1. Care of Patients with Noninfectious Lower Respiratory Problems
Chapter 32
Care of Patients with Noninfectious Lower Respiratory Problems
Mrs. Marion Kreisel MSN, RN
NU230 Adult Health 2
Fall 2011

2. Chronic Airflow Limitation
Chronic airflow limitation includes the chronic lung diseases:
Asthma
Chronic bronchitis
Pulmonary emphysema

3. Chronic Airflow Limitation

4. Chronic Obstructive Pulmonary Disease (COPD)
COPD includes:
Emphysema
Chronic Bronchitis
Characterized by bronchospasm and dyspnea
Tissue damage is not reversible and increases in severity, eventually leading to respiratory failure

5. Asthma Intermittent disease
Reversible airflow obstruction and wheezing

7. Asthma: Pathophysiology
Bronchial asthma is an intermittent and reversible airflow obstruction affecting only the airways, not the alveoli
Airway obstruction occurs by:
Inflammation
Airway hyperresponsiveness

8. Asthma: Etiology
Classified into different types based on triggering events
Inflammation occurs in response to specific allergens, general irritants, microorganisms, and aspirin
Hyperresponsiveness occurs with exercise, URI, or unknown reasons

9. Asthma: Special Considerations
Older Adults:
Teach how to prevent asthma attacks
Women:
35% higher incidence in women than men
Teach correct use of preventive and rescue drugs

10. Collaborative Management
Assessment:
History
Physical assessment and clinical manifestations:
Audible wheeze and increased respiratory rate
Increased cough
Use of accessory muscles
”Barrel chest” from air trapping
Long breathing cycle
Cyanosis
Hypoxemia

11. Laboratory Assessment
Assess arterial blood gas level
Arterial oxygen level may decrease in acute asthma attack
Arterial carbon dioxide level may decrease early in the attack and increase later, indicating poor gas exchange

12. Pulmonary Function Tests
The most accurate measures for asthma are pulmonary function tests using spirometry including:
Forced vital capacity (FVC)
Forced expiratory volume in the first second (FEV1)
Peak expiratory flow rate (PEFR)
Residual Volume (RV) is increased

13. Interventions
Patient education: asthma is often an intermittent disease; with guided self-care, patients can co-manage this disease, increasing symptom-free periods and decreasing the number and severity of attacks
Peak flow meter should be used twice daily by the patient if in red zone administer rescue drugs STAT!
Personal drug therapy plan

14. Asthma: Drug Therapy
Pharmacologic management is based on the step category for severity and treatment
Preventive therapy drugs:
Used to change the airway responsiveness to prevent asthma attacks
Used every day, regardless of symptoms
Rescue drugs are used to actually stop an attack once it has started

15. Asthma: Drug Therapy Bronchodilators:
Short-acting beta2 agonists: rapid bronchodilation but short term relief (Proventil, Albuteral, Ventolin, Xopenex)
Long-acting beta2 agonists: slow bronchodilation with long term relief (Serevent & Foradil)
Beta 2 agonists bind to the beta 2 adrenergic receptors & cause an increase in the intracellular level of Cyclic Adenosine Monophosphate (cAMP) This substance triggers smooth muscle relaxation

16. Asthma: Drug Therapy Cont:
Cholinergic antagonists: Purpose to both rescue & prevent asthma attacks (Atrovent & Spiriva)
Cholinergic antagonists also known as Anticholinergic drugs block the parasympathetic nervous system resulting in increased bronchodilation and decreased pulmonary secreations.
Methylxanthines: Used when other types of management are ineffective.
Need to monitor drug levels
High side effects
Example of Drugs: Theodur (theophylline), (oxtriphylline), Choledyl

17. Asthma: Drug Therapy (Cont’d)
Anti-Inflammatory agents: decrease the inflammatory response in the airways. Can be given systemically or inhaled.
Corticosteroids: decrease inflammatory & immune response (Flovent:Fluticasone, Pulmicort:Budesonide, Asmanex: mometasone)
NSAIDs: inhaled or taken orally used to prevent asthma attacks taken on a regular basis. They are have different mechanisms of action (Nedocromil:Tilade, Cromolyn Sodium:Intal NOT USED AS A RESCUE DRUG
Leukotriene antagonists: Oral drugs work to prevent attacks: Singulair: Montelukast, Accolate:Zafirlukast
Immunodulators

18. Other Treatments for Asthma
Exercise and activity is recommended to promote ventilation and perfusion
Oxygen therapy is delivered via mask, nasal cannula, or endotracheal tube in acute asthma attack:
Heliox can improve oxygen therapy

19. Status Asthmaticus
Status asthmaticus is a severe, life-threatening, acute episode of airway obstruction that intensifies once it begins and often does not respond to common therapy
If the condition is not reversed, the patient may develop pneumothorax and cardiac or respiratory arrest
Treatment: IV fluids, potent systemic bronchodilator, steroids, epinephrine, and oxygen

20. Emphysema
Two major changes: loss of lung elasticity and hyperinflation of the lung
Dyspnea and the need for an increased respiratory rate
Air trapping caused by loss of elastic recoil in the alveolar walls, overstretching and enlargement of the alveoli into bullae, and collapse of small airways (bronchioles)

21. Chronic Bronchitis
Inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially tobacco smoke
Inflammation, vasodilation, congestion, mucosal edema, and bronchospasm
Affects only the airways, not the alveoli
Production of large amounts of thick mucus

22. COPD: Etiology and Genetic Risk
Cigarette smoking
Air pollution

23. COPD: Complications Hypoxemia Acidosis Respiratory infections
Cardiac failure, especially cor pulmonale
Cardiac dysrhythmias

24. COPD: Physical Assessment and Clinical Manifestations
History
General appearance
Respiratory changes
Cardiac changes

25. Dyspnea Assessment Tool

26. Laboratory Assessment
ABG values for abnormal oxygenation, ventilation, and acid-base status
Sputum samples
CBC
Hemoglobin and hematocrit blood tests
Serum electrolyte levels
Chest x-ray
Pulmonary function test

27. Impaired Gas Exchange
Nonsurgical interventions for chronic obstructive pulmonary disease:
Airway management
Monitoring patient at least every 2 hours
Cough enhancement
Oxygen therapy
Drug therapy
Pulmonary rehabilitation

28. Drug Therapy Beta-adrenergic agents Cholinergic antagonists
Methylxanthines
Corticosteroids
NSAIDs
Mucolytics

29. Surgical Management Lung transplantation for end-stage patients
Preoperative care and testing
Operative procedure through a large midline incision or a transverse anterior thoracotomy
Postoperative care and close monitoring for complications

30. Ineffective Breathing Pattern
Assessment of patient for breathing pattern and respiratory infection
Interventions for the chronic obstructive pulmonary disease patient:
Specific breathing techniques
Positioning to help alleviate dyspnea
Energy conservation

31. Ineffective Airway Clearance
Assessment of breath sounds
Interventions for compromised breathing:
Careful use of drugs
Controlled coughing
Chest physiotherapy with postural drainage
Suctioning
Positioning

32. Ineffective Airway Clearance (Cont’d)
Hydration via beverage and humidifier
Flutter-valve mucus clearance devices
Tracheostomy

33. Imbalanced Nutrition
Interventions to achieve and maintain body weight:
Prevent protein-calorie malnutrition through dietary consultation
Monitor weight, skin condition, and serum prealbumin levels
Dyspnea management
Food selection to prevent weight loss

34. Anxiety Interventions for increased anxiety:
Important to have patient understand that anxiety will worsen symptoms
Plan ways to deal with anxiety

35. Activity Intolerance Interventions to increase activity level:
Encourage patient to pace activities and promote self-care
Do not rush through morning activities
Gradually increase activity
Use supplemental oxygen therapy

36. Potential for Pneumonia or Other Respiratory Infections
Risk is greater for older patients
Interventions include:
Avoidance of large crowds
Pneumonia vaccination
Yearly influenza vaccine

37. COPD: Community-Based Care
Home care management:
Long-term use of oxygen
Pulmonary rehabilitation program
Health teaching:
Drug therapy
Manifestations of infection
Breathing techniques
Relaxation therapy

38. Cystic Fibrosis
Genetic disease affecting many organs, lethally impairing pulmonary function
Present from birth, first seen in early childhood, although almost half of all people with cystic fibrosis in the United States are adults
Error of chloride transport, producing thick mucus with low water content
Mucus plugs up glands, causing atrophy and organ dysfunction

39. Cystic Fibrosis

40. Cystic Fibrosis: Nonpulmonary Manifestations
Adults: usually smaller and thinner than average owing to malnutrition
Abdominal distention
Gastroesophageal reflux, rectal prolapse, foul-smelling stools, steatorrhea
Vitamin deficiencies
Diabetes mellitus

41. Cystic Fibrosis: Pulmonary Manifestations
Respiratory infections
Chest congestion
Limited exercise tolerance
Cough and sputum production
Use of accessory muscles
Decreased pulmonary function
Changes in chest x-ray result
Increased anteroposterior diameter

42. Cystic Fibrosis: Nonsurgical Interventions
Nutritional management:
Weight maintenance
Vitamin supplementation
Diabetes management
Pancreatic enzyme replacement
Prevention/maintenance therapy:
Chest physiotherapy
Positive expiratory pressure
Active cycle breathing technique
Exercise

43. Cystic Fibrosis: Nonsurgical Interventions (cont’d)
Exacerbation therapy:
Avoid mechanical ventilation
Supplemental oxygen
Heliox
Airway clearance techniques
Drug therapy
Patient education on prevention of exacerbation

44. Cystic Fibrosis: Surgical Management
Lung and/or pancreatic transplantation:
Does not cure the disease, because the genetic defect in chloride transport in other tissues and the upper airways remains
Extends life by 10 to 20 years
Patient is at continued risk for lethal pulmonary infections

45. Primary Pulmonary Hypertension (PPH)
PPH occurs in the absence of other lung disorders, and its cause is unknown
Pathologic problem is blood vessel constriction with increasing vascular resistance in the lung
The heart fails (cor pulmonale)
Without treatment, death occurs within 2 years

46. Pharmacologic Interventions
Warfarin therapy
Calcium channel blockers
Endothelin-receptor antagonists
Natural and synthetic prostacyclin agents
Digoxin and diuretics
Oxygen therapy

47. Interstitial Pulmonary Disease
Affects the alveoli, blood vessels, and surrounding support tissue of the lungs rather than the airways
Restrictive disease: thickened lung tissue, reduced gas exchange, “stiff” lungs that do not expand well
Slow onset of disease
Dyspnea is most common manifestation

48. Sarcoidosis
Granulomatous disorder of unknown cause that affects the lungs most often
Autoimmune responses in which the normally protective T-lymphocytes increase and damage lung tissue
Corticosteroids are the main type of therapy

49. Idiopathic Pulmonary Fibrosis
Common restrictive lung disease
Example of excessive wound healing
Inflammation that continues beyond normal healing time, causing extensive fibrosis and scarring
Mainstays of therapy: corticosteroids and other immunosuppressants
Sentences and phrases

50. Occupational Pulmonary Disease
Can be caused by exposure to occupational or environmental fumes, dust, vapors, gases, bacterial or fungal antigens, or allergens
Worsened by cigarette smoke
Prevention through special respirators and adequate ventilation

51. Lung Cancer A leading cause of cancer deaths worldwide
Poor long-term survival because of late-stage diagnosis
Bronchogenic carcinomas
Paraneoplastic syndromes
Staged to assess size and extent of disease
Etiology and genetic risk

52. Lung Cancer (Cont’d) Health promotion and maintenance Assessment:
History
Pulmonary manifestations
Nonpulmonary manifestations
Psychosocial assessment
Diagnostic assessment

53. Lung Cancer: Nonsurgical Management
Chemotherapy
Targeted therapy
Radiation therapy
Photodynamic therapy

54. Lung Cancer: Surgical Management
Lobectomy
Pneumonectomy
Segmentectomy
Wedge resection

55. Common Incision Locations for Partial or Total Pneumonectomy

56. Chest Tube Placement

57. Chest Tube Chambers
Chamber 1: collects the fluid draining from the patient
Chamber 2: water seal that prevents air from entering the patient’s pleural space
Chamber 3: suction control of the system

58. Nursing Care After Thoracotomy
Pain management
Respiratory management
Pneumonectomy care
Chest Tube Care: Make sure water is bubbling gently. If not quickly and carefully reposition patient to see if blockage is the reason. If this does not fix the problem this is an emergency and lead to excessive pressure in the chest.
Have at the bedside always sterile occlusive gauze and padded clamps incase tube becomes dislodged.
Be very careful when milking tube, it can cause more damage than good.

59. Interventions for Palliation
Oxygen therapy
Drug therapy
Radiation therapy
Thoracentesis and pleurodesis
Dyspnea management
Pain management
Hospice care

60. NCLEX TIME

61. Question 1
Which ethnic group is typically known to have the highest prevalence of smoking?
African Americans
Asians
Caucasians
American Indians
Answer: D
Rationale: Smoking prevalence is highest among Northern Plains American Indians and Alaskan Natives.

62. Question 2
Approximately what percentage of the adult population in the United States smoke cigarettes? 5%
10%
20%
30%
Answer: C
Rationale: According to the CDC, an estimated 45.3 million people, or 20.8% of all adults, smoke cigarettes in the United States.
Source: CDC: Adult cigarette smoking in the United States: Current estimates (updated November 2007). Retrieved March 6, 2008, from

63. Question 3
Which correctly reflects the prevalence of asthma when comparing the adult and child populations in the United States? The percentage of children who have asthma is ________ than adults.
Higher than
Lower than
The same as
Answer: A
Rationale: According to CDC statistics, 9.4% of children currently have asthma, whereas 7.3% of non-institutionalized adults have asthma.
Source: Pleis, J.R., & Lethbridge-Çejku, M. (2006). Summary health statistics for U.S. adults: National Health Interview Survey, National Center for Health Statistics. Vital and Health Statistics, Dec(232), Retrieved March 6, 2007, from

64. Question 4
Which risk factor is responsible for the majority of deaths from lung cancer?
Cigarette smoking
Occupational radiation exposure
Chronic exposure to asbestos
Air pollution
Answer: A
Rationale: According to the American Cancer Society, cigarette smoking is the major risk factor and is responsible for 85% of all lung cancer deaths.

65. Question 5
A patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in
the red zone. The nurse should immediately:
Repeat the PEF reading to verify the results.
Take the patient’s vital signs.
Administer the rescue drugs.
Notify the patient’s prescriber.
Answer: C
Rationale: A peak expiratory flow (PEF) reading in the red zone indicates a range that is 50% below the patient’s personal best PEF reading and indicates serious respiratory obstruction. The patient needs to receive the rescue drugs immediately, and then the prescriber needs to be notified. Repeating the PEF reading and taking vital signs are also important, but doing so first delays the administration of the rescue drugs.