MEGA Gas Exchange PP.pdf

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Robin K. Long, MSN, RN, CPNP  15 million in U.S. COPD: INCIDENCE AND 900,000 in Canada PREVALENCE 4th leading caus...

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Robin K. Long, MSN, RN, CPNP  15 million in U.S. COPD: INCIDENCE AND 900,000 in Canada PREVALENCE 4th leading cause of morbidity and mortality in the U.S. GAS EXCHANGE  Pathophysiology Overview CONCEPT  Def: A collection of lower airway disorders that interfere with airflow EXEMPLAR: and gas exchange. COPD includes: CHRONIC   Emphysema OBSTRUCTIVE  A destructive problem of lung elastic tissue that reduces its ability to recoil after stretching, leading to PULMONARY  hyperinflation of the lung. Chronic bronchitis DISEASE  An inflammation of the bronchi and bronchioles caused by exposure to (COPD) irritants, especially cigarette smoke.  Emphysema is a destructive problem of lung elastic tissue (alveoli) that reduces its ability to recoil after stretching, leading to hyperinflation of the lung. Alveoli are damaged.  Results in air trapping  See increased work of breathing  “air hunger” sensation  Gas exchange decreased: (CO2 retention, respiratory acidosis) EMPHYSEMA  Inflammation of the bronchi and bronchioles (bronchiolitis) caused by exposure to irritants (cigarette smoke)  Irritant triggers inflammation, vasodilation, mucosal edema, congestion, and bronchospasm.  Bronchitis affects only the airways, not the alveoli.  Chronic inflammation increases the number and size of mucus- secreting glands, which produce large amounts of thick mucus. The bronchial walls thicken and impair airflow. This thickening, along with excessive mucus, blocks some of the smaller airways and narrows larger ones. The increased mucus provides a breeding ground for organisms and leads to chronic infection. CHRONIC BRONCHITIS Cigarette smoking is the greatest risk factor COPD: RISK FACTORS AND GENETIC Alpha1-antitrypsin deficiency RISK Asthma BASICS OF GAS EXCHANGE Hypoxemia Acidosis COMPLICATIONS OF COPD Respiratory infection Cardiac failure (cor pulmonale) Dysrhythmias Respiratory failure  History Risk factors Smoking history Breathing problems Activity level Weight COPD ASSESSMENT: Physical Assessment/Signs and Symptoms RECOGNIZE General Respiratory Cardiac changes CUES appearance Psychosocial Assessment BARREL CHEST COPD: ASSESSMENT: RECOGNIZE CUES (2 OF 2) Laboratory assessment  ABG’s (baseline, repeat, follow pattern).  See hypoxemia and hypercapnia  Pox (to gauge treatment response), 45).  High CO2 levels reduce respiratory drive. Can lead to respiratory arrest.  Safe sats strategy: Aim for O2 sats 88-92%  Deliver O2 by Venturi mask (control amount delivered)…(24 %- 28%). Careful with NC delivery…uncontrolled pure O2 delivery COPD PATIENTS AND O2 ADMIN..CAREFUL!  Weight loss  Dyspnea management  Small meals 2-3 x/day, eat big meal when most hungry  Good food selection/high calorie foods  Pursed lip breathing and inhaler before eating.  Anxiety prevention  Write down a plan  Pursed lip breathing/diaphragm breathing  Support people/counseling for anxiety  Hypnosis, relaxation techniques PREVENTING WEIGHT LOSS AND MINIMIZING ANXIETY  Decreasing Infection  Pneumonia complication  Improving Endurance  Fatigue  Help with ADL’s  Energy conservation DECREASING INFECTION AND IMPROVING ENDURANCE  SMOKING CESSATION!  I-PREPARE model COPD: HEALTH PROMOTION AND MAINTENANCE COPD: CARE COORDINATION AND TRANSITION MANAGEMENT  Home care management  Use of oxygen  Self-management education  Drug therapy  Breathing techniques  Health care resources  Attain and maintain gas exchange at a level within his or her chronic baseline values  Achieve an effective breathing pattern that decreases the work of breathing  Maintain a patent airway  Achieve and maintain a body weight within 10% of his or her ideal weight  Have decreased anxiety  Increase activity to a level acceptable to him or her  Avoid serious respiratory infections COPD: EVALUATION: EVALUATE OUTCOMES NCLEX STYLE QUESTIONS COPD content QUESTION 1 A client with COPD who smokes 1 PPD presents for a routine appointment. Which client statement causes the nurse to suspect an increase in dyspnea? A. “I prop myself up at night to sleep.” B. “I decided to put on some makeup today.” C. “I have a productive cough in the morning.” D. “I have gained weight since I was here last.” ANS: A  Clients with COPD, who smoke, may have a productive morning cough. Weight loss (not gain) often occurs when dyspnea is increased due to the increased metabolic demand. A disheveled appearance may indicate an increase in dyspnea, if the client doesn’t feel well enough to perform ADLs. Sleeping propped up indicates that breathing may be worse while lying down. ANSWER TO QUESTION 1 QUESTION 2 The nurse is assessing a client with a chest tube following a pneumonectomy. Which assessment finding requires nursing intervention? A. Bandage around the posterior tube is loose. B. 2 cm of water is in the second chest tube chamber. C. The water in the water seal chamber rises and falls with inhalation/exhalation. D. Bubbling present in the water seal chamber when the client coughs. ANS: A  After lung surgery, two tubes, anterior and posterior, are used. Dressings around the wound should not be loose. Other findings are normal. ANSWER TO QUESTION 2 QUESTION 3 A client with a history of asthma reports shortness of breath. The nurse observes that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. What is the priority nursing action? A. Obtain vital signs. B. Administer rescue drugs. C. Notify the health care provider. D. Repeat the PEF reading to verify results. ANS: B  A PEF reading in the red zone indicates a range that is 50% below the client’s personal best PEF reading and indicates serious respiratory obstruction. The client needs to receive rescue drugs immediately, and then the health care provider should be notified. Repeating the PEF reading and taking vital signs are also important, but doing so delays the administration of the rescue drugs. These can be done after rescue drugs are given. ANSWER TO QUESTION 3 NSG 170 Gas Exchange Pediatric Asthma R. Long, MSN, RN, CPNP  CONCEPTS The priority concept in this chapter is Gas Exchange The interrelated concepts in this chapter are Perfusion Inflammation Cellular Regulation  RESPIRATORY SYSTEM REVIEW Upper airway Nares (or nostrils), pharynx (throat) Larynx is located between the pharynx and trachea and houses the vocal cords. Ciliated mucous membranes Tonsils Lower airway Trachea, bronchi, bronchioles and lung periphery (alveoli) Alveoli where gas exchange occurs RESPIRATORY SYSTEM DIAGRAM MECHANISM OF GAS EXCHANGE  DIFFERENCES IN PEDIATRIC AND ADULT RESPIRATORY SYSTEM Lack of or insufficient surfactant Smaller airways and undeveloped cartilage Obligatory nose breather (infant) Less well-developed intercostal muscles Brief periods of apnea common (newborn) Faster respiratory rate; increased metabolic needs Eustachian tubes relatively horizontal Tonsillar tissue enlargement More flexible larynx, susceptible to spasm Abdominal breathers  ASTHMA: INCIDENCE AND PREVALENCE Can occur at any age Highest between 10-17 years of age Leading cause of acute and chronic illness in children Most frequent admitting diagnosis in Childrens’ hospitals 8.3% of children in US have asthma Higher in African American population More common in urban than rural settings  ASTHMA-PATHO Chronic disease that occurs intermittently Genetic and environmental factors Result: Inflammation and airway tissue sensitivity A reversible obstructive airway disease characterized by Increased airway responsiveness to a variety of stimuli Bronchospasm resulting from constriction of bronchial smooth muscle (bronchoconstriction) Inflammation and edema of the mucous membranes that line the small airways and the subsequent accumulation of thick secretions in the airways (mucous production)  PATHO, CONT.. Immediate Reaction Allergens activate IgE receptors on mast cells Histamines, leukotrienes and prostaglandins released Causes bronchoconstriction Non allergic stimuli (cold air, exercise) also cause bronchoconstriction Late Reaction Eosinophils, basophils, neutrophils attracted to the respiratory tract Causes inflammation, edema, mucous production/plugging Get bronchoconstriction and hyperesponsive airways (can last weeks to months).  ASTHMA (PATHO) Pictured above is a normal bronchial tube and lumen compared to a bronchial tube during asthma episode.  BRONCHIAL ASTHMA Pictured above: With bronchial asthma, the bronchiole is obstructed on expiration, particularly by muscle spasm, edema of the mucosa, and thick secretions.  ASTHMA ASSESSMENT-HISTORY Premature Family history Previous episodes of wheezing Cough, coughing at night, cough during or after exercise SOB Allergies (food, meds, etc..) Triggers Allergic rhinitis or eczema? Ever hospitalized for asthma? # of episodes in the last year?  RISK FACTORS Family history of asthma Previous severe lower respiratory infections Presence of allergy/allergic rhinitis (seasonal allergies) or atopy (eczema) Called Allergic triad… More common in boys Prematurity  ASTHMA TRIGGERS Variety of stimuli: Cold air/change in weather Smoke Allergens (pollen, dander, dust, mold, cockroach droppings) Viral /bacterial infections Stress Exercise Environmental pollutants (smoking, carpets) Foods Medications (aspirin, NSAIDs, beta blockers)  ASTHMA ASSESSMENT- SIGNS AND SYMPTOMS Vital signs (HR and RR) Color (circumoral…) Lung sounds-wheezing, aeration, stridor, cough, chest tightness Accessory muscles (retractions) Clavicular Sternal (supra and sub) Intercostal Neck muscles Abdomen Restless, apprehension, anxiety, diaphoresis Tripod position Difficulty talking, eating and walking Symptoms worse at night  ASTHMA ASSESSMENT-DIAGNOSTICS Laboratory assessment Pulse ox End tidal CO2 monitoring (carbon dioxide) ABG’s (arterial blood gas) Peak flow meter (daily) CXR Pulmonary function tests Diagnostic for asthma Forced vital capacity (FVC)-decreased Forced expiratory volume in first second (FEV1)- decreased Increased residual volume  ASTHMA DIAGNOSTICS, CONT. See allergic rhinitis (seasonal allergies), sinusitis and nasal polyps in asthmatic patients IgE skin testing for allergens (for specific allergens) Blood and sputum See eosinophils present  ASTHMA: ASSESSMENT: RECOGNIZE CUES Assessment: Noticing Key Features of Disease: Asthma Symptoms and Control Level Symptoms Controlled Partly Uncontrolled Controlled Daytime symptoms of wheezing, dyspnea, coughing present more than twice weekly Waking from night sleep with None of these 1-2 of these 3-4 of these symptoms of wheezing, dyspnea, coughing Relieved (rescue) drug needed more than twice weekly Number of times per week activity was limited or stopped by symptoms Adapted from Global Initiative for Asthma (GINA). 2018. Pocket Guide for asthma management and prevention.  CLASSIFICATIONS OF ASTHMA Intermittent Mild persistent Moderate persistent Severe persistent  THERAPEUTIC MANAGEMENT OF ASTHMA Goal: Improve airflow and gas exchange 4 Domains: Assessing, Collaboration, Avoidance and Meds Recognize early signs of an asthma episode Follow an asthma action plan Avoidance of triggers Administer medications and treatments Education for patient and family Close f/u and collaboration with PCP, parents, school, etc.  ASTHMA MEDICATIONS Drug therapy Rescue drugs (used to stop an attack) (ACUTE) SABA’s (short acting beta adrenergic agonists) Bronchodilators (MDI, nebulizer) Albuterol( ProAir HFA, Ventolin, Proventil) Levalbuterol (Xopenex) Terbutaline (Breatheair) Anticholinergics Ipratropium bromide (Atrovent) (kids 12 and older) Combined with a SABA (albuterol)..duo neb Corticosteroids (short term..5 to 7 days) PO (prednisone, prednisolone) IV (Solumedrol)  ASTHMA MEDS, CONT.. Control therapy drugs (LONG TERM..prevention) Daily use, prevention Anti-inflammatory agents (inhaled) Budesonide (Pulmicort), fluticasone (Flovent), beclomethasone (Qvar) LABA’s (long-acting beta 2 adrenergics) Salmeterol (Serevent) and formaterol (Foradil) Combo meds Symbicort (budesonide and formoterol) (ICS and LABA) Advair (fluticasone and salmeterol) (ICS and LABA) Leukotriene inhibitors Decreases action of leukotrienes Montelukast (Singular) Give as young as 1 year old (sprinkles/chewables) Anti IgE antibody Omalizumab (Zolair), Nucala SQ injection every 4 weeks For allergic type asthma  ASTHMA MEDS, CONT.. Xanthines Older drug Theophylline (Slo bid, Theodur) Relaxes bronchial smooth muscle, increase HR Need to monitor levels for toxicity Theophylline level  SIGNS AND SYMPTOMS (NEED FOR EMERGENCY TREATMENT) Worsening wheeze, cough, or shortness of breath No improvement after bronchodilator use Difficulty breathing Trouble with walking or talking Discontinuation of play Listlessness or weak cry Gray or blue lips or fingernails Poor aeration, minimal or no wheezing noted  STATUS ASTHMATICUS Severe, life-threatening, acute episode of airway obstruction Intensifies once it begins, often does not respond to common therapy Can develop pneumothorax and cardiac or respiratory arrest Treatment—IV fluids, potent systemic bronchodilator, steroids, epinephrine, oxygen Prepare for emergency intubation ASTHMA ACTION PLAN  VA ASTHMA ACTION PLAN https://www.vdh.virginia.gov/content/uploads/sites/58/ 2016/12/Asthma-Action-Plan-2019.pdf  ENVIRONMENTAL MODIFICATIONS Pollen and dust Wash sheets weekly in hot water No wool or down blankets Dust-proof covers on pillows and mattresses Replace carpet with wood or tile No drapes or blinds; use curtains or shades Air filters and cleaners, use air conditioner Household humidity at 40-50% Multilayer vacuum bags Clean with dust-attracting rags/towels  ENVIRONMENTAL MODIFICATIONS, CONT.. Mold Clean with mold inhibitor Dry shoes thoroughly Moisture remover in closets Avoid basements No rubber or inner-spring mattresses Use air conditioner Humidity below 35%, use a dehumidifier House ventilation Limit number of indoor plants  ENVIRONMENTAL MODIFICATIONS, CONT. Dander Keep pets outside, if possible House ventilation Air cleaners Dust covers on mattresses and pillow cases Frequent vacuuming Air purifier  EDUCATION/PREVENTION OF ASTHMA Collaboration/communication between patient, parents, PCP’s and school nurses. Frequent visits to PCP/education ongoing. Know and avoid triggers Alter environment Use your peak flow! Know yourself! Take your medications! Seek medical help as soon as symptoms not responding to treatment. Don’t wait! Questions/Comments? Anemias: Fe deficiency and Blood transfusions ROBIN K. LONG, MSN, RN, CPNP Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  2 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Gas exchange 3 & tissue perfusion Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Anemia  Reduction in:  Number of RBCs Amount of hemoglobin Amount of hematocrit  Clinical indicator & not specific disease  Many causes Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Normal RBC’s vs Anemia 5 Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Decreased RBC’s: Why? 6 3 Main Causes  Increased Destruction  Autoimmune hemolytic anemia  G6PD deficiency anemia  Decreased production  Fe deficiency…lack of Fe in diet  Chronic blood (RBC) loss  Acute Trauma  Gastritis  Menstruation  hemorrhoids Nursing Interventions are the same..no matter the cause. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. H & H - part of the CBC 7 Hemoglobin Hematocrit  Iron-rich protein in  Percentage of red blood cells packed RBC’s per  Oxygen carrying deciliter of blood capacity of RBC’s  Label is %  g/dL  Varies with age  Varies with age  Men