1. Nursing Management of Clients with Stressors of Respiratory Function Chronic Airflow Limitation (CAL) Pneumonia Tuberculosis NUR133 Lecture #5 K. Burger, MSEd, MSN, RN, CNE

2. Chronic Airflow Limitation (CAL) Term used for Chronic lung diseases: - Emphysema - Emphysema - Chronic Bronchitis - Bronchial Asthma

3. COPD Chronic Obstructive Pulmonary Disease  Emphysema  Chronic Bronchitis Bronchospasm, dyspnea Non-reversible and progressive Continously symptomatic

4. Asthma Reversible airflow obstruction d/t:  Inflammation  Airway hyperresponsiveness  Hyperresponsiveness leading to bronchospasms

5. Asthma -stimulus or allergen- chemical mediators released. Within minutes: DyspneaWheezingCough Mucus production

6. Inflammatory process TRIGGER Allergen binds to IgE Release of inflammatory chemicals WBCs come to the area WBCs release Mediators which produce more inflammation Blood vessel dilation/ Capillary leak Tissue swelling / Increased secretion

7. Asthma  Common agents or stimuli: -fog, smog, smoke -odors, aerosols -exercise -cold air  Allergens- dust mites, animal dander, pollen, cockroaches, foods, medicines.

8. Asthma Asthma  FOCUSED Respiratory assessment 1. Expiratory and Inspiratory wheezing 2. Dry or moist cough 3. Dyspnea, signs of hypoxemia, anxiety 4. increased HR, BP, RR 5. Diaphoresis, Pallor 6. Cyanosis 7. Nasal flaring 8. Use of accessory muscles

9. Asthma  Diagnostic Assessment  ABGs / PO2 low, PCO2 high, PH low  SaO2 low  Eosinophils / serum and sputum  PFTs / FEV and PERF  CXR

10. Asthma STEP SYSTEM MILD INTERMITTENT MILD PERSISTENT MODERATE PERSISTENT SEVERE PERSISTENT

11. Complications of Asthma - Respiratory infections - Status Asthmaticus - pneumothorax - respiratory arrest - respiratory arrest - cardiac arrest - cardiac arrest

12. Asthma Nursing Diagnoses 1. Impaired Gas Exchange related to alveolar membrane changes, airflow limitation, respiratory muscle fatigue, excess production of mucus. 2. Ineffective Breathing pattern related to airflow obstruction (narrowed airways), and fatigue. 3. Ineffective Airway Clearance related to excessive secretions, fatigue and ineffective cough.

13. Asthma Interventions  Client Education A. Identify causes B. Proper environmental changes C. Stress management, rest, and sleep C. Stress management, rest, and sleep D. Correct use of inhalers E. Correct use of peak flow meter and step wise approach to med management approach to med management F. What to do if an attack occurs

14. Asthma –How to use a METERED DOSE inhaler (without spacer) correctly: 1. Shake inhaler 2. Tilt head back, breathe out fully 3. Open mouth, mouthpiece 1-2” away 4. As you begin to breathe in deeply, press down and release medicine. 5. Breathe in deeply and slowly for 3-5 sec. 6. Hold your breathe for 10 sec 7. Breathe out slowly

15. Asthma Drug Therapy  Bronchodilator  Beta agonists short-acting long-acting  Anti-cholinergics  Methylxanthines  Anti-inflammatory  Corticosteroids  Anti-leukotriene  Mast cell stabilizers  Monoclonal antibodies  Inhaled agents

16. Asthma  Pharmacologic stepped approach to treating asthma symptoms  Step 1- mild intermittent- beta 2 agonist  Step 2.- mild persistent – add cromolyn  Step 3.- moderate persistent- add inhaled corticosteroid, may add theophylline.  Step 4.- Severe persistent- add po steroids

17. Chronic Obstructive Pulmonary Disease EMPHYSEMA  Loss of lung elasticity  Hyperinflation of lungs / air trapping  Diaphragm flattening  Increased airflow resistance  Ineffective gas exchange  Retained CO2 (hypercapnia)  Chronic respiratory acidosis

18. Chronic Obstructive Pulmonary Disease CHRONIC BRONCHITIS  Chronic inflammation of airways  Mucosol edema  Increased # of mucous glands  Bronchial wall thickening  Impaired airflow AND gas exchange  Hypoxemia, hypercapnia, respiratory acidosis

19. COPD COPD  FOCUSED assessment 1. Rapid, shallow respirations & dyspnea 2. Irregular breathing patterns 2. Irregular breathing patterns 3. Moist cough 4. Limited diaphragmatic excursion 5. Decreased fremitus 6. Hyperresonant percussion 7. Crackles 8. Barrel chest 9. Cyanosis 10.Clubbing 10.Clubbing 11.Orthopneic posturing 11.Orthopneic posturing

20. COPD  DIAGNOSTIC ASSESSMENT  ABGs  SaO2  CXR  PFT  Serum AAT  ECG  H&H, Electrolytes, WBC

21. Complications of COPD  Respiratory infection  Cor pulmonale  Cardiac dysrhythmias

22. Nursing Diagnoses for COPD  Impaired gas exchange  Ineffective breathing pattern  Ineffective airway clearance  Activity intolerance

23. Interventions for COPD  Airway maintenance  Cough enhancement  Oxygen therapy  Energy conservation  Drug therapy  Surgical interventions

24. COPD Drug Therapy  Bronchodilators  Anti-Inflammatory drugs  Inhalants AND systemic drugs  PLUS Mucolytics

25. Pneumonia  Community acquired pneumonia (CAP) Versus Versus  Nosocomial pneumonia  Higher incidence in: Elderly, immunocompromised, CAL, mechanically vented, chronically ill  5 th leading cause of death in US

26. Pneumonia Assessment  Chest pain, dyspnea, tachypnea, SOB  Cough & hemoptysis  Crackles & wheezes  Tactile fremitus  Percussion  Fever and chills  Hypoxemia

27. Pneumonia Nursing Diagnoses  Impaired gas exchange  Ineffective airway clearance  Potential for sepsis  Acute pain

28. Pneumonia Interventions  C&DB q2h/ incentive spiro  O2 therapy / Positioning HOB elevated  Maintain hydration  Medications: bronchodilators, expectorants, antibiotics  Client teaching: completion of med rx, influenza and pneumococcal vaccinnations

29. Tuberculosis  Causative organism: Mycobacterium tuberculosis  Incidence increasing worldwide  Highest prevalence: immunocompromised, people living in crowded and or poor living conditions  Exposure versus infection versus active

30. Tuberculosis Assessment  Persistent, productive cough  Hemoptysis  Fever and night sweats  Fatigue  Anorexia  Weight loss  Progressive and persistent S & S

31. Tuberculosis Diagnostic Assessment  Purified Protein Derivative PPD Positive = 10mm induration or > general Positive = 10mm induration or > general 5mm induration or > Hx HIV 5mm induration or > Hx HIV  CXR  Sputum for acid-fast bacillus AFB  Sputum culture; BACTEC  PCR assay  NEW: Quantiferon TB Gold Test QFT-G

32. Tuberculosis Nursing Diagnoses  Impaired gas exchange  Ineffective airway clearance  Fatigue  Deficient knowledge  Ineffective therapeutic regimen maintenance

33. Tuberculosis Interventions  Combination drug therapy Isoniazid (INH) Rifampin (RIF)  Plus Pyrazinamide (PZA) Ethambutol or Streptomycin  RIFATAR = NEW med combo of INH, RIF, & PZA  LONG TERM THERAPY!!!!! 6-12 months duration  CLIENT EDUCATION!!!!!