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Care of the Chronic Respiratory Client

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1 Care of the Chronic Respiratory Client
Keith Rischer RN, MA, CEN

2 Todays Objectives Compare & 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.


4 Obstructive Airway Disorders
Increase resistance to airflow Bronchi smooth muscle innervated by autonomic nervous system Parasympathetic stimulation Sympathetic stimulation Inflammatory mediator response COPD Chronic-recurrent obstruction Emphysema bronchitis COPD COPD

5 Obstructive Disorders:Asthma
Patho Intermittent & reversible airway obstruction INFLAMMATION-Chronic Antibody molecules (IgE) Mast cells>histamine>WBC Physiological response to inflammation Vessel dilation>capillary leakage>tissue swelling>incr. secretions Airway hyper-responsiveness Childhood Allergens smoking Cold/dry air Bacteria Bronchospasm edema & mucous Impacts over 20 million in US Pathophysiology -Clinical syndrome characterized by increased responsiveness of the tracheobronchial tree/airways NOT ALVEOLI to a variety of stimuli -Chronic inflammationairways become hyperresponsive to specific antigens and other stimuli such as physical exertion or breathing cold air ASTHMA IS REVERSIBLE AIRFLOW OBSTRUCTION WHILE EMPHYSEMA AND COPD ARE IRREVERSIBLE ALLERGENS BIND TO IgE molecules on mast cells chemicals released that cause inflammatory response Blood vessel dilation-cap leak which leads to tissue swelling…increased secretions-mucous production…MOST COMMON CAUSE OF ASTHMA

6 What is a Mast Cell? Bag of Granules Located in connective tissue
close to blood vessels Histamine released Increase blood flow Increase vascular permeability Binds to H1, H2 receptors Most important activator of inflammation Cellular bags of granules that includes histamine Located in loose connective tissue, close to blood vessels such as under the skin, GI track and the Respiratory Track Histamine is stored here until released during an inflammatory response When 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

7 Etiology of asthma Intrinsic etiologies uncertain causes
physical or psychological stress exercise-induced Extrinsic etiologies antigen-antibody (allergic) reaction to specific irritants air pollutants sinusitis cold and dry air Meds-ASA food additives hormonal influences GE reflux Can occur at any age Half of adults who have-had as a child More common in urban than rural settings Responsible for 5000 deaths in US annually

8 Clinical manifestations of Asthma
Severe dyspnea wheezing with expiration or inspiration Which is worse… Tachypnea Cough Feelings of chest tightness Prolonged expiration Diminished breath sounds Increased heart rate and blood pressure Restlessness, anxiety, agitation Severity and duration of symptoms are unpredictable The progressive airway obstruction unresponsive to treatment leads to status asthmaticus, and emergency condition clients with severe airway obstruction may not be able to move enough air to produce wheezing

9 Asthma: Lab & Dx Findings
Decreased pO2 Decreased pCO2 Early Late findings Elevated eosinophil count CXR Pulmonary Function Test Forced vital capacity (FVC) Peak flow meter ABG’s pH 7.28 pO2-55 pCO2-60 HCO3-22 O2 sats-86% RA pH 7.35 pO2-75 pCO2-30 O2 sats-90% RA Pulmonary Function Test Forced vital capacity (FVC)…most important…volume of air exhaled from full inhalation to exhalation

10 Pharmacologic Treatment Options
Relievers = short-acting bronchodilators quickly relieves bronchoconstriction and symptoms Controllers = daily medications taken on a long-term basis useful for controlling persistent asthma includes anti-inflammatory agents and long-acting bronchodilators

11 Beta-2 agonists chart 33-5 p.590-592
Mechanism bronchodilation through bronchial smooth muscle relaxation mediated by beta-2 receptors in the lung Short Acting albuterol (Proventil, Ventolin) Xopenex Pirbuterol (Maxair autoinhaler) Terbutaline (Brethaire) Long acting Salmeterol-Serevent Onset: minutes Duration: 4-6 hours By stimulating B2 receptors in lungs triggers smooth muscle relaxation Provide rapid but ST relief Most useful when attack begins or about to begin activity such as aexercise Long acting

12 Beta-2 agonists Uses: Adverse effects:
Rescue medication to relieve acute symptoms & prevention of bronchospasms prior to a precipitating event (e.g. exercise) Adverse effects: Tachycardia Restlessness Tremors Palpitations paradoxical bronchoconstriction

13 Anticholinergics Mechanism Ipratropium (Atrovent)
block parasympathetic nervous system influence SNS dominates Ipratropium (Atrovent) Onset: minutes, peak: 1-2 hours Duration: 4-8 hours Adverse effects drying of mouth and respiratory secretions increased wheezing in some individuals Mechanism block parasympathetic nervous system influence SNS dominates THEREFORE WHAT ARE EXPECTED EFFECTS…increased bronchodilation and decr pulm secretions

14 Inhaled Corticosteroids
Mechanism Decrease inflammation block late reaction to allergens and reduce airway hyperresponsiveness inhibit microvascular leakage Common Meds…used qd budesonide (Pulmocort) fluticasone (Flovent) triamcinolone (Azmacort)

15 Inhaled Corticosteroids (cont.)
Uses: long-term prevention of symptoms (suppression, control, and reversal of inflammation) reduce/eliminate oral steroid use Adverse effects: oral candidiasis ??systemic effects at high doses **use spacer to prevent oral candidiasis, rinse mouth after use

16 Oral Corticosteroids Common agents Uses LT Side Effects Prednisone
methylprednisolone (Medrol, Solu-Medrol) Uses short term (3-10 days) “burst therapy” to gain prompt control of asthma to prevent progression of exacerbation, speed recovery, and reduce relapse long-term prevention of symptoms in severe persistent asthma LT Side Effects HTN Peptic ulcers Skin fragility Impaired immunity Thromboembolism Cushingoid appearance

17 Asthma:Combination Inhalers
Advair Diskus Fluticasone Salmeterol (serevent) Frequency 1 inhalation q12 hours Combivent MDI Ipratropium (atrovent) Albuterol 2 puffs 4 times daily Leukotriene Antagonists (anti-inflammatory) Montelukast (Singulair) Antagonizes or prevents the effects of leukotrienes which cause the following: Airway edema Smooth muscle constriction RESULT IS DECREASED INFLAMMATORY EFFECT…

18 Asthma: Other Medications
Leukotriene Antagonists anti-inflammatory Montelukast (Singulair) Therapeutic response Decreased frequency & severity of attacks Decreased exercise induced bronchoconstriction Mast cell stabilizers Mechanism Cromolyn sodium (Intal) Frequency 1-2 inhalations 4 times daily A 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 obstruction increased secretion of mucus mucosal accumulation bronchoconstriction infiltration of inflammatory cells in the airway wall

19 Asthma:Regimen by Severity
Mild Short-acting beta-agonist inhaler Anti-inflammatory inhaler used for mild symptoms occurring daily Moderate Anti-inflammatory inhaler plus medium-dose corticosteroid inhaler used for moderate symptoms occurring daily or more often Severe Anti-inflammatory inhaler plus long-acting bronchodilator plus oral corticosteroid used for severe symptoms occurring daily or more often Mild Short-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 medications Anti-inflammatory inhaler; used for mild symptoms occurring daily Moderate Anti-inflammatory inhaler plus medium-dose corticosteroid inhaler; used for moderate symptoms occurring daily or more often Severe Anti-inflammatory inhaler plus long-acting bronchodilator plus oral corticosteroid; used for severe symptoms occurring daily or more often

20 Priority Nursing Diagnoses for Asthma
Impaired gas exchange r/t… Ineffective breathing pattern r/t… Ineffective airway clearance r/t… Anxiety r/t… Deficient knowledge Impaired gas exchange r/t…bronchospasm…secretions Ineffective breathing pattern r/t… Ineffective airway clearance r/t… Anxiety r/t… Deficient knowledge

21 Asthma:Critical Care Management
Status asthmaticus/severe asthma Physical assessment Dyspnea/tachypnea Wheezing I/E Diminished aeration to no air movement Accessory muscles Medical management …remember A,B,C,s O2 Albuterol neb Epinephrine subq Establish IV IV steroids (solumedrol) Prepare for possible intubation Status asthmaticus/severe asthma Life threatening emergency that intensifies and does not respond to therapy Presents with extremely labored breathing wheezing

22 Planning and implementation for Asthma
Assess respiratory and oxygenation status Administer supplemental oxygen as needed Administer broncholdilators as prescribed Observe characteristics of sputum Identify/avoid/remove precipitating factors Teach patient relaxation techniques Prepare for IV access Be prepared for intubation Diagnostic studies Emotional support for patient and family

23 Expected outcomes/evaluation
Absence of dyspnea, chest tightness, wheezing Respiratory rate breaths per minute Pulse oximetry/arterial blood gas values within normal range for client Bilaterally clear and equal breath sounds Afebrile Adequate airway clearance Absence/resolution of anxiety Clear chest x-ray or return to patient’s baseline Normal or improved peak flow

24 Asthma: Patient Education
Identify asthma triggers Teach patient/family proper used of metered-dose inhaler Chart 33-6 p.593 Rescue inhalers! Instruct client regarding the use of peak flow meter for self-assessment of asthma status Asthma symptoms requiring emergency intervention

25 Emphysema

26 Emphysema: Patho Loss of lung elasticity Hyperinflation of lung
Alveolar destruction Excessive enlargement Loss of “curves” impairs gas exchange Compensation… Hyperinflation of lung Secondary to air trapping “barrel chest” appearance “Pink puffer O2 diffused easier than CO2 CO2 accumulates causing chronic resp. acidosis Impacts 11 million in US…4th leading cause of death responsible for 100,000 annually There 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 collapse The trapping of air results in a hyperinflated lung, causing the “barrel chest” appearance Enzymes from smoking damage alveoli and small airways by breaking down elastin Alveoli lose elasticity and collapse The 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

27 Emphysema: Causes & Complications
Cigarette smoking Pack years required Smoke>enzyme elastase protease>destroys alveoli Destroys cilia Chronic respiratory inflammation air pollution Complications Hypoxemia & acidosis Resp. infections/pneumonia Cur pulmonale Cardiac dysrhythmias Cigarette smoking Pack years required…8 years for physiologic changes but no sx 20 pack years early stage sx Cur pulmonale ASSESS FOR PITTING EDEMA-JVD-RIGHT SIDED HF

28 Emphysema: PhysicalAssessment…A,B,C’s
General appearance Emaciated Barrel chest Airway/breathing Dyspnea Tachypnea Accessory muscle use Pursed lip breathing Lung sounds overall diminished, and wheezes or crackles may be present Dry cough more so than productive O2 sats… Circulation tachycardia (inadequate oxygenation) Arrythmias

29 Emphysema: Diagnostic Tests
ABGs Chronic resp. acidosis Compensation w/HCO3 Assess pO2, pCO2 and HCO3 CBC WBC Hgb Hct polycythemia Chest x-ray hyperinflated lungs with a flattened diaphragm ABG’s pH 7.35 pO2-55 pCO2-60 HCO3-22 O2 sats-86% RA HCO3-35

30 ED COPD Case Study 84yr female
PMH: COPD, asthma, HTN, anxiety, mitral stenosis HPI: 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 CP VS: T P-122 (ST) R-36 BP-202/105 sats 88% RA Assessment: Neuro-a/o notably anxious Resp-diminished bilat w/exp. Wheezing CV-2/6 murmur

31 ED COPD Case Study Medical Priorities… Nursing priorities
Nursing assessments… Nursing interventions… Medical Priorities… Stat albuterol neb PIV Combivent neb Solumedrol 125mg IV Tylenol po

32 ED COPD Case Study CXR Labs Large left lower lobe infiltrate BMP CBC
Na 138, K+ 3.9, creat. 1.16, gluc 112 CBC WBC 7.0, Hgb 13.3, Hct 39.9, plat. 217 UA neg Plan-admission to medical floor/tele

33 Chronic Bronchitis A disorder of chronic airway inflammation
Major & small bronchioles Chronic productive cough lasting at least 3 months during 2 years Chronic exposure to irritants smoking An inflammatory response in the small & large airways resulting in… Vasodilation Congestion mucosal edema broncospasm

34 Chronic Bronchitis: Patho
Etiology Smoking Chronic inflammation Increase in # and size of mucous glands More mucous bronchial walls thicken/edema airflow is impeded Smaller airways are blocked Airflow and gas exchange impacted pO2… pCO2… Cilia disappear, and the airway clearance function is lost Unlike emphysema, cannot increase breathing efforts to maintain blood gases “blue bloater” Polycythemia The 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 mucosa As the bronchial walls thicken, airflow is impeded Unlike emphysema, the individual with bronchitis cannot increase breathing efforts to maintain blood gases Presence 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

35 Chronic Bronchitis: Clinical Manifestations
Productive cough Primarily occurring during winter season foul-smelling sputum Dyspnea and activity intolerance Frequent pulmonary infections “Blue bloater” bluish-red skin discoloration from cyanosis and polycythemia Barrel chest

36 Emphysema/Bronchitis:Medical Management
Goals improve ventilation promote patent airway by removal of secretions Remove environmental pollutants O2 and neb therapy Chest physiotherapy Mechanical ventilation Surgical procedure bullectomy lung volume reduction lung transplantation

37 Emphysema/Bronchitis: Medications
Beta-adrenergic agonists bronchodilators in COPD by nebs or MDI Anticholinergics Atrovent administered as maintenance by inhaler most effective bronchodilators for COPD Theophylline may be beneficial to strengthen diaphragm contractility and decrease work of breathing Corticosteroids may be beneficial for pts. w/asthma history Immunizations flu and pneumonia Abx Bronchodilators controversial use in COPD, but maintenance therapy may be used to reduce dyspnea Beta-adrenergic agonists used as bronchodilators in COPD and administered by nebs or MDI Anticholinergics Atrovent administered as maintenance by inhaler; considered one of the most effective bronchodilators for COPD Theophylline controversial use in COPD but may be beneficial to strengthen diaphragm contractility and decrease work of breathing Corticosteroids controversial, but may be beneficial for pts. With asthma history

38 Emphysema/Bronchitis: Priority Nursing Dx p.600-606
Impaired gas exchange r/t… Ineffective breathing pattern r/t… Ineffective airway clearance r/t… Imbalanced nutrition r/t… Anxiety r/t… Activity intolerance r/t… Fatigue r/t… Deficient knowledge Impaired gas exchange r/t… Ineffective breathing pattern r/t… Ineffective airway clearance r/t… Anxiety r/t… Deficient knowledge

39 Emphysema/Bronchitis: Nursing Care Priorities remember A,B,C’s…
Administer low-flow O2 as needed Position patients to maintain effective breathing Closely monitor & assess resp. status Auscultation O2 sats Response to acute interventions/O2 Provide education and referrals for pts. w/risk behaviors Referral to smoking cessation Pulmonary conditioning program Develop appropriate nutritional plans Energy conservation Exercise conditioning Assess understanding to education

40 Emphysema/Bronchitis: Patient Education
Smoking cessation Teach clients how to avoid occupational or environmental pollutants Pursed lip breathing Maintain adequate nutrition with emphasis on higher calorie intake Nutrition may be optimal with frequent small meals, and cc of fluid daily Teach energy conservation techniques Pursed lip breathing-REDUCES AMOUNT OF STALE AIR IN LUNGS

41 Emphysema/Bronchitis: Expected Outcomes
Activity tolerance is optimized Pulmonary irritants such as smoking, air pollution, or occupational exposure are avoided Pulmonary infections are reduced in number and severity Nutritional intake is adequate but not excessive for individual energy needs

42 Pulmonary Tuberculosis
Patho Mycobacterium tuberculosis (bacillus) Most common bacterial infection globally Aerosolized Susceptible host Nonspecific pneumonitis alveoli or bronchus 5-15% ultimately develop Cell mediated immunity 2-10 weeks later w/+ mantoux

43 Pulmonary Tuberculosis: Infection
Inflammation in lungs surrounded by lymphocytes, collagen Caseation necrosis Necrotic tissue turned into granular mass that become calcified Seen in low to middle lobes Can spread systemically to brain, liver , kidneys, bone marrow

44 Incidence HIV Immigrant populations Crowded areas Elderly Homeless
LTC, prison, Elderly Homeless Poverty

45 Physical Assessment/Diagnosis
Fatigue, lethargy, nausea, weight loss Fever…night sweats Persistent cough…productive streaked w/blood Decreased aeration, crackles Diagnosis Positive smear acid-fast bacillus + sputum culture…takes 1-3 weeks to confirm Mantoux 5-10mm induration

46 Treatment chart 34-7 p.643 Combination Pt. education Isoniazid (INH)
Rifampin Pt. education Compliance! 6 months treatment required Sputum specimens q2-4 weeks during therapy No longer contagious after 2-3 weeks of treatment Once negative x3 cured

47 Nursing Priorities Airborne precautions Ventilated room
N-95 mask or PAPR for any staff entering room TB drugs can cause nausea-anticipate Nutrition

48 Lung Cancer: Patho Bronchial epithelium Histologic cell type
90% primary Obstruction Histologic cell type Small cell vs. non small cell Small cell 20% of all lung CA 99% correlation w/smoking Adenocarcinoma 35% of all lung CA Spread between smokers and non smokers Metastasis Circulatory & lymphatic Leading cause of cancer deaths 186,000 new cases annually w/165,000 deaths in US 5 year survival only 14% Due to fact that most cases dx at late stage when mets has already taken place SMOKING-WOMEN ARE NOW SEEING INCR INCIDENCE DUE TO MORE SMOKING

49 Lung Cancer: Clinical Manifestations
Non-specific & occur late Depend on type & location of tumor Bronchitis/pneumonitis secondary to obstruction Chills Fever Cough Bloody sputum Dyspnea Use of accessory muscles Wheezing-diminished aeration

50 Lung Cancer: Diagnostic
CXR CT Bronchoscopy Bronchial washing Needle/surgical biopsy Made by direct exam of cancer cells

51 Lung Cancer:Medical Management
Non-surgical Chemotherapy N&V Mucositis Alopecia Immunosuppression Pan cytopenia Radiation Best results when used w/surgery or chemo Daily for 5-6 weeks Esophagitis…esophagus proximal to lungs Side effects Skin irritation & peeling Fatigue Nausea Taste changes Chemotherapy Treatment of choice for lung CA Chemotherapy, in its most general sense, refers to treatment of disease by chemicals that kill cells, specifically those of micro-organisms or cancer most chemotherapeutic drugs work by impairing mitosis (cell division), effectively targeting fast-dividing cells Radiation therapy (or radiotherapy) is the medical use of ionizing radiation as part of cancer treatment to control malignant cells Radiation therapy is commonly applied to the cancerous tumour. SMALL DOSES OVER LONGER TIME FOUND TO BE BENEFICIAL

52 Lung Cancer:Medical Management
Surgical Thoracotomy Tumor removal Lobectomy Removal lobe of lung Pneumonectomy Entire lung

53 Lung Cancer: Thoracotomy-Postop p.618-622
Chest tube Drain placed in pleural space to restore intrapleural pressure Chest tube banded & connected to Pleurovac collection chamber w/several feet tubing Drainage system First chamber Drainage from client Second chamber Water seal Third chamber suction Chest tube Drain placed in pleural space to restore intrapleural pressure Allows for re-expansion of lung Prevents air and fluid from returning to the chest

54 Chest Tube: Nursing Priorities
Assess resp. status closely Check water seal for bubbling Milk NOT strip every 2 hours Assess color-amount drainage Call MD if >100cc/hr x2 hours first 24 hours Sterile guaze/occlusive dressing at bedside Check water seal for bubbling…IF YOU CLAMP THE TUBING CLOSE TO THE PT-IT STOPS…WHAT DOES THIS TELL YOU?

55 Mechanical Ventilation
The use of an ET and POSITIVE pressure to deliver O2 at preset tidal volume Modes Assist Control (AC) TV & rate preset Additional resp. receive preset TV Synchronized Intermittent Mandatory Ventilation (SIMV) Additional resp. receive own TV Used for weaning Continuous Positive Airway Pressure (CPAP) Bi-pap Non-mechanical receive both insp. & exp. Pressures w/facemask Modes Assist Control (AC) Synchronized Intermittent Mandatory Ventilation (SIMV) Bi-pap Continuous Positive Airway Pressure (CPAP)

56 Mechanical Ventilation
Terminology Rate Tidal volume 10-15cc/kg Fraction of inspired O2 concentration (FiO2) Use lowest possible to maintain O2 sats Positive End Expiratory Pressure (PEEP) Minute volume RR x TV AC12-TV %-+5

57 Mechanical Ventilation: Adverse Effects
Complications Aspiration Infection-VAP Stress ulcer of GI tract Tracheal damage Ventilator dependancy Decreased cardiac output Positive pressure decr. venous return & CO Barotrauma pneumothorax Positive pressure decr. venous return & CO Increases intrathoracic pressure

58 Mechanical Ventilation:Nursing Priorities
Monitor VS-breath sounds closely Assess ET securement/length at lip Clearance of secretions Closed suction-maintains sterility Do not do routinely Pre-oxygenate Sedation Propofol Oral care Nutritional support

59 Mechanical Ventilation:Nursing Priorities
Ventilator Alarm Troubleshooting High pressure Secretions-needs sx Tubing obstructed or kinked Biting ET Low pressure Disconnection of tubing Follow tubing from ET to ventilator

60 Oxygen Delivery Atmospheric room air %.......??? Nasal cannula
Add 3% for each liter of flow to FiO2 1-6 liters Oxymizer Reservoir to increase FiO2 per liter delivery 6-12 liters Face mask 40-50% FiO2 8-15 liters Face mask w/non-rebreather 90-100% FiO2 15 liters

61 Respiratory 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° F He 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.

62 Respiratory Case Study
Physical exam reveals the following: Vital signs: T 101° F, P 115, R 30, BP 120/80 O2 sats 90% on room air Respirations 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.

63 Respiratory 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.

64 Respiratory 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.

65 Respiratory 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.

66 Respiratory 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.

67 Respiratory 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).

68 Respiratory 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."

69 Respiratory 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.

70 Respiratory 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 resuscitation D) 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.

71 Respiratory Case Study
The remainder of Mr. Johnson's hospital stay is uneventful and is transferred back to the floor Which 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.

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