergency conditionclients with severe airway obstruction may not be able to move enough air to produce wheezing
9Asthma: Lab & Dx Findings Decreased pO2Decreased pCO2EarlyLate findingsElevated eosinophil countCXRPulmonary Function TestForced vital capacity (FVC)Peak flow meterABG’spH 7.28pO2-55pCO2-60HCO3-22O2 sats-86% RApH 7.35pO2-75pCO2-30O2 sats-90% RAPulmonary Function TestForced vital capacity (FVC)…most important…volume of air exhaled from full inhalation to exhalation
10Pharmacologic Treatment Options Relievers = short-acting bronchodilatorsquickly relieves bronchoconstriction and symptomsControllers = daily medications taken on a long-term basisuseful for controlling persistent asthmaincludes anti-inflammatory agents and long-acting bronchodilators
11Beta-2 agonists chart 33-5 p.590-592 Mechanismbronchodilation through bronchial smooth muscle relaxation mediated by beta-2 receptors in the lungShort Actingalbuterol (Proventil, Ventolin)XopenexPirbuterol (Maxair autoinhaler)Terbutaline (Brethaire)Long actingSalmeterol-SereventOnset: minutesDuration: 4-6 hoursBy stimulating B2 receptors in lungs triggers smooth muscle relaxationProvide rapid but ST reliefMost useful when attack begins or about to begin activity such as aexerciseLong acting
12Beta-2 agonists Uses: Adverse effects: Rescue medication to relieve acute symptoms & prevention of bronchospasms prior to a precipitating event (e.g. exercise)Adverse effects:TachycardiaRestlessnessTremorsPalpitationsparadoxical bronchoconstriction
13Anticholinergics Mechanism Ipratropium (Atrovent) block parasympathetic nervous system influenceSNS dominatesIpratropium (Atrovent)Onset: minutes, peak: 1-2 hoursDuration: 4-8 hoursAdverse effectsdrying of mouth and respiratory secretionsincreased wheezing in some individualsMechanismblock parasympathetic nervous system influenceSNS dominates THEREFORE WHAT ARE EXPECTED EFFECTS…increased bronchodilation and decr pulm secretions
14Inhaled Corticosteroids MechanismDecrease inflammationblock late reaction to allergens and reduce airway hyperresponsivenessinhibit microvascular leakageCommon Meds…used qdbudesonide (Pulmocort)fluticasone (Flovent)triamcinolone (Azmacort)
15Inhaled Corticosteroids (cont.) Uses:long-term prevention of symptoms (suppression, control, and reversal of inflammation)reduce/eliminate oral steroid useAdverse effects:oral candidiasis??systemic effects at high doses**use spacer to prevent oral candidiasis, rinse mouth after use
16Oral Corticosteroids Common agents Uses LT Side Effects Prednisone methylprednisolone (Medrol, Solu-Medrol)Usesshort term (3-10 days) “burst therapy” to gain prompt control of asthmato prevent progression of exacerbation, speed recovery, and reduce relapselong-term prevention of symptoms in severe persistent asthmaLT Side EffectsHTNPeptic ulcersSkin fragilityImpaired immunityThromboembolismCushingoid appearance
17Asthma:Combination Inhalers Advair DiskusFluticasoneSalmeterol (serevent)Frequency1 inhalation q12 hoursCombivent MDIIpratropium (atrovent)Albuterol2 puffs 4 times dailyLeukotriene Antagonists (anti-inflammatory)Montelukast (Singulair)Antagonizes or prevents the effects of leukotrienes which cause the following:Airway edemaSmooth muscle constrictionRESULT IS DECREASED INFLAMMATORY EFFECT…
18Asthma: Other Medications Leukotriene Antagonistsanti-inflammatoryMontelukast (Singulair)Therapeutic responseDecreased frequency & severity of attacksDecreased exercise induced bronchoconstrictionMast cell stabilizersMechanismCromolyn sodium (Intal)Frequency1-2 inhalations 4 times dailyA leukotriene antagonist is a hormone antagonist acting upon leukotrienes.It has been demonstrated that leukotrienes are implicated in bronchoconstriction and in the inflammatory cascade leading to asthma. Leukotriene modifiers are an important therapeutic advance in managing asthma.Leukotrienes assist in the pathophysiology of asthma, causing or potentiating the following symptoms:airflow obstructionincreased secretion of mucusmucosal accumulationbronchoconstrictioninfiltration of inflammatory cells in the airway wall
19Asthma:Regimen by Severity MildShort-acting beta-agonist inhalerAnti-inflammatory inhaler used for mild symptoms occurring dailyModerateAnti-inflammatory inhaler plus medium-dose corticosteroid inhalerused for moderate symptoms occurring daily or more oftenSevereAnti-inflammatory inhaler plus long-acting bronchodilator plus oral corticosteroidused for severe symptoms occurring daily or more oftenMildShort-acting beta-agonist inhaler; used for mild symptoms occurring twice weekly or less; also used for intermittent symptomatic relief and may be combined with long-acting medicationsAnti-inflammatory inhaler; used for mild symptoms occurring dailyModerateAnti-inflammatory inhaler plus medium-dose corticosteroid inhaler; used for moderate symptoms occurring daily or more oftenSevereAnti-inflammatory inhaler plus long-acting bronchodilator plus oral corticosteroid; used for severe symptoms occurring daily or more often
20Priority Nursing Diagnoses for Asthma Impaired gas exchange r/t…Ineffective breathing pattern r/t…Ineffective airway clearance r/t…Anxiety r/t…Deficient knowledgeImpaired gas exchange r/t…bronchospasm…secretionsIneffective breathing pattern r/t…Ineffective airway clearance r/t…Anxiety r/t…Deficient knowledge
21Asthma:Critical Care Management Status asthmaticus/severe asthmaPhysical assessmentDyspnea/tachypneaWheezing I/EDiminished aeration to no air movementAccessory musclesMedical management …remember A,B,C,sO2Albuterol nebEpinephrine subqEstablish IVIV steroids (solumedrol)Prepare for possible intubationStatus asthmaticus/severe asthmaLife threatening emergency that intensifies and does not respond to therapyPresents with extremely labored breathing wheezing
22Planning and implementation for Asthma Assess respiratory and oxygenation statusAdminister supplemental oxygen as neededAdminister broncholdilators as prescribedObserve characteristics of sputumIdentify/avoid/remove precipitating factorsTeach patient relaxation techniquesPrepare for IV accessBe prepared for intubationDiagnostic studiesEmotional support for patient and family
23Expected outcomes/evaluation Absence of dyspnea, chest tightness, wheezingRespiratory rate breaths per minutePulse oximetry/arterial blood gas values within normal range for clientBilaterally clear and equal breath soundsAfebrileAdequate airway clearanceAbsence/resolution of anxietyClear chest x-ray or return to patient’s baselineNormal or improved peak flow
24Asthma: Patient Education Identify asthma triggersTeach patient/family proper used of metered-dose inhalerChart 33-6 p.593Rescue inhalers!Instruct client regarding the use of peak flow meter for self-assessment of asthma statusAsthma symptoms requiring emergency intervention
26Emphysema: Patho Loss of lung elasticity Hyperinflation of lung Alveolar destructionExcessive enlargementLoss of “curves” impairs gas exchangeCompensation…Hyperinflation of lungSecondary to air trapping“barrel chest” appearance“Pink pufferO2 diffused easier than CO2CO2 accumulates causing chronic resp. acidosisImpacts 11 million in US…4th leading cause of death responsible for 100,000 annuallyThere is loss of elastic recoil as a result of the destruction of the elastin and collagen fibers found in the lung; without this recoil, air is trapped in the lung and airways collapseThe trapping of air results in a hyperinflated lung, causing the “barrel chest” appearanceEnzymes from smoking damage alveoli and small airways by breaking down elastinAlveoli lose elasticity and collapseThe patient has the ability to maintain blood gases by hyperventilating and keeps a pink appearance of the skin, thus know as a “pink puffer” early in the disease; cyanosis may develop in later stages
27Emphysema: Causes & Complications Cigarette smokingPack years requiredSmoke>enzyme elastase protease>destroys alveoliDestroys ciliaChronic respiratory inflammationair pollutionComplicationsHypoxemia & acidosisResp. infections/pneumoniaCur pulmonaleCardiac dysrhythmiasCigarette smokingPack years required…8 years for physiologic changes but no sx20 pack years early stage sxCur pulmonaleASSESS FOR PITTING EDEMA-JVD-RIGHT SIDED HF
28Emphysema: PhysicalAssessment…A,B,C’s General appearanceEmaciatedBarrel chestAirway/breathingDyspneaTachypneaAccessory muscle usePursed lip breathingLung soundsoverall diminished, and wheezes or crackles may be presentDry cough more so than productiveO2 sats…Circulationtachycardia (inadequate oxygenation)Arrythmias
29Emphysema: Diagnostic Tests ABGsChronic resp. acidosisCompensation w/HCO3Assess pO2, pCO2 and HCO3CBCWBCHgbHctpolycythemiaChest x-rayhyperinflated lungs with a flattened diaphragmABG’spH 7.35pO2-55pCO2-60HCO3-22O2 sats-86% RAHCO3-35
30ED COPD Case Study 84yr female PMH: COPD, asthma, HTN, anxiety, mitral stenosisHPI: productive cough of green phlegm the last 4 days. Primary MD started on po Prednisone and Abx.Developed incr. SOB through the night with pronounced fever/chills w/left shoulder pain that increases w/movement. Denies CPVS: T P-122 (ST) R-36 BP-202/105 sats 88% RAAssessment:Neuro-a/o notably anxiousResp-diminished bilat w/exp. WheezingCV-2/6 murmur
31ED COPD Case Study Medical Priorities… Nursing priorities Nursing assessments…Nursing interventions…Medical Priorities…Stat albuterol nebPIVCombivent nebSolumedrol 125mg IVTylenol po
32ED COPD Case Study CXR Labs Large left lower lobe infiltrate BMP CBC Na 138, K+ 3.9, creat. 1.16, gluc 112CBCWBC 7.0, Hgb 13.3, Hct 39.9, plat. 217UAnegPlan-admission to medical floor/tele
33Chronic Bronchitis A disorder of chronic airway inflammation Major & small bronchiolesChronic productive cough lasting at least 3 months during 2 yearsChronic exposure to irritantssmokingAn inflammatory response in the small & large airways resulting in…VasodilationCongestionmucosal edemabroncospasm
34Chronic Bronchitis: Patho EtiologySmokingChronic inflammationIncrease in # and size of mucous glandsMore mucousbronchial walls thicken/edemaairflow is impededSmaller airways are blockedAirflow and gas exchange impactedpO2…pCO2…Cilia disappear, and the airway clearance function is lostUnlike emphysema, cannot increase breathing efforts to maintain blood gases“blue bloater”PolycythemiaThe bronchial mucosal glands hypertrophy and there is an increase in the number and size of goblet cells accompanied by inflammatory cell infiltration an edema of the bronchial mucosaAs the bronchial walls thicken, airflow is impededUnlike emphysema, the individual with bronchitis cannot increase breathing efforts to maintain blood gasesPresence of cyanosis and edema give the bronchitis client the term “blue bloater”In the severe state of chronic hypoxia, the kidneys increased the production of RBCs in an attempt to bring more oxygenated blood to the cells, causing polycythemia, increased blood viscosity, and a higher risk for blood clots
35Chronic Bronchitis: Clinical Manifestations Productive coughPrimarily occurring during winter seasonfoul-smelling sputumDyspnea and activity intoleranceFrequent pulmonary infections“Blue bloater”bluish-red skin discoloration from cyanosis and polycythemiaBarrel chest
36Emphysema/Bronchitis:Medical Management Goalsimprove ventilationpromote patent airway by removal of secretionsRemove environmental pollutantsO2 and neb therapyChest physiotherapyMechanical ventilationSurgical procedurebullectomylung volume reductionlung transplantation
37Emphysema/Bronchitis: Medications Beta-adrenergic agonistsbronchodilators in COPD by nebs or MDIAnticholinergicsAtrovent administered as maintenance by inhalermost effective bronchodilators for COPDTheophyllinemay be beneficial to strengthen diaphragm contractility and decrease work of breathingCorticosteroidsmay be beneficial for pts. w/asthma historyImmunizationsflu and pneumoniaAbxBronchodilatorscontroversial use in COPD, but maintenance therapy may be used to reduce dyspneaBeta-adrenergic agonistsused as bronchodilators in COPD and administered by nebs or MDIAnticholinergicsAtrovent administered as maintenance by inhaler; considered one of the most effective bronchodilators for COPDTheophyllinecontroversial use in COPD but may be beneficial to strengthen diaphragm contractility and decrease work of breathingCorticosteroidscontroversial, but may be beneficial for pts. With asthma history
39Emphysema/Bronchitis: Nursing Care Priorities remember A,B,C’s… Administer low-flow O2 as neededPosition patients to maintain effective breathingClosely monitor & assess resp. statusAuscultationO2 satsResponse to acute interventions/O2Provide education and referrals for pts. w/risk behaviorsReferral to smoking cessationPulmonary conditioning programDevelop appropriate nutritional plansEnergy conservationExercise conditioningAssess understanding to education
40Emphysema/Bronchitis: Patient Education Smoking cessationTeach clients how to avoid occupational or environmental pollutantsPursed lip breathingMaintain adequate nutrition with emphasis on higher calorie intakeNutrition may be optimal with frequent small meals, and cc of fluid dailyTeach energy conservation techniquesPursed lip breathing-REDUCES AMOUNT OF STALE AIR IN LUNGS
41Emphysema/Bronchitis: Expected Outcomes Activity tolerance is optimizedPulmonary irritants such as smoking, air pollution, or occupational exposure are avoidedPulmonary infections are reduced in number and severityNutritional intake is adequate but not excessive for individual energy needs
42Pulmonary Tuberculosis PathoMycobacterium tuberculosis (bacillus)Most common bacterial infection globallyAerosolizedSusceptible hostNonspecific pneumonitis alveoli or bronchus5-15% ultimately developCell mediated immunity 2-10 weeks later w/+ mantoux
43Pulmonary Tuberculosis: Infection Inflammation in lungs surrounded by lymphocytes, collagenCaseation necrosisNecrotic tissue turned into granular mass that become calcifiedSeen in low to middle lobesCan spread systemically to brain, liver , kidneys, bone marrow
44Incidence HIV Immigrant populations Crowded areas Elderly Homeless LTC, prison,ElderlyHomelessPoverty
46Treatment chart 34-7 p.643 Combination Pt. education Isoniazid (INH) RifampinPt. educationCompliance! 6 months treatment requiredSputum specimens q2-4 weeks during therapyNo longer contagious after 2-3 weeks of treatmentOnce negative x3 cured
47Nursing Priorities Airborne precautions Ventilated room N-95 mask or PAPR for any staff entering roomTB drugs can cause nausea-anticipateNutrition
48Lung Cancer: Patho Bronchial epithelium Histologic cell type 90% primaryObstructionHistologic cell typeSmall cell vs. non small cellSmall cell 20% of all lung CA99% correlation w/smokingAdenocarcinoma35% of all lung CASpread between smokers and non smokersMetastasisCirculatory & lymphaticLeading cause of cancer deaths186,000 new cases annually w/165,000 deaths in US5 year survival only 14%Due to fact that most cases dx at late stage when mets has already taken placeSMOKING-WOMEN ARE NOW SEEING INCR INCIDENCE DUE TO MORE SMOKING
49Lung Cancer: Clinical Manifestations Non-specific & occur lateDepend on type & location of tumorBronchitis/pneumonitis secondary to obstructionChillsFeverCoughBloody sputumDyspneaUse of accessory musclesWheezing-diminished aeration
50Lung Cancer: Diagnostic CXRCTBronchoscopyBronchial washingNeedle/surgical biopsyMade by direct exam of cancer cells
51Lung Cancer:Medical Management Non-surgicalChemotherapyN&VMucositisAlopeciaImmunosuppressionPan cytopeniaRadiationBest results when used w/surgery or chemoDaily for 5-6 weeksEsophagitis…esophagus proximal to lungsSide effectsSkin irritation & peelingFatigueNauseaTaste changesChemotherapyTreatment of choice for lung CAChemotherapy, in its most general sense, refers to treatment of disease by chemicals that kill cells, specifically those of micro-organisms or cancermost chemotherapeutic drugs work by impairing mitosis (cell division), effectively targeting fast-dividing cellsRadiation therapy (or radiotherapy) is the medical use of ionizing radiation as part of cancer treatment to control malignant cellsRadiation therapy is commonly applied to the cancerous tumour.SMALL DOSES OVER LONGER TIME FOUND TO BE BENEFICIAL
52Lung Cancer:Medical Management SurgicalThoracotomyTumor removalLobectomyRemoval lobe of lungPneumonectomyEntire lung
53Lung Cancer: Thoracotomy-Postop p.618-622 Chest tubeDrain placed in pleural space to restore intrapleural pressureChest tube banded & connected to Pleurovac collection chamber w/several feet tubingDrainage systemFirst chamberDrainage from clientSecond chamberWater sealThird chambersuctionChest tubeDrain placed in pleural space to restore intrapleural pressureAllows for re-expansion of lungPrevents air and fluid from returning to the chest
54Chest Tube: Nursing Priorities Assess resp. status closelyCheck water seal for bubblingMilk NOT strip every 2 hoursAssess color-amount drainageCall MD if >100cc/hr x2 hours first 24 hoursSterile guaze/occlusive dressing at bedsideCheck water seal for bubbling…IF YOU CLAMP THE TUBING CLOSE TO THE PT-IT STOPS…WHAT DOES THIS TELL YOU?
55Mechanical Ventilation The use of an ET and POSITIVE pressure to deliver O2 at preset tidal volumeModesAssist Control (AC)TV & rate presetAdditional resp. receive preset TVSynchronized Intermittent Mandatory Ventilation (SIMV)Additional resp. receive own TVUsed for weaningContinuous Positive Airway Pressure (CPAP)Bi-papNon-mechanicalreceive both insp. & exp. Pressures w/facemaskModesAssist Control (AC)Synchronized Intermittent Mandatory Ventilation (SIMV)Bi-papContinuous Positive Airway Pressure (CPAP)
56Mechanical Ventilation TerminologyRateTidal volume10-15cc/kgFraction of inspired O2 concentration (FiO2)Use lowest possible to maintain O2 satsPositive End Expiratory Pressure (PEEP)Minute volumeRR x TVAC12-TV %-+5
58Mechanical Ventilation:Nursing Priorities Monitor VS-breath sounds closelyAssess ET securement/length at lipClearance of secretionsClosed suction-maintains sterilityDo not do routinelyPre-oxygenateSedationPropofolOral careNutritional support
59Mechanical Ventilation:Nursing Priorities Ventilator Alarm TroubleshootingHigh pressureSecretions-needs sxTubing obstructed or kinkedBiting ETLow pressureDisconnection of tubingFollow tubing from ET to ventilator
60Oxygen Delivery Atmospheric room air %.......??? Nasal cannula Add 3% for each liter of flow to FiO21-6 litersOxymizerReservoir to increase FiO2 per liter delivery6-12 litersFace mask40-50% FiO28-15 litersFace mask w/non-rebreather90-100% FiO215 liters
61Respiratory Case Study Darrell Johnson is a 62-year-old male who comes to the Emergency Room with a 4-day history of increased sputum production, a change in the character of sputum, increased shortness of breath, and a fever of 101° FHe has a smoking history of 2 packs a day for the past 20 years, and he smoked 1 pack a day prior to that beginning at the age of 14.He reports that he had asthma as a child, and that he has been treated with Albuterol inhalers from time to time as an adult. Mr. Johnson has been hospitalized twice with pneumonia, most recently 2 years ago.
62Respiratory Case Study Physical exam reveals the following:Vital signs: T 101° F, P 115, R 30, BP 120/80O2 sats 90% on room airRespirations shallow and labored, with use of respiratory accessory muscles.Increased anteroposterior (AP) diameter of the chest.Skin dry and warm to touch, with inelastic skin turgor, and fingernail clubbing present.
63Respiratory Case Study Which assessment is most important for the nurse to complete next?A) Auscultate breath sounds. B) Determine pupillary response to light. C) Observe for jugular vein distention. D) Palpate pedal pulses.Which assessment finding supports Mr. Johnson's diagnosis of pneumonia?A) Pulse rate of 115. B) BP of 120/80. C) Increased AP diameter of the chest. D) Fingernail clubbing.The nurse auscultates crackles bilaterally in the lower posterior lung fields, with diminished breath sounds noted throughout all lung fields. Mr. Johnson's chest x-ray shows infiltrate in the lung bases bilaterally. Mr. Johnson is admitted to the acute care facility with a medical diagnoses of COPD pneumonia and is transported to the nursing unit.
64Respiratory Case Study Arterial Blood Gases were obtained with the following results:pH 7.28.pCO2 55.HCO3 25.pO2 89.Based on these ABG results, which acid base imbalance is Mr. Johnson experiencing?A) Metabolic acidosis. B) Metabolic alkalosis. C) Respiratory acidosis. D) Respiratory alkalosis.
65Respiratory Case Study Which nursing diagnosis has the highest priority when planning care for Mr. Johnson?A) Altered nutrition, less than body requirements. B) Activity intolerance. C) Anxiety related to increased shortness of breath. D) Ineffective airway clearance.When prioritizing needs, always remember the ABC's: Airway, Breathing, and Circulation.
66Respiratory Case Study Mr. Johnson is admitted to his room on the Medical Nursing Unit. The healthcare provider prescribes the following:Bedrest with bedside commode.O2 at 2 L/minute via nasal cannula.Diet as tolerated.Continuous O2 saturation monitoring via pulse oximeter.IV fluid of 5% Dextrose and 0.45 Normal Saline at 3 liters per day.Obtain a sputum culture.Medications include:Ampicillin (Unasyn) 1 gm IVPB every 6 hours.Nebulizer treatments every 4 hours and PRN with saline and albuterol (Ventolin).Triamcinolone (Azmacort) inhaler, 2 puffs twice a day.Albuterol (Ventolin) inhaler, 2 puffs 4 times a day.Methylprednisolone (Solu-Medrol) 125 mg IVPB every 8 hours.
67Respiratory Case Study Which nursing action should be implemented before administering the prescribed Unasyn?A) Assess the apical heart rate. B) Obtain O2 saturation recording. C) Obtain a sputum culture. D) Record Mr. Johnson's weight.Which assessment is most important for the nurse to perform while Mr. Johnson is receiving Ventolin?A) Monitor temperature. B) Measure intake and output. C) Monitor pulse and BP. D) Measure central venous pressure (CVP).
68Respiratory Case Study The nurse observes Mr. Johnson as he uses his inhalers. Using a spacer, he takes 2 puffs of the Ventolin, followed a minute later by 2 puffs of the Azmacort.After observing Mr. Johnson, what client teaching should the nurse initiate?A) "Administer the Azmacort first, followed by the Ventolin." B) "Using a spacer reduces medication absorption." C) "Inhale deeply before sealing the mouthpiece." D) "Wait at least one minute between each puff of the same medication."Which instruction should the nurse provide Mr. Johnson for an acute episode of asthma?A) "Administer the Azmacort as soon as possible." B) "Use the Ventolin inhaler for acute asthma attacks." C) "Call your healthcare provider before administering any medication." D) "You will need IV Solu-Medrol for your next acute attack."
69Respiratory Case Study Continuous monitoring of Mr. Johnson's oxygen saturation indicates readings ranging between 90%-91%.After checking the sensor site to make sure the readings are accurate, which intervention should the nurse initiate next?A) Increase the oxygen to 6 L/minute per nasal cannula. B) Elevate the head of the bed to a high-Fowler's position. C) Remove the pulse oximeter to reduce anxiety. D) Obtain and administer a prescription for pain relief.Which action should the nurse implement to ensure accurate oxygen saturation readings via a pulse oximeter?A) Elevate the extremity to which the sensor is attached. B) Assess adequacy of circulation prior to applying the sensor. C) Keep the sensor exposed to adequate lighting. D) Remove the sensor when taking the B/P.
70Respiratory Case Study During the night, Mr. Johnson calls the nurse to report a sudden inability to catch his breath.Upon assessment, the nurse notes that Mr. Johnson's respiratory rate has increased to 40 with obvious dyspnea, and his O2 saturation reading is 55. His pulse is 110, weak, and thready, and his blood pressure is 70/40.Which interventions should the nurse initiate immediately?A) Place resusitation equipment in the room. B) administer high flow O2 C) establish IV access and initiate IV fluid resuscitationD) Initiate CPR.Mr. Johnson is transferred to the Medical Intensive Care Unit where he is treated for acute respiratory distress syndrome (ARDS). He is successfully treated with mechanical ventilator support, and he is in stable condition when he is transferred back to the Med-Surg Unit a week later.
71Respiratory Case Study The remainder of Mr. Johnson's hospital stay is uneventful and is transferred back to the floorWhich outcome statement is the best indicator that Mr. Johnson's pneumonia is resolved and he is ready to be discharged?A) Sputum culture is negative. B) Unasyn peak and trough levels are within normal limits. C) Oxygen saturation level is 92%. D) Temperature is 98° F.Which additional discharge instruction should the nurse include in the teaching plan to promote optimal health for Mr. Johnson?A) Avoid physical exertion. B) Avoid crowds and people with infections. C) Limit intake of oral fluids. D) Stay indoors except in the early morning.Mr. Johnson, his son, and the nurse discuss the use of anti-smoking hypnosis tapes, along with other measures to promote good health upon his discharge. Mr. Johnson agrees to follow all the discharge instructions and states that he understands the use of his medications, including the correct use of his metered dose inhaler.