Chapter 20 Management of Patients with Chronic Pulmonary Disease PDF

Chapter 20 Management of Patients with Chronic Pulmonary Disease Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chronic Pulmonary Disease  Chronic obstructive pulmonary disease (COPD) is a slowly progressive respiratory disease of airflow obstruction o Chronic...

Chapter 20 Management of Patients with Chronic Pulmonary Disease Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chronic Pulmonary Disease  Chronic obstructive pulmonary disease (COPD) is a slowly progressive respiratory disease of airflow obstruction o Chronic bronchitis, emphysema o Preventable and treatable but not fully reversible o Involving the airways, pulmonary parenchyma, or both o Fourth leading cause of death in the United States for people of all ages  Other chronic pulmonary diseases o Bronchiectasis, asthma, cystic fibrosis Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology of COPD Airflow limitation is progressive, associated with abnormal inflammatory response to noxious particles or gases Chronic inflammation damages tissue Scar tissue in airways results in narrowing Scar tissue in the parenchyma decreases elastic recoil (compliance) Scar tissue in pulmonary vasculature causes thickened vessel lining and hypertrophy of smooth muscle (pulmonary hypertension) Copyright © 2022 Wolters Kluwer · All Rights Reserved Chronic Bronchitis Cough and sputum production for at least 3 months in each of 2 consecutive years Ciliary function is reduced, bronchial walls thicken, bronchial airways narrow, and mucous may plug airways Alveoli become damaged, fibrosed, and alveolar macrophage function diminishes The patient is more susceptible to respiratory infections Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology of Chronic Bronchitis Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? Patients with chronic bronchitis are more susceptible to respiratory infection. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 True Rationale: The functions of alveolar macrophages are altered in patients with chronic bronchitis. Macrophages are essential to destroy foreign materials, such as bacteria. Without functional macrophages, bacterial, viral and mycoplasma infections become more likely with acute episodes of bronchitis. Exacerbations of chronic bronchitis are most likely to occur during the winter when viral and bacterial infections are more prevalent. Copyright © 2022 Wolters Kluwer · All Rights Reserved Clinical Manifestations of COPD Three primary symptoms o Chronic cough o Sputum production o Dyspnea Weight loss due to dyspnea “Barrel chest” Copyright © 2022 Wolters Kluwer · All Rights Reserved Characteristics of Normal Chest Wall and Chest Wall in Emphysema Copyright © 2022 Wolters Kluwer · All Rights Reserved Typical Posture of a Person with COPD Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment and Diagnosis of COPD Health history, refer to Chart 20-2 Pulmonary function tests Spirometry Arterial blood gas Chest x-ray Copyright © 2022 Wolters Kluwer · All Rights Reserved Complications of COPD Respiratory insufficiency and failure Pneumonia Chronic atelectasis Pneumothorax Cor pulmonale Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of COPD Promote smoking cessation Reducing risk factors Managing exacerbations Providing supplemental oxygen therapy Pneumococcal vaccine Influenza vaccine Pulmonary rehabilitation Managing exacerbations Copyright © 2022 Wolters Kluwer · All Rights Reserved Medications to Treat COPD Bronchodilators, MDIs o Beta-adrenergic agonists o Muscarinic antagonists (anticholinergics) o Combination agents o Refer to Figure 20-5 and Tables 20-3 and 20-4 Corticosteroids Antibiotics Mucolytics Antitussives Copyright © 2022 Wolters Kluwer · All Rights Reserved Surgical Management of COPD Bullectomy Lung volume reduction Lung transplant Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of COPD Refer to Chart 20-4 Assessing the patient: obtain history, review diagnostic tests Achieving airway clearance Improving breathing patterns Improving activity tolerance MDI patient education Copyright © 2022 Wolters Kluwer · All Rights Reserved Bronchiectasis Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles Caused by: o Airway obstruction, pulmonary infections o Diffuse airway injury o Genetic disorders o Abnormal host defenses o Idiopathic causes Copyright © 2022 Wolters Kluwer · All Rights Reserved Clinical Manifestations and Medical Management of Bronchiectasis Chronic cough Purulent sputum in copious amounts Clubbing of the fingers Postural drainage Chest physiotherapy Smoking cessation Antimicrobial therapy Bronchodilators and mucolytics Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of Bronchiectasis Focus is on alleviating symptoms and clearing pulmonary secretions Patient teaching o Smoking cessation o Postural drainage o Early signs and symptoms of respiratory infections o Conserving energy Copyright © 2022 Wolters Kluwer · All Rights Reserved Asthma Chronic inflammatory disease of the airways that causes hyperresponsiveness, mucosal edema, and mucus production Inflammation leads to cough, chest tightness, wheezing, and dyspnea Asthma is largely reversible; spontaneously or with treatment Allergy is the strongest predisposing factor Copyright © 2022 Wolters Kluwer · All Rights Reserved Clinical Manifestations of Asthma Cough, dyspnea, wheezing Exacerbations o Cough, productive or not o Generalized wheezing o Chest tightness and dyspnea o Diaphoresis o Tachycardia o Hypoxemia and central cyanosis Copyright © 2022 Wolters Kluwer · All Rights Reserved Medications Used in the Treatment of Asthma Quick-relief medications o Beta-2 adrenergic agonists o Anticholinergics Long-acting medications o Corticosteroids o Long-acting beta-2 adrenergic agonists o Leukotriene modifiers Copyright © 2022 Wolters Kluwer · All Rights Reserved Patient Teaching for Asthma How to identify and avoid triggers Proper inhalation techniques How to perform peak flow monitoring How to implement an action plan When and how to seek assistance Copyright © 2022 Wolters Kluwer · All Rights Reserved Cystic Fibrosis Most common autosomal recessive disease among the Caucasian population Genetic screening to detect carriers Genetic counseling for couples at risk Genetic mutation changes chloride transport which leads to thick, viscous secretions in the lungs, pancreas, liver, intestines, and reproductive tract Respiratory infections are the leading cause of morbidity and mortality Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of CF  Chronic: control of infections; antibiotics  Acute: aggressive therapy involves airway clearance and antibiotics based on results of sputum cultures  Anti-inflammatory agents  Corticosteroids; inhaled, oral, IV during exacerbations  Inhaled bronchodilators  Oral pancreatic enzyme supplementation with meals  Cystic fibrosis transmembrane conductance regulator (CFTR) modulators are a new class of drugs and help to improve function of the defective CFTR protein Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of CF Strategies that promote removal of pulmonary secretions o CPT and breathing exercises Remind patient to reduce risk factors for resp infection Adequate fluid and electrolyte intake Palliative care Discuss end-of-life issues and concerns Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #2 Which of the following should a patient do after using a metered dose inhaler (MDI) containing a corticosteroid? A. Wait at least 5 minutes before drinking any liquid B. Use a soft bristle toothbrush for brushing teeth during the next 24 hours C. Monitor for hyperthermia which could be a sign of an infection D. Rinse mouth with water immediately after use Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 D. Rinse mouth with water immediately after use. Rationale: Rinsing the mouth with water after using an MDI with corticosteroid is necessary to avoid development of thrush in the oral cavity. Copyright © 2022 Wolters Kluwer · All Rights Reserved Risk Factors for COPD Exposure to tobacco smoke Older adults Occupational exposure Pollution Genetic abnormalities Refer to Chart 20-1 Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Care of Patients with COPD Evaluate exposure to respiratory irritants Nursing interventions to promote oxygenation o Incentive spirometry o Postural drainage o Chest percussion and vibration o Breathing exercises Administer medications to promote gas exchange and oxygenation o Oxygen o Bronchodilators Copyright © 2022 Wolters Kluwer · All Rights Reserved Oxygen Therapy Administration of oxygen at greater than 21% to provide adequate transport of oxygen in the blood while: o Decreasing the work of breathing and reducing stress on the myocardium Hypoxemia: a decrease in the arterial oxygen tension in the blood Hypoxia: a decrease in oxygen supply to the tissues and cells that can also be caused by problems outside the respiratory system Severe hypoxia can be life threatening Copyright © 2022 Wolters Kluwer · All Rights Reserved Oxygen Toxicity May occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period Symptoms include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates on x-ray Prevention: o Use lowest effective concentrations of oxygen o PEEP or CPAP prevent or reverse atelectasis and allow lower oxygen percentages to be used Copyright © 2022 Wolters Kluwer · All Rights Reserved Oxygen Administration Cylinder, piped-in, concentrator Classified as low flow or high flow Devices (Refer to Table 20-2) o Nasal cannula o Oropharyngeal catheter o Masks o Transtracheal catheter Copyright © 2022 Wolters Kluwer · All Rights Reserved Education Plan for Patients with COPD Patient education for o Smoking cessation o Medication administration o Breathing exercises o Regular exercise o Realistic goals o Emergency management Refer to Chart 20-5 Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #3 Is the following statement true or false? An advantage of the Venturi mask is the high level of supplemental oxygen delivery even though the mask is poorly fitted to the patient’s face. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 False Rationale: The Venturi mask is tighter fitting than the non-rebreathing mask but delivers low levels of supplemental oxygen. Whereas a low-flow oxygen delivery system may imprecisely deliver high concentrations of oxygen (e.g., up to 100% via a non- rebreathing mask), the Venturi mask, which is a high- flow system, is specifically designed to deliver precise but lower concentrations of oxygen (less than 30% oxygen). Copyright © 2022 Wolters Kluwer · All Rights Reserved Home Oxygen Nurse instructs the patient about oxygen: o Safe methods for administering in the home o Available in gas, liquid, concentrated o Portable devices o Humidity must be provided o Community resources See Chart 20-7 Copyright © 2022 Wolters Kluwer · All Rights Reserved Self-Management of Asthma Exacerbations o Status asthmaticus Peak flow monitoring o Refer to Chart 20-8 Action plan o Refer to Figure 20-11 Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #4 Is the following statement true or false? Increasing PaCo2 levels for a patient in status asthmaticus is a sign of improvement. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #4 False Rationale: Status asthmaticus is a rapid onset, severe, and persistent asthma that does not respond to conventional therapy. Patients are often hospitalized for treatment. Increasing levels of PaCO2 indicate a worsening condition with inadequate gas exchange. Copyright © 2022 Wolters Kluwer · All Rights Reserved