Perioperative Care PDF

EXAM 1 OUTLINE REMEMBER : APIE - Assessment(recognize clues), Planning(goals/outcome), Implementation(action) ,Evaluation (prioritization of questions) SBAR- situation , background , assessment , recommendation Perioperative Care (Chap...

EXAM 1 OUTLINE REMEMBER : APIE - Assessment(recognize clues), Planning(goals/outcome), Implementation(action) ,Evaluation (prioritization of questions) SBAR- situation , background , assessment , recommendation Perioperative Care (Chapters 15,16, 17: pp. 283-337) ★ Consists of Three Phases: Preoperative ,Intraoperative, Postoperative Preoperative The preoperative phase commences when the decision for surgery is made and ends when the patient is transferred to the surgical suite.During this time, the preoperative nurse takes on a multitude of roles, including educator, advocator, and admittance nurse. Preoperative checklist includes : Documentation Physical preparation A full medical history (including prescription, over-the-counter, herbal, and other alternative therapies) Assessment of the patient’s health status Collection of information and paperwork necessary for intraoperative and postoperative care Completion of preoperative orders (IV antibiotics, thromboembolic-deterrent [TED] hose, No anticoagulant(aspirin,heparin,warfarin etc.) Patient education regarding the entire surgical process Advance directive: names the power of attorney and defines patient wishes if patient becomes unable to make mental decision or becomes incompetent Obtaining informed consent by the provider /surgeon.This Component Includes : ❖ Consent for procedure itself ❖ Name of surgeon to perform surgery ❖ Name, type and reason of the surgery ❖ Reason intervention will benefit the patient ❖ Alternative options ❖ Consent for anesthesia ( Could also be a separate consent)& blood products The initial time-out “pause for cause”: Starts when patient enters surgical facility then performed again by circulating nurse upon transfer to surgical suit proceeding incision by entire team ❖ Correct Patient :All information on the identification band are correct,the name of the surgeon ❖ The correct procedure that will be completed by the surgeon,  ❖ The correct surgical site :The correct side of the body on which the surgery will occur if this is a unilateral procedure. Time-out is performed again by circulating nurse upon transfer to surgical suite Explain the priority assessments for the surgical patient Four Goal to accomplish: 1.) Determine the patient's level of knowledge 2.) Informed consent has been obtained 3.)Determine the patient’s level of anxiety 4.) Obtain relevant information Patient Assessment Patient History Patient History Age ( important to acknowledgments risk Current medications : Identify all factors ) home medication prescribed ,over Height and weight the counter or herbal remedies Vital signs ( know baseline) including med taken prior to Allergies : Thoroughly documented of surgery any Any medical implants or devices medication, food ,dye allergies and reaction of if Any piercings or dental implants severe or mild sensitivities to latex Nutrition deficiencies Last oral intake : Full stomach increases Family history risk of aspiration, time of last oral intake depends Social history on Institution 6-8 hrs History of mental illness or abuse Full Medical history : Chronic conditions Support systems and living conditions and implants Advance directives Surgical history : any previous surgeries Alcohol, Drug use ( can compromise ,poor healing or negative responses to Patient response to anesthesia ) Anesthesia Smoking ( Can cause greater risk for Previous anesthesia & responses to respiratory depression) anesthesia Systems assessment Cardiovascular : Peripheral pulses, color, skin Integumentary : assessing appearance, turgor, capillary refill, temperature, and edema are such as skin integrity and hygiene important parameters to assess Gastrointestinal : note typical bowel habits Respiratory : assesses the patient’s breathing for of the patient and bowel sounds rate, depth, rhythm, and adventitious breath Genitourinary : Document any devices noted sounds and pulse oximetry for urinary elimination, such as an indwelling Neurological : Assessment of general cognition urinary catheter.note any unusual odor or and the ability to understand commands and color of the urine mental status Liver/Renal Assessment : note potential renal or liver disease in the surgical patient  Identify the vital preoperative preparation for the patient Laboratory assessment : A complete metabolic panel provides baseline information on renal and liver functions, including liver enzymes, albumin, electrolytes, blood urea nitrogen,creatinine, CBC , WBC, H&H Radiological assessment : MRI,CAT,ECG Intravenous line insertion Bowel and bladder preparation: If laxatives are enemas are needed Skin preparation : Cleaning with Betadine or chlorhexidine to remove microorganisms Medications : antibiotic Ensure removal of jewelry, dentures and prosthetics Inform anesthesia and surgical personnel of presence of any implants Develop teaching and support strategies for the surgical patient and their family Client problems: knowledge deficit ,fear and anxiety Educating and teaching clients what to expect of the OR experience can help control anxiety. Make sure the client has good knowledge of the procedure and answer questions for reinsurance. Teach clients how to prevent postoperative complications to achieve the best post-op outcome Ensure prior to transfer: 1. Consents completed 2. History and assessment complete 3. Learning needs met 4. Skin and bowel prep complete 5. Preoperative medication administered, IV Intraoperative Begins when admitted into the surgical suit (OR) ends when transferred up PACU Define Terms ➔ Outpatient surgical Setting:Performed in or out of a hospital setting not admitted into Hospital less invasive ➔ Inpatient surgical settings : Invasive long and admitted into the hospital ➔ Both inpatient and outpatient Surgical settings have anesthesiologist,sterile operating environment, post-anesthesia care unit (PACU) ➔ Anesthesia “ lack of or no sensation”  Surgical categories ➔ Diagnostic surgeries are biopsy or exploratory procedures to determine source of disorder ➔ Curative surgeries repair or remove causes of disorders. ➔ Restorative surgeries are those that repair disorders, such as a total hip replacement; they improve patient function by reconstructing mechanical parts of the body ➔ Palliative Surgeries procedures are for comfort and help relieve pain ➔ Cosmetic surgeries restore or improve personal appearance ➔ Transplant surgeries are done to replace non functioning or poorly functioning organs to improve or sustain life. ➔ Elective surgery is surgery that the patient chooses to have. It is performed for their well-being but is not absolutely necessary. ➔ Urgent surgery necessary surgery done 24-48 hrs to prevent injury, may be scheduled rather than done immediately ➔ Emergency surgery is unscheduled and is done immediately to save a patient’s life ➔ Minor procedures are performed under a local anesthesia ➔ Major surgeries are longer more complex with a higher degree of risk and performed under general anesthesia Identify the roles and responsibilities of operating room (OR) team members Sterile Team Members Surgeon ~Leader of the surgical team ~Responsible for performing the surgery may have one or more providers assisting Surgical Assistants ~Physician Assistant (PA) : helping in the OR, the PA provides both preoperative and postoperative care for patients ~Surgical First Assistant (SFA) : Under the surgeon’s direction, the SFA provides aid in exposing the surgical site ~Nurse Practitioner (NP) ~RN First Assistant (RNFA) The scrub nurse or ~Works directly with the surgeon within the sterile field by passing surgical technologist instruments, sponges and other items needed during the procedure “Scrub” ~They also aid in setting up the OR, helping surgical team donn gloves, and count instrument and sponges after surgery ~ Also restores OR for next surgery ★ The team members work together in the sterile field(OR table) and maintain a sepsis  Non Sterile Team Members Anesthesia provider ~Responsible for maintaining and sustaining the physiological status of the patient throughout the surgical process and safety of pt ~Will meet with patient and pre-op for consent and may insert IV Circulating RN ~Observes the surgical procedure from a broad perspective ~Responsibilities include: Initial Assessment in Pre-op area Assist the anesthesia provider, surgeon and scrub nurse ~Aids in donning surgeon and scrub PPE, helps count instruments, sponges and documents Unlicensed Assistive ~Work under the supervision of a perioperative RN Personnel ( UAP) ~Duties include: Patient transport, Positioning and securing of patients on OR table ~Delivery of specimens to lab, blood pickup and housekeeping duties OR Director/ ~Responsible for oversight of the OR Coordinator/ Manager ~Accountable for budget and staffing ⭐️The preoperative assessment Explain priority assessments and procedures in the OR 1. Determine the patient’s level of knowledge related to the planned surgery, potential complications, and interventions, such as insertion of an indwelling catheter, and provide education as appropriate. This time also allows the patient to voice specific concerns or questions regarding the procedure. 2. Confirm that informed consent for the proposed surgical procedure has been obtained. 3. Determine the patient’s level of anxiety to support their management of preoperative fears and postoperative concerns. 4. Obtain relevant information about the patient, which may include: Verification of the patient’s name and date of birth; Verifying that the medical record numbers match the patient’s name band Verification of NPO status prior to surgery 6-8 hrs Determination of medications taken in the morning prior to surgery Assessment of skin color, temperature, and integrity (i.e., tattoos, bruises) Verification of health history, including current medications Verification of allergy status and specific allergic reactions the patient experiences, such as a rash or itching Verification of placement of any metal implants, especially automatic implanted cardioverter defibrillators and pacemakers Assessment of family support ⭐️ Verification of patient’s religious and cultural preferences The surgical pause, and a fire risk assessment Done prior to the start of the procedure verifies: 1. Correct patient 2. Correct procedure 3. Correct surgeon 4. Correct position/site 5. Correct equipment 6. Correct imaging studies ⭐️The surgical (hand/arm) scrub 1. Done to prevent surgical site infections 2. wash with a disposable scrub sponge from a clean area to a less clean area 3. Long- Acting antimicrobial soap 3- 5 minutes 4. Jewelry removed ,Nails clean and short ⭐️The donning of surgical attire 1. Consist of a surgical gown ,scrubs, eye protection/shield, hair net/cap, shoe covers and sterile gloves Discuss types of anesthesia utilized in the OR General anesthesia ★ Is a reversible unconscious state where you are put to sleep where there is no sensation , muscle relaxation, partial or complete loss of memory Variety of methods: IV agents Complications of General Anesthesia Barbiturates : They are excellent anesthetics and amnestics with a short onset and duration of Respiratory depression action.no analgesia (absence of pain) Malignant Hyperthermia (MH) Benzodiazepines : Midazolam (Versed), Triggering agent (volatile gas except Diazepam (Valium) : Longer time to onset but nitrous oxide, succinylcholine) causes have a longer duration than barbiturates. They sustained muscular contraction related are excellent amnestics and no analgesia. to increase in intracellular calcium ion Propofol (Milky Appearance): It has a fast concentration. onset of action. The effects wear off quickly Hypermetabolism: Acidosis, first sign when the medication is discontinued. The patient unexplained tachycardia, hypercarbia, is awake more quickly than with other sedatives hypoxemia, hyperthermia( late sign) , but provides no analgesia Muscle rigidity(most specific sign) Ketamine : patient appears to be “dissociated” Treatment: Dantrolene ( muscle relaxer) from the external environment but not necessarily asleep. Patients may experience hallucinations, so it is generally used in conjunction with amnestics for sedation. It is an excellent analgesic and sedative Muscle relaxants Volatile agents (gasses) Depolarizing Agents : Cause muscle twitching Nitrous oxide prior to relaxation it can't be reversed and quick acting 30-45 sec Nondepolarizing Agents: Longer onset takes minutes to act with no muscle twitching and can be reversed, is progressive from smaller to larger muscle Reversal agents for Nondepolarizing agents: Cholinergic agents: Neostigmine (Prostigmin), atropine is given concurrently to prevent the side effect of neostigmine for bradycardia and dry mouth Regional Anesthesia ★ a local anesthetic used to block or anesthetize a nerve or nerve fibers. Types include: spinal, epidural( continuous ) ,nerve blocks Complications : Hypotensive due to vasodilation of the nerves ,Spinal headache from leakage of CSF into the epidural space ,Seizures ,Respiratory depression ,Nerve damage Local Anesthetics ★ Disrupts sensory nerve impulse transmission to a specific area, No loss of consciousness, Injects agent into tissue through which incision will pass Examples: Lidocaine ( my be mixed with epinephrine to proline ) and Novocaine Monitored Anesthesia Care (MAC) ★ provides anesthesia without unconsciousness. ★ Objectives: Maintenance of consciousness Elevation of pain threshold Enhanced cooperation Some degree of amnesia Minimal variation in vital signs Quick and safe return to activities of daily living, AWAKE PT SIGN OUTSIDE OR ★ provides anesthesia without unconsciousness. The patient has a decreased level of consciousness but maintains a patent airway and responds appropriately to verbal commands and physical stimulation Analyze the importance of airway management in the OR ~Protecting and ensuring proper oxygenation and ventilation. Airway compromise can be caused by relaxation of the soft tissues of the oropharynx. Complications:Laryngospasm,Bronchial Intubation( deflating on one lung )Tracheal+esophageal perforation, Aspiration  ⭐️ Examine risks and complications for the surgical patient High Risk Complications due to positioning :Geriatric patients, Pediatric patients ,Extremely thin patients, Obese patients ,Paralyzed patients ,Diabetic patients, Patients with prosthetics or arthritic joints , Patients with infections or previous trauma Positions 1. The supine position: abdominal, abdominothoracic, vascular, orthopedic, head/neck, and ophthalmic operations 2. The Trendelenburg position: lower abdomen or pelvis when it is desirable to move the abdominal viscera away from the pelvic area for better exposure 3. The Fowler’s position: For cranial procedures 4. The prone position/ventral recumbent: Padding is needed to support bony prominences , used for spinal operation 5. The lateral: Is used primarily for thoracic, renal, and orthopedic (hip) procedures. 6. The lithotomy position: is used for vaginal, obstetrical, urological, and rectal procedures and for radical resections of the groin, the vulva, and the rectal areas Develop support strategies for the surgical patient and their family Teaching: Explain to the patient what to expect, Keep the family updated every 2 hrs Postoperative Begins Immediately after surgery in PACU and continues until first follow-up appointment Discuss the significance of the postoperative period ❖ After surgery patients are transferred to the Post-Anesthesia Care Unit (PACU) for close observation after anesthesia , control pain and prevent complications: Malignant hyperthermia PACU Phases of Care Phase I Close monitoring, including blood pressure, respiratory rate, temp control, oxygen levels, cardiac monitoring, level of sedation, and end-tidal CO2 monitoring, or PACU/ICU capnography.The goals of care in this phase are to stabilize the patient’s vital signs, allow the patient to wake up from anesthesia, and achieve adequate pain control Phase II The focus of nursing care is on preparing the patient to be discharged to an extended-care environment or home Phase III Extended observation of postanesthesia care, focuses on providing ongoing care for patients remaining in the postoperative care area after discharge criteria have been met. Extended observation starts after phase II critical elements have been met, but additional care is needed because a transfer bed is not ready or transportation home is unavailable.  Explain the priority assessments for the post-surgical patient Airway patency(Open,unobstructed) Respiratory status, including oxygen saturation (and capnography, if indicated) and auscultation of lung sounds If adventitious lung sounds are present Vital signs: every 10-15 min ~Blood pressure ~Pulse: apical and peripheral ~Cardiac monitor rhythm ~Hemodynamic pressure readings, if indicated ~Temperature Neurological function, including level of consciousness, orientation, motor function, and sensation Temperature and color of skin Manage Nausea/vomiting zofran can be used Pain and comfort level : Analgesics ,Non-pharmacologic interventions, Patient-controlled analgesia (PCA) only the patient should press the button Condition of dressings; assessing for bleeding or drainage Condition of visible incisions Presence and patency of IV catheters, drains, and other catheters Hydration status and fluid therapy, Urine output Diagnostic Test Labs : Chest radiograph ,Electrocardiogram Implementing( action/ interventions) 1. Connect to cardiac monitor 2. Start admission assessment immediately : Handoff from OR / Handoff to inpatient unit 3. Check Patient's level of consciousness LOC 4. Check all drains , dressing and tubes for patency 5. Check dressing for bleeding 6. Document vital signs 10-15 min. To get patients vital, baseline and presenting status to compared to pre-op 7. Medicare as ordered  Postoperative Inpatient Potential Complications Respiratory Atelectasis one or more long collapse Pneumonia Pulmonary embolism Cardiovascular Fluid and electrolyte imbalance ,Tachycardia Dehydration Surgical fluid/blood loss Clot formation lower extremities Neurological Delirium : disorganized thinking Postoperative cognitive decline ( typical in gero population ) Gastrointestinal Postoperative ileus slowing of the gastric and bowl mobility , nausea , vomiting Urinary Urinary retention less than 30ml mean dehydration Integumentary Surgical site infection will appear red, warm, inflamed and painful may have purulent drainage Dehiscence wound incision reopening: cleaned , drained with sterile dressing Evisceration mainly in the abdomen protruding bowel contents contact surgeon and cover with wet sterile dressing Assessment Recognizing cues (data) Implementing( action/ interventions) Respiratory : adventurous breath sound Respiratory care Vital signs Fluid management Pulse ox Mobility every 2 hrs Peripheral perfusion cap refills DVT prophylaxis : heparin , Lovenox Neurological Diet management Gastrointestinal Surgical site and wound management Genitourinary Pressure injury prevention: reposition every 2 hrs Skin/drains : surgeon changes first dressing Fall prevention/ bed alarm Pain Managing constipation Fluid and electrolyte balance Remove Foley catheter : prevent infection Inventive sphygmometer : pneumonia and Atelectasis Patient Teaching Unit education Most common post op complication is Safety topics hypertension and Tachycardia due to blood or Discharge education fluid loss other cause could be pain, infection or anxiety  Respiratory Assessment (Chapter 23: pp. 457- 476) ★ Functions of the Respiratory System : Ventilation, Respiration, Acid-base balance, Speech, Sense of smell,Fluid balance Physiology of the Respiratory System ▪ Inspiration: occurs when there is stimulation of the phrenic nerve. The phrenic nerve is responsible for the movement and contraction of the diaphragm. ▪ Expiration :Is a passive process that occurs as the diaphragm relaxes. As the diaphragm relaxes, pressure is exerted on the lungs by the chest and abdominal cavity. The decrease in the size of the thoracic cavity causes an increase in pressure within the lungs that exceeds atmospheric pressure, causing air to passively leave the lungs through expiration. ▪ Respiration: Respiration is the exchange of oxygen and carbon dioxide at the alveolar level. ▪ Dead space/shunt : Areas of the tracheobronchial tree that do not participate in gas exchange or respiration are referred to as dead space. ▪ Ventilation-perfusion mismatch : when there is no perfusion of functioning alveoli by the pulmonary capillaries (dead space) because of an obstruction of blood flow through the pulmonary capillaries, there is a high ventilation–perfusion mismatch, or adequate ventilation with poor perfusion  Data collection Physical Assessment History of present illness Inspection Factors that exacerbate or improve symptoms Speech Pain Clubbing of fingernails(long term poor O2) Cough Nose Changes in weight Mouth Dyspnea Neck Health History Thorax ▪ Current medications Vital signs ▪ Allergies Spinal abnormalities :scoliosis, kyphosis, and ▪ Past medical history lordosis ▪ Previous surgeries Palpation ▪ Family history Trachea ▪Chronic disease Crepitus ▪ Occupation/Area of residence Thorax ▪ Smoking history Percussion(Tapping) ▪ Social history Auscultation(listen) ▪ Recent travel Diagnostic studies Imaging Arterial blood gas PaCO2: 35-45 mm Hg pH: 7.35-7.45 HCO3- : 22-26 mEq/L PaO2 : 80 to 100 mm Hg Pulse oximetry Saturation of hemoglobin with oxygen 95%-99/100% Capnography and capnometry Continuous PaCO2 monitoring Sputum analysis Check for microorganisms and/or abnormal cell growth Chest x-ray Identify problems with lungs, heart, and pleural Space Pulmonary function test(determines lung function) Lung volumes Lung functioning Bronchoscopy Direct visualization of respiratory tract Analysis of tissue specimen Biopsy Thoracentesis Needle into pleural space to remove specimen, fluid, or air Lung biopsy Removal of lung tissue for analysis  Pneumonia (Chapter 24: pp. 492-496) ★ Pneumonia is an inflammation of the functional lung tissue resulting from a bacterial, viral, or fungal infection. Describe the pathophysiology of pneumonia 1. Organisms enter the respiratory tract through droplets or aspiration 2. The organisms evade the protective mechanisms of the respiratory tract 3. Organism initiate the inflammatory process 4. The respiratory protective mechanisms become either ineffective or overwhelmed 5. Organisms can localize to one or more lobes or spread throughout the lung Identify the types of pneumonia Cause of pneumonia Category of pneumonia Noninfectious causes: ~Community Acquired (CAP):individuals who have Aspiration : avoid by giving small bits and not been recently hospitalized or are living outside of eating slowly a healthcare/long-term care facility. Ex nursing home ~Hospital Acquired (HAP) : Typically develops in Silent aspiration : inflammation of lung patients 48 hours after hospital admission Inhalation ~Health-Care Associated (HCAP): occurs in Infectious Causes: individuals outside of the hospital but after significant Bacteria exposure to the healthcare setting. Ex doctor Viruses appointment Mycoplasma Fungi Protozoa ~flu is a common cause Describe who is affected by pneumonia Advanced age Long term care residences Patients on a ventilator are the highest risk of catching pneumonia Smoking Chronic respiratory diseases (asthma, emphysema) Immune system dysfunction (HIV/AIDS, Transplantations)  Altered mental status Prolonged immobility Aspiration of stomach contents or foreign materials Prolonged NPO status Diminished cough, gag and/or swallowing reflexes Exposure to air pollution Hospitalization for longer than 48 hrs Poor oral hygiene Discuss diagnostic assessment findings Clinical Manifestations/ S/S Complications Fever Acute meningitis Tachypnea/dyspnea,SOB Empyema : Collection of purulent drainage in Tachycardia the pleural space : chest tube needed Chills Bacteremia (Bacteria in the bloodstream) Cough (productive or nonproductive) Atelectasis Pleuritic chest pain Septic shock Fatigue Acute respiratory failure with multiple organ In the more severe cases, you might see purulent or failure blood-tinged sputum, hypotension or dysrhythmias Cough up blood : hemoptysis Diagnostic Evaluation IMAGE ~Bronchoscopy : Examine inside the bronchi/lung and remove lung tissue ~Imaging studies: Chest x-ray : can tell where the infection is CT scans of the chest ~Laboratory studies: CBC , WBC ~C-reactive protein level: detect the presence of inflammation and infection ~Arterial Blood Gasses ABG: starts off alkalosis then becomes acidosis because of increasing symptoms ~Sputum cultures (Gram stain) ~Blood cultures  Discuss what is the treatment for Pneumonia ★ Administering oxygen is the first treatment step for patients that need to prevent or reverse hypoxia due to pneumonia ★ Adequate hydration supports the patient's cardiovascular status and assists in thinning respiratory secretions Assessment Recognizing cues (data) Client Problems Subjective Data ~Ineffective peripheral tissue perfusion related to ~Patient history decreased gas exchange ~Ineffective breathing pattern Objective Data ~Impaired gas exchange ~Vital signs ~Risk for acute confusion ~Physical Assessment ~Activity intolerance ~Adventitious breath sounds Implementing( action/ interventions) Evaluation Identify patients at risk for pneumonia A patient recovering from pneumonia will Administer humidified oxygen as needed demonstrate: Administer antibiotics/Meds as ordered Stable vital signs Encourage the use of an incentive spirometer Unlabored breathing Encourage coughing and deep breathing:Teach Oxygen saturation above 92% (or returned to their patient how to splint covering abdomen with pillow baseline) Vibration/ percussion Absence of cough/sputum production Early mobility Clear chest x-ray Patient positioning: raise HOB Increased energy levels and activity tolerance Monitor intake and output Ensure adequate nutritional support Treatment: Medications Educate and teach the patient on: Oxygen Therapy Hand Hygiene and respiratory etiquette Bronchodilator therapy with albuterol or Combivent Encourage adequate rest Antipyretics Encourage proper nutrition and fluid intake( up to 3000 ml to break up secretion) Antibiotic therapy vancomycin , zosyn Understanding signs and symptoms Ant-inflammatory agents Encouraging the “at risk” patients to get a Mucolytic ex. Mucinex pneumonia AND flu vaccine annually Cough expectorants  Tuberculosis (Chapter 24: pp.496-502) ★ Caused by Mycobacterium tuberculosis : Slow-growing slender, rod-shaped Gram positive acid fast organism with a waxy outer capsule Delineate (describe) the pathogenesis of tuberculosis (TB) ❖ Tuberculosis is spread from person to person via aerosolization ❖ Transmission usually requires close, frequent or prolonged exposure.When inhaled, Microbacterium lodge in alveoli in the small distal (upper) airways 1. Local inflammatory response occurs a. Granuloma Forms from alveolar macrophages with neutrophils are brought to the site to isolate and prevent spread of the infection.It is then surrounded by collagen fibroblast and lymphocytes WBC. b. Center of the lesion contains necrotic tissue, becomes a granular mass c. 2. TB infection can be detected by skin test It take 2-10 weeks to develop positive skin test 3. In a Healthy person cavities are formed, calcify are seen on chest x-ray called primary Lesion but , If immune system becomes compromised the granuloma can liquify and become activated and may become systemic 4. Reactivation Tuberculosis : Occurs in persons who have chronic diseases or are immunosuppressed/ immunocompromised 5. High Risk PT : HIV( high risk), Elderly, diabetic, sepsis, malnourishment, chronic renal disease, immunosuppressant, long-term steroid administration, and cancer (chemotherapy), IV Drug users/substance abusers (compromise immune system) , organ translate Pt, immigrates , healthcare worker , overcrowded housing.  Latent tuberculosis infection (LTBI) Individuals with an intact immune system, a granuloma forms and limits further proliferation and spread of the Mycobacterium. Necrosis at the center of the granuloma leads to fibrosis and calcification. no symptoms, do not feel ill, and are not contagious. Primary tuberculosis infection (PTBI) Individuals with a weakened immune response are unable to control the multiplication of Mycobacterium. Granuloma formation is initiated but is unable to progress to calcification.Primary TB infection is often asymptomatic and is confirmed only by positive sputum cultures and a positive skin test. This person is not infectious. Primary progressive TB infection (PPTBI) Initial symptoms are relatively nonspecific and consist of fatigue, weight loss, and night sweats. A cough develops eventually and produces a rusty-colored or blood-streaked sputum. As the disease progresses, dyspnea, orthopnea, and rales become evident.This person is infectious. Drug-resistant M. tuberculosis (MDR TB) This means that one or more of the first-line medications used for the treatment of TB are not effective. Drug-resistant TB can be caused by primary or secondary means. Primary resistance is caused by person-to-person transmission of the resistant organism. Secondary (acquired) resistant TB develops during treatment and results from an ineffective treatment regimen or an incomplete treatment regimen.Emergence of multidrug-resistant (MDR) strains disproportionately seen in the poor, underserved, and minorities Extensively drug resistant (XDR TB): Resistance to the first line TB drug at least one ~2 first line , 2 second and quinolone second line TB drug and at least one drug in the antibiotics quinolone antibiotic subclass typically for patients with HIV due to the mutation that occurs in the tb  Differentiate the various diagnostic studies used for the detection and diagnosis of tuberculosis Clinical Manifestations/ S/S Complications ◼ Fatigue ◼ Miliary Tuberculosis: aggressive ◼ Weight loss ◼ Pleural Effusion and Empyema ◼ Anorexia ◼ Genitourinary Tuberculosis ◼ Low-grade fever ◼ Tuberculosis Meningitis ◼ Night sweats ◼ Skeletal Tuberculosis ◼ Cough begins dry then becomes productive rusty-colored or blood-streaked sputum Diagnostic Testing Diagnostic Testing ◼ Intradermal PPD (Mantoux) test : Most ◼ Interferon Gamma Release Assay blood commonly used reliable diagnostic test for TB ,O.1 Test :Indicates TB infection can be used to ml purified protein derivative (PPD) given test false BCG test – does not distinguish intradermally then check 48-72 hrs later ,Chest x active vs latent, ray after positive PPD= redness/lump/rash ◼QuantiFERON–TB Gold: Use to Diagnose ~5 mm or greater=HIV-infected persons,exposure & infection ◼T-SPOT TB test : should be given to pt w/TB (5-9 mm for immunocompromised), Persons with fibrotic the are living with family members that show and organ transplants up positive ~10 mm induration = recent immigrants, IV drug abusers, residents /employees of high-risk settings, mycobacteriology ◼ Sputum Culture : Definitive diagnosis and laboratory personnel, if medication regimen is working Infants, children, and adolescents exposed to adults in high-risk categories Based on medication utilized ~15 mm or Greater= considered positive in any person, Liver function tests and renal function studies including persons with no known risk factors for TB. Vision examination ◼ Chest x-ray : Used to evaluate pulmonary Audiometric testing tuberculosis findings.Dense lesions in apical and posterior segments of upper lobe with cavity formation may be noted. Use to Diagnose ◼ Acid-fast bacillus smear (AFB) :Determines tubercle bacilli ,Not specific for tuberculosis  Categorize the mechanism of action, side effects, and nursing implications of drug therapy for tuberculosis ★ Goals of therapy include: Make disease noncommunicable to others, reduce symptoms of the disease, effect a cure in the shortest possible time ★ Chemotherapeutic agents (antituberculosis agents) 6 to 12 months ★ Prophylactic Treatment: used to prevent active disease ,single drug given for 6-12 months used when recent skin test convert from negative to positive ★ Initial Phase (first 2 months daily therapy) ★ Continuation Phase (remaining 4+ months of therapy) ★ Acute adherence to therapy is critical for survival.Effective treatment should show negative cultures within 2 to 3 months if cultures are positive consider drug resistance and add 2 to 3 other drugs to the regimen ★ Directly Observed Therapy (DOT) : Is a when patient isn't compliant in taking the medication as scheduled and requires them to be monitored either by them coming to you or you going to them ★ Bacillus Calmette-Guerin (BCG) vaccine : Widely used in developing countries , will give inaccurate PPD positives and must do an Gamma Assay ,QuantiFERON – TB Gold or chest x-ray test. First line medication initial phase Drug Therapy Adverse effect Isoniazid (INH) ◼Monitor for hepatotoxicity and Yellowing of skin, nausea ,vomiting neurotoxicity, test liver for hepatitis ,diarrhea, anorexia, dark urine, *Antitubercular ◼ Give Vitamin B6 (pyridoxine) to ,peripheral neuropathy, hepatotoxicity, prevent neurotoxicity optic neuritis ◼ Avoid alcohol ◼Interfere with the metabolism zepam Avoid foods containing tyramine, Diazepam (Valium) can cause them to increase isoniazid toxicity ,may cause become toxic redness or itching of the skin; hot feeling; rapid or pounding heartbeat; ◼ Teach patient to report of changes sweating; chills; cold, clammy feeling; in vision headache; or ◼ avoid aged cheeses, pickled or smoked fish red wine, tuna , soy sauce ◼Take med on empty stomach ◼Cause birth defects Rifampin (RIF)(Rifadin ◼Monitor for hepatotoxicity, anemia or Nausea ,vomiting, heartburn, Makes you the most sick thrombocytopenia epigastric pain , diarrhea ,orange Daily ◼ Inform the patient that urine and discoloration of urine, tears ,sweat, *Antibiotic other secretions will be orange unusual bleeding and bruising  ◼ Avoid alcohol ◼ May interfere with efficacy of oral ◼ Teach patient to report: yellowing of contraceptives, steroids , digoxin , the skin, pain or swelling of joints, loss Warfarin of appetite, or malaise Pyrazinamide (PZA) ◼Monitor for hepatotoxicity, anemia or Hepatotoxicity, fatal hemoptysis *Antibiotic hyperuricemia ,hemolytica anemia, gout arthritis ◼ Drink a glass of water with each dose, 3-6 L increase fluid during the ◼ Teach patient to report: (jaundice) day yellowing of the skin, pain or swelling ◼Renal and kidney labs are done of joints, loss of appetite, or malaise ◼ Wear sunscreen or protective immediately clothing to prevent photosensitivity reactions ◼ Avoid alcohol Ethambutol ◼Obtain baseline visual acuity tests Nausea, vomiting, headache, (EMB)(Myambutol) ◼ Determine color discrimination dizziness, optic neuritis, gout arthritis, Will be dropped if other 3 ability Hepatotoxicity ,Hyperuricemia( too medication are working ◼Renal and kidney labs are done much uric acid in your blood) *Antibiotic ◼Pregnancy safe but not for kids ◼ Teach to report changes in vision Immediately, can't distinguish between red and green ★ Vitamin B6 (pyridoxine): prevents isoniazid associated peripheral neuropathy (numbness and tingling in the feet) ★ If no drug resistance is demonstrated in the cultures after the first 2 months of therapy, four + months of therapy will continue with isoniazid and rifampin (continuation phase) Second line medication Drug Therapy Adverse effect Streptomycin IM injection ◼Should be used only in multi-drug Tinnitus , Deafness and vertigo ( a resistance TB (MDR-TB) sensation of motion or spinning that is ◼ Ototoxicity often described as dizziness ), ◼ Monitor renal function studies and urine output (nephrotoxic) ◼ Consume at least 2-3L of fluid daily ◼ Aminosalicylic acid(Paser) ◼ Capreomycin (Capastat) ◼ Ciprofloxacin (Cipro) ◼ Cycloserine(Seromycin) ◼Ethionamide(Trecator-S) ★ Monitor during medication therapy :Liver Function Test( LFTs), BUN, creatinine, sputum culture,auditory and vision tests Organize care based on the nursing process for a patient diagnosed with tuberculosis. Assessment Recognizing cues (data) Nursing Diagnosis (Related to )/Client problems ◼Patient’s exposure to TB, living situation ◼ Ineffective airway clearance ◼ Country of Origin or out of country travels ◼ Alteration in gas exchange related to ◼ Previous results of TB tests necrosis of lung tissue ◼ Ask if Bacillus Calmette-Guerin (BCG) vaccine ◼ Alteration in comfort: pain related to given? pleurisy ◼Temperature ◼ Ineffective coping related to isolation and ◼ Sputum : Blood change rustic color long-term therapy ◼ Breath Sounds : Wheezing , rales, rhonchi ◼Knowledge deficit ◼ Oxygen Saturation : Can be decreased due to ◼Misinterpretation destruction of lung tissue ◼ Symptom free in early stages * Results of diagnostic testing ◼ Latent TB infection have positive skin test but ◼ Tuberculin skin test or Interferon gamma release symptom free assay ◼ Active TB disease Initial: fatigue, malaise, ◼ Acid-fast bacilli in sputum anorexia, unexplained weight loss, low-grade fevers, ◼ Chest x-ray night sweats, cough with white frothy sputum ◼ Sputum culture ◼ Active TB disease advanced: Rust colored sputum / Hemoptysis ( cough up blood) ◼ HIV-infected patients: atypical physical exam and chest x-ray findings. Classic s/s may be attributed to other HIV opportunistic infections Planning ( goals / outcomes ) Implementing( action/ interventions) Goals: Pt will 1.Health Promotion Selective screening in high risk ◼ Have functional pulmonary function groups : Identify contacts of positive TB patients to ◼ Comply with therapeutic regimen be screened and treated if necessary, Positive skin ◼ Have no recurrence of disease test must receive a chest x-ray for further workup ◼ Take appropriate measures to prevent the 2. Acute Intervention :Promote airway clearance, spread of the disease Humidified oxygen , Advocating adherence to treatment regimen , Administer Antibiotics as Ordered, Promote activity and ensure adequate nutrition 3. Ambulatory and Home Care : Educate patient about TB while at home, Sputum specimens every  2-4 weeks, Avoid inhalants/aerosols, Medication adherence ,Side effects of therapy and Follow-up care at least for one year during treatment For patients suspected of having TB: ◼ Airborne precautions isolation/ Negative pressure 6-12 per hr /N95 mask ◼Oxygen Administration with humidify ◼ Start appropriate drug therapy ◼ Receive immediate medical laboratory workup Asthma (Chapter 26: pp.523-507) ★ Asthma is a reactive airway disorder, characterized by:Chronic inflammation airway constriction and Increased mucus production ★ Sympathetic nervous system is the flights or flight, beta-1 works on the heart and kidneys and beta-2 works on the smooth muscle for relaxation ★ Parasympathetic nervous system cholinergic system rest and digest for vasoconstriction and bronchoconstriction Relate the pathophysiology and clinical manifestations of chronic respiratory disorders to their effects on ventilation and respiration ★ Airways are in a state of persistent inflammation, Inflammatory mediators present: Eosinophils, neutrophils, lymphocytes and edema can be present.First labs are Chest X-Ray , ABG or EKG. Acute/Early Phase 1. Inflammatory mediators are released by mast cells histamine, prostaglandins(cause inflammation ) 2. Leukotrienes (cause bronchoconstriction).Then Inflammatory cells release other inflammatory mediators cytokines and Bradykinin 3. Parasympathetic receptors trigger bronchoconstriction of bronchial smooth muscle 4. Increased capillary permeability causes mucosal edema 5. Mucus production is stimulated decreasing air movement  Late phase 6.Inflammatory cells damage airway epithelium , produce mucosal edema ,impair mucociliary clearance, prolong bronchoconstriction resulting in decreased airflow, increased airway resistance and increased work of breathing Compare and contrast etiology, risk factors, and clinical manifestations of persons with chronic respiratory disorders Etiology Risk factors Decreased airflow Allergies (more common in children) Increased airway resistance Genetics Increased work of breathing Environmental Eczema Pollution Preventative Measures Avoidance of known triggers Environmental modification in home Environment Avoid from cold air Protecting airway from cold air Early treatment Triggers Clinical manifestations Exposure to allergens Chest tightness Respiratory tract infections Cough Exercise Dyspnea Inhaled irritants ( paint , aerosols ) Wheezing Emotional upsets Increased Sputum Food and Drugs Tachypnea and Tachycardia GastroEsophageal Reflux Disease (GERD)- Anxiety and Apprehension stomach acid into the lung SOB=short of breath  Status Asthmaticus An acute exacerbation of asthma that is unresponsive to repeated doses of typical rescue medications (bronchodilators) , vary from mild to severe with bronchospasm, inflammation, and excessive mucus production with mucus plugging.Life-threatening Emergency Complications Treatment may include Severe, prolonged asthma not responding to Endotracheal intubation routine treatment Leads to: Mechanical ventilation respiratory failure Oxygen Hypoxia Aggressive drug treatment: Hypercapnia -IV fluids Acidosis -Systemic bronchodilators -IV steroids(decrease inflammation) Cough-Variant Asthma Complications Goals of Treatment Presents with persistent cough without Daily management wheezing or dyspnea Control symptoms and prevent acute attacks May delay diagnosis During an attack Restore airway patency Restore alveolar ventilation Diagnostic Testing ➔ Pulmonary Function Tests (PFT’s) : evaluate degree of airway obstruction is completed in a pulmonary function lab ➔ Forced expiratory volume (FEV) : using spirometry to measures the amount of air force out after a full inspiration ➔ Challenge or Bronchial Provocation Testing : methacholine or histamine is inhaled to cause lung to have a hyper response , PFT’s are performed to Diagnosis of asthma can be confirmed ➔ Pulse Oximetry: noninvasive method of measuring oxygen saturation (SPO2 95-100%). Aides in determining severity of respiratory distress ➔ Arterial Blood Gas(ABG): utilized during an acute attack , hypoxemia will be noted. Initially = hypoxemia with respiratory alkalosis With progression = profound hypoxemia with respiratory acidosis ➔ Skin testing : Identifies specific allergic triggers involving multiple skin pricks which introduce a specific substance, positive results display a wheal and flare reaction at the site. Allergens introduced are food, environmental, and animal which are common in the geographic location.  Disease Monitoring Peak Expiratory Flow Rate (PEFR) The volume of air forcefully expelled from the lungs in one quick exhalation allowing to assist with evaluation of bronchial hyperresponsiveness or if they are responding well to the medication( done before and after meds). Encouraged to do daily around the same time and repeated three times but using highest score Normal PEFR determined for each patient Green (80 – 100% of personal best) = Good Yellow (50 – 79% of personal best) = Caution Red (50% or less of personal best) = bronchodilator needed immediately ★ GOAL IS FOR AIRWAY CONTROL Medications are used to : Prevent and control symptoms , decrease severity and frequency of exacerbations and reverse airway obstruction Nebulizers :Machine delivers liquid medication as a fine mist breathed in with normal respirations via face mask or handheld device may take up to 30 minutes to deliver the total dose Metered Dose Inhalers (MDI) AKA “Inhaler” : Use propellant in delivery of medication activation of device must be timed correctly a spacer recommended Dry Powder Inhaler (DPI): Medication delivered as a dry powder to lungs.More medication delivered to lungs vs MDI, no propellant needed or timing needed Single dose DPI : Medication supplied in capsule or tablet form , Punctured or crushed in DPI device. Patients must be taught not to ingest orally. Do not shake/ rinse after use of all inhalers Multiple dose DPI : contained in container , Single dose is exposed with activation Oral Medications: Utilized for long term control or short term treatment, Increased risk of systemic absorption Intravenous Medications: Limited use for severe cases, often used for short term treatment of acute conditions Subcutaneous Injections: Given for treatment of allergic triggers in severe cases  Medication Exemplars Mechanism of Action Nursing Implications Classification Beta2-Adrenergic Albuterol (Proventil, Ventolin) -Most frequently prescribed Adverse effects: Agonist Agents (Short = Administered via metered drug of choice for palpitations, headaches, Acting) dose inhalers or nebulizers bronchoconstriction to treat throat irritation, tremor, acute bronchospasm nervousness, restlessness Last 2-6 hours Activate the sympathetic and tachycardia Usually PRN Other Short Acting nervous system causing Contraindications: AKA “Rescue med Levalbuterol(Xopenex) = Inh bronchial smooth muscle hypersensitivity to albuterol neb or aerosol relaxation, resulting in Precautions: history of Metaproterenol (Alupent) = bronchodilation tachydysrhythmias, cardiac PO or Inh neb Inhibits the release of disease, coronary artery Terbutaline (Brethine) = SQ inflammatory chemicals from disease or hypertension Drug injection mast cells interactions: Concurrent use Can be used to prevent of beta blockers , MAOIs exercise-induced (monoamine oxidase bronchospasm inhibitors) antidepressants ,Products containing Caffeine Beta2-Adrenergic albuterol (VoSpireER) = PO Activate the sympathetic Instruct the patient to inform Agonist Agents (Long arformoterol (Brovan) = inh nervous system causing the health care provider Acting) by neb bronchial smooth muscle (HCP) if any worsening of formoterol (Foradil) = DPI relaxation, resulting in symptoms occurs Does not terminate salmeterol (Serevent) = DPI bronchodilation for 12 hrs Assess patient PEFR with a acute bronchospasm peak flow meter Assess vitals before, during Limit Caffeine intake and after administration Take exactly as directed Assess for cyanosis or Continue to take even if pallor feeling better Assess lung sounds Report palpitations or SOB not relieved by the drug After inhaling drug, rinse mouth with water and spit; avoid swallowing drug,no breastfeeding Anticholinergic Agents Ipratropium (Atrovent) Block parasympathetic Common Adverse Effects: Short term nervous system to block dry mouth, nausea, GI Alternative bronchoconstriction. Work distress, cough, drying of the bronchodilators well in combination with beta nasal mucosa, hoarseness, Long – Aclidinium (Tudorza) agonists for additive effect paradoxical bronchospasm = COPD Treatment Produces a bitter taste May Long – umeclidinium Can relieve bronchospasm worsen glaucoma (Incruse Ellipta) = COPD within minutes Contraindications: Treatment Peak effect in 1-2 hours Hypersensitivity to soya Lasts up to 6 hours lecithin (used in propellant) or Drug of choice for treatment hypersensitivity to ipratropium of COPD Use Caution: with Prescribed off label for use closed-angle glaucoma,  in Asthma urinary retention, prostatic hyperplasia, or bladder neck obstruction Anticholinergic Agents Tiotropium (Spiriva) = COPD Ensure pt rinse mouthpiece Assess for history of Treatment , Long term at least weekly and rinse glaucoma, urinary retention or Does not terminate their mouth with water to complete respiratory history acute bronchospasm Administered via DPI, once a prevent swallowing the Monitor for urinary retention day medication or dry mouth, notify HCP of changes in vision or urinary retention Methylxanthines Chemically related to Theophylline (Theo-Dur, others) PO / IV /no inh Narrow therapeutic index : ➡️ Relaxes bronchial smooth muscle and suppresses airway responsiveness to Common Adverse Effects: nausea, vomiting, headache, irritability and insomnia.,tachy caffeine, caffeine use 10-15 mcg/mL Toxic level: stimuli Serious: dysrhythmias, may falsely elevate greater than 20 mcg/mL Less effective than beta-2 hypotension and seizures drug concentration Monitor serum levels and adrenergic agonists Contraindications/Use levels report if elevated or toxic This is an alternate drug caution with: seizure used when other drugs fail disorders, heart failure, No longer a primary to provide symptomatic relief cardiac dysrhythmias drug for asthma May be used with a Active peptic ulcer disease Narrow therapeutic corticosteroid Liver disease index with a risk of Interactions: Common toxicity antibiotics , St John’s wort herbal remedy for depression Shorter acting than decrease med effects, Aminophylline (Truphylline) PO ➡️ theophylline Same action and adverse effects of theophylline Caffeine and Smoking increases rate of drug clearance from body, a Available in IV form change in this habit must be Approved to treat asthma reported to the HCP and COPD Anti-inflammatory Corticosteroids Decrease inflammation of Monitoring with long term Agents the airways by inhibiting the therapy, Bone physiology , Does not terminate Inhaled: long term utilized synthesis and release of weight gain, Growth acute bronchospasm daily to suppress inflammatory mediators suppression, Suppression of inflammation with little side Inhibit the number of the signs of infection due to Most effective effects circulating leukocytes and anti inflammatory properties medication for beclomethasone (Qvar) inh decrease vascular PO and IV monitoring: long-term asthma budesonide (Pulmicort) inh permeability peptic ulcer disease, control fluticasone (Flovent) inh mometasone (Asmanex) inh Result is diminished mucus hyperglycemia( increase Inhaled: Drug of production and decreased blood sugar), impaired wound choice to prevent and edema healing PO, IV: used for short term manage asthma Decrease bronchial management of acute asthma exacerbations hyperresponsiveness to can cause systemic adverse Methylprednisolone (Solu-Medrol, allergens effects with long term Depo-Medrol, Medrol) PO, IV therapy  Prednisone (Steraped) PO: no NSAID due to peptic ulcers Prednisolone (Orapred) PO Hydrocortisone (Solu-Cortef) PO, Anti-inflammatory Beclomethasone (QVAR) Reduces inflammation and Adverse effects: Agents immune response, thus Hoarseness, dry mouth, decreasing frequency of changes in taste, Not for use to asthma attacks oropharyngeal candidiasis terminate an acute May take 3 to 4 weeks for Serious adverse effects: attack optimum benefits Development of cataracts (long term therapy), corticosteroid toxicity Growth inhibition in children May mask the signs of infection Contraindications: Hypersensitivity to the drug Anti-inflammatory Mast cell stabilizer Serve limited but important Perform complete respiratory Agents role in prophylaxis of asthma history and COPD When used with albuterol, Prevent release of use albuterol first histamine and other Allow several weeks for drug inflammatory mediators in to have airways maximum effect Rinse mouth after use to take away bitter aftertaste; do not swallow the drug Anti-inflammatory Mast cell stabilizer: Stabilizes mast cells, thus Adverse effects: Cough, Agents Cromolyn preventing inflammatory pharyngealirritation, response bronchospasm Prevents inflammation in Contraindications: asthma Hypersensitivity to the drug May be used 10 – 15 Discontinue if eosinophilia minutes prior to known develops= the presence of exposure to allergen to too many eosinophils in the prevent attack body Anti-inflammatory Leukotriene modifiers Reduce inflammation by Perform a complete Agents either blocking an enzyme respiratory history Available by PO route only that controls leukotriene Assess for hepatic Metabolized by the liver synthesis or by blocking impairment and history of Delayed onset, not for acute leukotriene receptors alcoholism attacks Monitor lab findings that reflect liver status, including Leukotriene Modifiers CBC and hepatic function Zafirlukast (Accolate) PO tests Montelukast (Singulair) PO Check for drug interactions  Zileuton (Zyflo CR) PO Report signs of liver problems: darkened urine, jaundice, clay colored stools, fatigue Report nausea, itching, infection Attend all scheduled appointments with HCP and LAB visits Do not breast-feed Take on an empty stomach Notify HCP of pregnancy Anti-inflammatory Montelukast (Singulair) Blocks leukotriene receptors Adverse Effects: Headache, Agents in airways, there by nausea, diarrhea. Rare preventing airway edema neuropsychiatric events and inflammation including suicidal ideation, hallucinations, aggressiveness or depression Contraindications / Precautions: Hypersensitivity to the drug Pre-existing hepatic impairment No major drug interactions reported Must monitor Liver Function Tests: serum alanine aminotransferase (ALT) values Anti-inflammatory Monoclonal Antibodies Prevents inflammation and Potential serious side Agents Omalizumab (Xolair) -first dampens response to effects: Uncommon but biologic therapy for asthma allergens include anaphylaxis, bleeding and severe dysmenorrhea Available only by Mild side effects include subcutaneous route irritation at injection site Expensive Instruct patient not to discontinue or reduce other asthma medications without consulting HCP ★ Key Nursing Responsibilities With Inhaled Medications:Observe proper use of inhaler, Wait prescribed time between inhalations and medications ,plan teaching strategies if needed. Rinse mouthpiece of MDI at least weekly and to rinse their mouths with water and spit after inhalation, to prevent swallowing medication ★ Always use bronchodilator FIRST  Assessment Recognizing cues (data) Nursing Diagnoses / Identifying Client Problems I Health History Ineffective Airway Clearance Physical Examination Impaired Gas Exchange Diagnostic studies Ineffective Breathing Pattern: related to Physiologic changes in lung ventilation, anxiety Anxiety : related to increased work of breathing , feelings of suffocation Ineffective Therapeutic Regimen Management Key Interventions /Take Action Patient Teaching Provide oxygen Use of asthma action plan Administer bronchodilators as ordered Avoid risk factors Administer anti-inflammatory Pursed-lip breathing medications/steroids as ordered Medication education Administer anticholinergics as ordered Peak flow meter Smoking cessation Proper inhaler technique Cleaning of respiratory equipment Evaluation of the outcomes :By following the treatment plan, should see fewer exacerbations, less visits to the emergency department or doctor sick visits, less use of rescue medications, longer periods of asymptomatic status COPD (Chapter 26 pg 530) ★ A disease category with two chronic airflow obstruction disorders : Chronic Bronchitis and Emphysema, while one often predominates, both disease processes can occur ★ Characterized by slowly progressive obstruction of the airways and destructive lung changes like periodic exacerbations occur ★ Respiratory infection : Dyspnea and sputum production ★ End result of disease processes are : airway narrowing, Increased resistance to airflow difficulty with expiration, ventilation (V) to perfusion (Q) mismatch occurs leading to impaired gas exchange, increase work of breathing,are trapping and impaired gas exchange ★ Goals for COPD Management 1. Assess and monitor the disease 2. Reduce risk factors 3. Manage stable COPD 4. Identify and manage exacerbations early  Pathophysiology Bronchitis : Excessive mucus produced in lower respiratory tract. Characterized by a productive cough lasting 3 or more months in 2 consecutive years 1. Inhalation of irritants leads to chronic inflammatory process 2. Goblet cells increase in size and number, and mucous glands enlarge 3. Thick tenacious mucus is produced in increased amounts 4. Changes in bronchial squamous cells impair the ability to clear mucus 5. Narrowed airways and excess secretion obstruct airflow, Ciliary function is impaired 6. Ventilation and perfusion imbalance can lead to hypoxia, hypercapnia, pulmonary hypertension 7. And may lead to right sided heart failure (Cor Pulmonale right ventricle fails) 8. Recurrent infections are common Emphysema :Loss of bronchiolar elasticity and destruction of alveolar walls leading to enlargement of abnormal air spaces in the lungs.Deficiency of alpha-1-antitrypsin: a genetic disorder in which there is inadequate protection against destructive enzyme activity in the lung 1. Macrophages from alveoli and CD-8 T lymphocytes increase and destroy lung tissue 2. Cytokines increase inflammation 3. Anti-proteinase used to protect lung tissue becomes inactivated leading to alveolar wall destruction occurs 4. Alveoli and air spaces enlarge with loss of corresponding portions of the pulmonary capillary bed and elastic recoil is lost 5. Increased risk of expiratory collapse and air trapping from loss of support tissue of airways. 6. Bronchioles or alveoli may be primary tissue involved COPD Manifestations Risk Factors COPD Few manifestations early in disease: Cigarette smoking – Primary cause Cough Air pollution Dyspnea Occupational exposure to noxious dusts and chemicals Exercise intolerance Familial and genetic factors Cough more frequently on early morning Lack of Alpha-1-antitrypsin for emphysema Manifestations Chronic Bronchitis Manifestations Emphysema Productive cough with copious(abundant) Insidious onset amounts of thick tenacious sputum Dyspnea – progressive Increased anterior-posterior chest diameter  Cyanosis “barrel chest” Evidence of right-sided heart failure Appear thin, tachypneic, use accessory Enlarged heart muscles with breathing Distended Neck Veins Sit leaning forward Liver engorgement Prolonged expiratory phase Adventitious sounds upon auscultation Breath sounds diminished Percussion tone is hyperresonant ~An insidious disease is any disease that comes on slowly and does not have obvious symptoms at first ~ Percussion tone is hyperresonant it could indicate air has filled the space around your lungs and is prohibiting them from expanding fully ➔ Diagnostic Tests ➔ Pulmonary Function Tests (PFT’s) : evaluate degree of airway obstruction is completed in a pulmonary function lab to diagnosis and examine the progression of the disease ➔ Ventilation-perfusion scanning : radioisotope is injected and inhaled to show pulmonary capillaries in the alveoli, inhaling shows ventilation and injecting show perfusion ➔ Serum alpha-1-antitrypsin levels :Normal 126-226 mg/dL ➔ Arterial blood gas Invasive (ABG) Severity of hypoxemia – PaO2, SaO2 Degree of acidosis – pH, PaCO2 ➔ Pulse oximetry : (95-100%) ➔ Complete Blood Count (CBC) with WBC differential ➔ Chest x-ray ➔ Sputum cultures  COPD Prevention / Treatment of Infections ★ Smoking Cessation before and after diagnosis, helps to prevent disease development and improve lung function.Decrease development of Comorbidities ★ Immunizations recommended ★ May be Given prophylactic antibiotic when infection present ★ Increased dyspnea with purulent sputum may treat with antibiotics ★ Bronchodilators are given by MDI, DPI, nebulizer or orally ★ Beta 2-adrenergic agonist frequently prescribed :Short acting rescue med is used prior to other inhaled agents , long Acting are used in combination therapy Anticholinergics Ipratropium bromide -frequently used Combivent combines Ipratropium (bronchodilators) has a longer duration of action with albuterol in convenient single administration Newer approved for COPD specifically Aclidinium (Tudorza Pressair) Umeclidinium (IncruseEllipta) Methylxanthine Theophylline – weak bronchodilator with Prescribed for other benefits (bronchodilators) narrow therapeutic effect 10-15 Stimulates respiratory drive Strengthens diaphragmatic contractions Improves cardiac output Improves quality of life for some with COPD Anti-inflammatory Corticosteroids (glucocorticoids) Long term oral administration can lead Agents Used when patient has frequent to: Cushingoid response exacerbations Thinning of the skin with easy IV preparations Improves symptoms and exercise bruising (Methylprednisolone) tolerance Rounding facial features (“moon-like” used initially during May reduce severity of exacerbations face) exacerbation with and underlying condition like asthma Cervicodorsal fat on upper back hospitalization Tapered dose is needed (“buffalo hump”) Oral (Prednisone) Poor wound healing from used during illness Corticosteroid/Beta 2 Agonist immunosuppression and dose tapered For severe symptoms thats not Insomnia or psychological depression down controlled with one drug and need both Excessive hair growth, Muscle categories wasting osteoporosis Advair Diskus (fluticasone propionate Symptoms of / Development of and salmeterol) Diabetes Mellitus due to elevated BS Antitussives Dextromethorphan (Delsym, Adverse effects: sedation and Robitussin DM) - acts directly on the dizziness with moderate/ high doses. To be used only with cough center in the medulla to elevate Overdose: CNS toxicity, dry non-productive the cough threshold slurred speech, ataxia, cough work to hyperexcitability, stupor, suppress the cough Opioid: May cause respiratory respiratory depression, seizures, reflex depression, bronchoconstriction coma, and toxic psychosis codeine PO Contraindications / Precautions Limit use to less than hydrocodone PO Not to be used with children under the a week Nonopioid age of 6 benzonatate (Tessalon) PO Drug interactions: Avoid pulmonary dextromethorphan (In many OTC MAOIs – excitation, hypotension, irritants such as remedies) PO hyperpyrexia smoking Additive CNS depressant effect with Do not take OTC alcohol, antihistamines, cough or cold antidepressants and opioids medicines Grapefruit lead to toxicity Monitor for drowsiness, report coughing up green or yellow secretions, difficulty breathing, or excessive drowsiness Antitussives Benzonatate (Tessalon)- Suppress Should not be used in children under cough reflex by anesthetizing stretch 10 years of age receptors in lungs Do not chew medication Expectorants Guaifenesin: Commonly used OTC drug Assess color, texture and odor of Often used in multi symptom OTC secretions Not for use in children preparations,but dosage range often too Increase fluid intake 2-3 Liters if not under 6 low for much benefit contraindicated Increase fluid content of secretions Do not take multiple OTC cold therefore reducing the viscosity medication preparations Allow secretions to be more easily Notify PCP if symptoms worsen removed through coughing Mucolytic Acetylcysteine (Mucomyst)- Dornase alfa (Pulmozyne)-Oral Administered via Inhalation Not available inhalation Approved for management Work to loosen thick, OTC Used in patients with cystic fibrosis, of thick bronchial secretions viscous bronchial chronic bronchitis, and other diseases Usually given with bronchodilators as secretions through with large amounts of bronchial may cause bronchospasm chemical breakdown= secretions Suction available for ineffective secretions become cough thinner Increase fluid intake Avoid smoking  Other Treatments ➔ Alpha-1-antitrypsin replacement therapy : Expensive weekly IV infusion shown to reduce rate of airflow decline ➔ Pulmonary Hygiene : Hydration , Cough “Huff Coughing” ,Percussion/vibration, Postural drainage ➔ Breathing Exercises : Pulmonary Rehabilitation, pursed-lip breathing slows the respiratory rate , position for comfort and ease of breathing fowlers or tripod, abdominal breathing ➔ Surgery : Lung Transplant (single or bilateral), lung reduction surgery used for advanced emphysema and lung hyperinflation reduces the volume and reshape to improve the elasticity of the lung ➔ Dietary Changes : minimize intake of dairy products and salt , recommended high Protein, higher fats, low carbohydrates , stay hydrated to loosen mucus ➔ Acupuncture ➔ Hypnotherapy and guided imagery : assist with anxiety ➔ Oxygen :Improves exercise tolerance mental functioning quality of life in advanced COPD and will decreases rate of hospitalization ➔ Oxygen – Warning! : with patients who have a chronic elevated carbon dioxide level in the blood , the drive to breathe changes from elevated CO2 level to Low Oxygen level. Increased Oxygen will decrease breathing leading to increased somnolence and respiratory failure usually are CO2 Retainers.Must monitor with ABG’s!  NURSING PROCESS Assessment Recognizing cues (data) Nursing Diagnoses / Identifying Client Problems Health History Impaired Gas Exchange Physical Examination Ineffective Airway Clearance : Related to copious amount Diagnostic studies : chest x ray , ABG, EKG of thick tenacious mucus decreased ciliary action loss of supportive tissue and air trapping Activity Intolerance Anxiety Imbalanced Nutrition Less than Body Requirements Key Interventions /Take Action Patient Teaching Administer medications as ordered Educate on dangers of smoking to all ages Provide oxygen Maintain adequate fluid intake 2-3 L Provide small, frequent meals with dietary Avoid respiratory irritants supplements Prevent exposure to infection Position – Semi-Fowler’s or Tripod Position Importance of pneumococcal vaccine and annual influenza immunization Identifying early signs of an infection or Prescribed exercise program exacerbation and the importance of seeking Maintaining nutrient intake medical attention for the following: Prescribed medications Fever Other prescribed therapies: Coughing,Breathing techniques Upper respiratory infection Increased shortness of breath or difficulty breathing Decreased activity tolerance or appetite Increased need for oxygen Evaluation of the outcomes :Decreased visits to the emergency department and hospitalizations, Medications taken as ordered, Avoids risk factors, Maintains healthy diet