Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 32 Care of Patients with Noninfectious Lower Respiratory Problems Block 2 Concepts 1. Asthma 2. COPD 3. Lung Cancer 4. Pleural Effusion

2 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Prevalence of Asthma  Estimated 20 million (8.4%) Americans affected  Estimated 300 million people affected worldwide  More common in adult women than men  Slightly more prevalent among African- Americans than Caucasians  Number of people with asthma continues to grow

3 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Asthma  Condition that occurs intermittently  Occurs in two ways:  Inflammation  Airway hyperresponsiveness leading to bronchoconstriction

4 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Pathophysiology of Asthma  Intermittent and reversible airflow obstruction affecting airways only, not alveoli  Airway obstruction:  Inflammation  Airway hyper-responsiveness

5 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Pathophysiology of Asthma (cont’d)

6 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Etiology  Different types based on how attacks are triggered  Caused by specific allergens, general irritants, microorganisms, aspirin  Hyper-responsiveness caused by exercise, URI, unknown reasons

7 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Etiology & Pathophysiology Continued  Bronchospasm  Aspirin & NSAID triggers  GERD

8 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Collaborative Management  Assessment  History  Physical assessment/clinical manifestations Audible wheeze, increased respiratory rate Increased cough Use of accessory muscles “Barrel chest” from air trapping Long breathing cycle Cyanosis Hypoxemia

9 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Laboratory Assessment  ABGs  Arterial O 2 may decrease in acute asthma attack  Arterial CO 2 may decrease early in attack and increase later (indicating poor gas exchange)

10 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Laboratory Assessment (cont’d)  Allergic asthma with elevated serum eosinophil count, immunoglobulin E levels  Sputum with eosinophils, mucous plugs, with shed epithelial cells

11 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Pulmonary Function Tests  Most accurate with use of spirometry  Forced vital capacity (FVC)  Forced expiratory volume in first second (FEV 1 )  Peak expiratory flow rate (PEFR)

12 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Interventions  Teaching for self-management  Use of peak flowmeter twice daily  Personal drug therapy plan

13 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Peak Flow Meters  Green Zone  Yellow Zone  Red Zone  Teaching Technique

14 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Peak Flow Technique Set the peak flowmeter at zero Use a standing position, without leaning or supporting yourself Take as deep a breath as you can. Place the mouthpiece of the meter in your mouth-wrap lips tightly Blow your breath out through the mouthpiece as hard and as fast as you are able. (If you cough, sneeze, or have any type of interruption while you exhale, reset the meter and perform the test again.) Reset and perform the test two additional times. Use the highest reading of the three to determine your current peak flow rate. Keep a record or graph of your peak flow rates and examine these for trends.

15 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Drug Therapy  Bronchodilators  Short- and long-acting beta 2 agonists  Cholinergic antagonists  Methylxanthines  Anti-inflammatory agents  Corticosteroids  NSAIDs  Leukotriene antagonists  Immunomodulators

16 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Drug Therapy  Based on step category for severity and treatment  Preventive therapy (controller drugs)  Change airway responsiveness to prevent asthma attacks  Used every day, regardless of symptoms  Rescue drugs  Actually stop attack once it has started

17 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Other Treatments for Asthma  Exercise and activity to promote ventilation and perfusion  Oxygen therapy via mask, nasal cannula, ET tube (acute asthma attack)

18 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Status Asthmaticus  Severe, life-threatening, acute episode of airway obstruction  Intensifies once it begins, often does not respond to common therapy  Patient can develop pneumothorax and cardiac/respiratory arrest  Treatment—IV fluids, potent systemic bronchodilator, steroids, epinephrine, oxygen

19 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Critical Thinking 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: A. Repeat the PEF reading to verify the results. B. Take the patient’s vital signs. C. Administer the rescue drugs. D. Notify the patient’s prescriber.

20 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Decision-Making Challenge Patient-Centered Care Evidence-Based Practice: Safety  The patient is a 22-year-old college student who has had asthma since childhood. She is being managed with fluticasone (Flovent) 50 mcg/puff, 2 puffs twice daily; salmeterol (Serevent) 1 puff twice daily; albuterol (Ventolin) 1-2 puffs every 4-6 hours as needed for wheezing. She reports that she is using the fluticasone and salmeterol as prescribed but needs to use the albuterol about every 2 hours. She also tells you that she is having difficulty sleeping and feels “like my heart is skipping some beats.” Her vital signs are BP, 136/88; P, 96 and irregular; R, 30, with slight wheezing on exhalation. Her oxygen saturation is 92%, and you notice that she has a slight tremor in both hands.

21 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. COPD

22 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chronic Obstructive Pulmonary Disease (COPD)  Includes:  Emphysema  Chronic bronchitis  Characterized by bronchospasm and dyspnea  Tissue damage not reversible; increases in severity, eventually leads to respiratory failure

23 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Emphysema  Loss of lung elasticity and hyperinflation of lung  Dyspnea; need for increased respiratory rate  Air trapping caused by loss of elastic recoil in alveolar walls, overstretching and enlargement of alveoli into bullae, collapse of small airways (bronchioles)

24 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Interaction of Chronic Bronchitis and Emphysema in COPD

25 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chronic Bronchitis  Inflammation of bronchi and bronchioles caused by chronic exposure to irritants, especially cigarette smoke  Inflammation, vasodilation, congestion, mucosal edema, bronchospasm  Affects only airways, not alveoli  Production of large amounts of thick mucus

26 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Complications  Hypoxemia/tissue anoxia  Acidosis  Respiratory infections  Cardiac failure, especially cor pulmonale  Cardiac dysrhythmias

27 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Right-Sided HF Caused by Chronic Bronchitis or COPD  Cor Pulmonale or Right –Sided HF  Hypoxia and hypoxemia  Increasing dyspnea  Fatigue  Enlarged and tender liver  Warm, cyanotic hands and feet, with bounding pulses  Cyanotic lips  Distended neck veins  Right ventricular enlargement (hypertrophy)  Visible pulsations below the sternum  GI disturbances, such as nausea or anorexia  Dependent edema  Metabolic and respiratory acidosis  Pulmonary hypertension

28 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Physical Assessment & Clinical Manifestations  History  General appearance  Respiratory changes  Cardiac changes

29 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Dyspnea Assessment Tool

30 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Laboratory Assessment  ABG values for abnormal oxygenation, ventilation, acid-base status  Sputum samples  CBC  Hemoglobin and hematocrit  Serum electrolytes  Serum AAT  Chest x-ray  Pulmonary function test

31 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Interventions  Improve oxygenation and reduce carbon dioxide retention  Prevent weight loss  Minimize anxiety  Improve activity tolerance  Prevent respiratory infection

32 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Drug Therapy  Beta-adrenergic agents  Cholinergic antagonists  Methylxanthines  Corticosteroids  NSAIDs  Mucolytics

33 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Nursing  The patient with COPD is expected to attain and maintain gas exchange at a level within his or her usual baseline values. Indicators include that the patient:  Maintains SpO 2 of at least 88%  Is not cyanotic  Maintains cognitive orientation  Coughs and clears secretions effectively  Maintains a respiratory rate and rhythm appropriate to his or her activity level

34 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Nursing Management-Fatigue  The patient with COPD often has chronic fatigue.  While in the acute phases of the illness, he or she may need extensive help with the ADLs of eating, bathing, and grooming.  As the acute problem resolves, encourage the patient to pace activities and provide as much self-care as possible.  Teach to not rush through morning activities, because rushing increases dyspnea, fatigue, and hypoxemia.  As activity gradually increases, assess the patient's response by noting skin color changes, pulse rate and regularity, blood pressure, oxygen saturation, and work of breathing.  Supplemental oxygen during periods of high energy use, such as bathing or walking.

35 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Expected Outcomes  Maintains his or her baseline SaO 2 with activity  Performs ADLs with no or minimal assistance  Performs selected activities with minimal dyspnea or tachycardia  When discharged, participates in family, work, or social activities as desired  Nursing Interventions Review  As activity level increases, assess the patient's response by noting skin color changes, pulse rate and regularity, blood pressure, oxygen saturation, and work of breathing.  Use of supplemental oxygen during periods of high energy use, such as bathing or walking. Interventions &

36 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Surgical Management  Lung reduction surgery  Preoperative care and testing  Operative procedure by median sternotomy or VATS  Postoperative care and close monitoring for complications

37 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Dyspnea Management  Needed during mealtime; can be reduced by resting before meals  4 to 6 small meals a day

38 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Community-Based Care  Home care management  Long-term use of oxygen  Pulmonary rehabilitation program  Teaching for self-management  Drug therapy  Manifestations of infection  Breathing techniques  Relaxation therapy

39 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. COPD Anxiety  Patients with COPD often have increased anxiety during acute dyspneic episodes, especially if they feel as though they are choking on excessive secretions. Also, anxiety has been shown to cause dyspnea.  Help the patient understand that anxiety can increase dyspnea, have a plan for dealing with anxiety. that states exactly what he or she should do if symptoms flare.  Anxiety plan provides confidence and control in knowing what to do, which often helps reduce anxiety. Stress the use of pursed-lip and diaphragmatic breathing techniques during periods of anxiety or panic.  Family, friends, and support groups can be helpful. Recommend professional counseling, if needed, as a positive suggestion. Stress that talking with a counselor can help identify techniques to maintain control over the dyspnea and feelings of panic.

40 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Critical Thinking  A client with moderate chronic obstructive pulmonary disease (COPD) is preparing to go home and has thrown away the information regarding smoking cessation. He states, “Why should I quit now after I have already caused this disease.” What is the nurse's best response?

41 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Based on the patient’s diagnosis, which clinical manifestations would you expect to see when assessing this patient? (Select all that apply.) A. Concave chest appearance B. Sitting in a forward posture C. Shortness of breath D. Bradycardia E. Use of accessory muscles (cont’d)

42 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. CASE STUDY The patient is a 55-year-old woman with a long history of COPD and 40 years of smoking cigarettes. She is being admitted to the pulmonary stepdown unit from the ED. The ED nurse tells you that the patient is on oxygen at 2 L per nasal cannula. She had a bronchodilator respiratory treatment in the ED as well. She has bilateral expiratory wheezes and crackles both anteriorly and posteriorly. A saline lock was placed in her right forearm for intermittent medications.

43 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. When the patient arrives to the unit, you complete her assessment and find her to be in acute respiratory distress. Her respirations are labored and her respiratory rate is 34. She states that she is severely short of breath. Her oxygen saturation is 82% on O 2 at 2 L via nasal cannula. Based on these findings, what should you do next? (cont’d)

44 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. While the Rapid Response Team is at the bedside, the patient’s health care provider arrives. The provider writes several orders. Which order is most important for you to implement immediately? A. Transfer to ICU B. Increase O 2 to 3 L per nasal cannula C. ABGs 30 min after oxygen is increased D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP (cont’d)

45 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. The patient is in the ICU for 3 days and then transferred back to the pulmonary stepdown unit. She is still slightly short of breath with exertion. Her O 2 saturation is 99% on oxygen at 2 L per nasal cannula. She denies any shortness of breath during your assessment. The provider plans to discharge the patient on home oxygen in the morning. What should you include in this patient’s discharge teaching? (cont’d)

46 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Lung Cancer

47 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Lung Cancer  Leading cause of cancer deaths worldwide  Poor long-term survival due to late-stage diagnosis  Bronchogenic carcinomas  Staged to assess size/extent of disease  Etiology and genetic risk

48 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. TNM Staging  Staging of lung cancer is performed to assess the size and extent of the disease. These factors are related to survival.  Lung cancer staging is based on the TNM system (T, primary tumor; N, regional lymph nodes; M, distant metastasis)  Refer to textbook for cancer staging system. Higher numbers represent later stages and less chance for cure or long-term survival.

49 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Lung Cancer (cont’d)  Health promotion and maintenance  Assessment  History  Pulmonary manifestations  Nonpulmonary manifestations  Psychosocial assessment  Diagnostic assessment

50 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Assessment Hoarseness Change in respiratory pattern Persistent cough or change in cough Blood-streaked sputum Rust-colored or purulent sputum Frank hemoptysis Chest pain or chest tightness Shoulder, arm, or chest wall pain Recurring episodes of pleural effusion, pneumonia, or Bronchitis Dyspnea Fever associated with one or two other signs Wheezing Weight loss Clubbing of the fingers

51 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Diagnosis  Diagnostic Assessment  The diagnosis of lung cancer is made by examination of cancer cells. Cytologic testing of early-morning sputum specimens may identify tumor cells; however, cancer cells may not be present in the sputum. When pleural effusion is present, fluid is obtained by thoracentesis for cytology  Most commonly, lung lesions are first identified on chest x-rays.  Computed tomography (CT) examinations are then used to identify the lesions more clearly.

52 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Nonsurgical Management  Chemotherapy  Targeted therapy  Radiation therapy  Photodynamic therapy

53 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Surgical Management  Lobectomy  Pneumonectomy  Segmentectomy  Wedge resection

54 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chest Tube Placement

55 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Nursing Care After Thoracotomy  Chest Tube Management  Pain management  Respiratory management

56 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chest Tube Chambers  Chamber 1: collects fluid draining from patient  Chamber 2: water seal prevents air from re- entering patient’s pleural space  Chamber 3: suction control of system

57 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chest Tube Drainage System

58 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Interventions for Palliation  Oxygen therapy  Drug therapy  Radiation therapy  Thoracentesis and pleurodesis  Dyspnea management  Pain management  Hospice care

59 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question for Students Which risk factor is responsible for the majority of deaths from lung cancer? A. Cigarette smoking B. Occupational radiation exposure C. Chronic exposure to asbestos D. Air pollution

60 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Nurse Assessment Oxygenation Review  Respirations rapid and shallow  Decreased oxygen saturation by pulse oximetry  Skin cyanosis or pallor (in lighter-skinned patients)  Cyanosis or pallor of the lips and oral mucous membranes (in patients of any skin color)  Tachycardia  Patient appears to work hard to inhale and exhale  Patient is restless or anxious

61 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Nurse Assessment Oxygenation Continued  Patient's general appearance is thin compared with height  Muscles of the neck appear thick  Arm and leg muscles appear thin  Fingers are clubbed  Chest is barrel-shaped (has a round rather than an oval shape with the front to back depth increased)  Ribs are spaced more than a fingerbreadth apart

62 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Nursing Management  Assisting the patient to an upright position, with arms resting on a table or armrests  Performing or assisting the patient to perform chest physiotherapy/pulmonary hygiene  Ensuring that oxygen delivery is kept low enough to maintain respirations of no fewer than 16 breaths per minute or per order  Prioritizing and pacing activities to prevent fatigue  Administering prescribed inhaled drugs  Administering respiratory therapy treatments or collaborating with the respiratory therapist to administer these treatments  Re-assessing respiratory status after respiratory therapy treatment  Ensuring a fluid intake of at least 3 liters per day or per order