Respiratory Disorder nursing care (1).docx

**Respiratory Disorder** +-----------------------------------+-----------------------------------+ | **Pulmonary system changes with | | | aging:** | | | |...

**Respiratory Disorder** +-----------------------------------+-----------------------------------+ | **Pulmonary system changes with | | | aging:** | | | | | | - **Alveoli (6)** | | | | | | | | | | | | - Alveolar surface area | | | decreases. | | | | | | - Diffusion capacity decreases. | | | | | | - Elastic recoil decreases. | | | | | | - Bronchioles and alveolar | | | ducts dilate. | | | | | | - Ability to cough decreases. | | | | | | - Airways close early. | | | | | | - | | | | | | Q. **What are some nursing | | | interventions for age related | | | changes in alveolar | | | function?** | | | | | | - Include inspection, | | | palpation, percussion, and | | | auscultation in lung | | | assessments. Rationale: | | | Inspection, palpation, | | | percussion, and auscultation | | | are needed to detect normal | | | age-related changes. | | | | | | - Help patient actively | | | maintain health and fitness. | | | Rationale: Health and fitness | | | help keep losses in | | | respiratory functioning to a | | | minimum. | | | | | | - Assess patient\'s | | | respirations for abnormal | | | breathing patterns. | | | Rationale: Periodic breathing | | | patterns (e.g., | | | Cheyne-Stokes) can occur. | | | | | | - Encourage frequent oral | | | hygiene. Rationale: Oral | | | hygiene aids in the removal | | | of secretions. | | | | | | **Pharynx and Larynx** | | | | | | - Muscles atrophy. | | | | | | - Vocal cords become slack. | | | | | | - Laryngeal muscles lose | | | elasticity, and airways lose | | | cartilage. | | | | | | **Q.** **What are some nursing | | | interventions for age related | | | changes in Pharynx and Larynx | | | function?** | | | | | | - Have face-to-face | | | conversations with patient | | | when possible. Rationale: | | | Patient\'s voice may be soft | | | and difficult to understand. | | | | | | **Pulmonary Vasculature** | | | | | | - Vascular resistance to blood | | | flow through | | | | | | - Pulmonary vascular system | | | increases | | | | | | - Pulmonary capillary blood | | | volume decreases. | | | | | | - Risk for hypoxia increases. | | | | | | **Q. What are some nursing | | | interventions for age related | | | changes in Pulmonary Vasculature | | | function?** | | | | | | - Assess patient\'s level of | | | consciousness and cognition. | | | Rationale: Patient can become | | | confused during acute | | | respiratory conditions. | | | | | | **Exercise Tolerance** | | | | | | \* The body's response to hypoxia | | | and hypercarbia decreases. | | | | | | **Q. What are some nursing | | | interventions for age related | | | changes in Exercise Tolerance?** | | | | | | \* Assess for subtle | | | manifestations of hypoxia. | | | Rationale: Early assessment helps | | | prevent complications. | | | | | | \* Muscle Strength | | | | | | \* Respiratory muscle strength, | | | especially the diaphragm and the | | | intercostals, decreases. | | | | | | **Q. What are some nursing | | | interventions for age related | | | changes in Muscle Strength?** | | | | | | \* Encourage pulmonary hygiene, | | | and help patient actively | | | maintain health and fitness. | | | Rationale: Regular pulmonary | | | hygiene and overall fitness help | | | maintain maximal functioning of | | | the respiratory system and | | | prevent illness. | | | | | | **Susceptibility to Infection** | | | | | | \* Effectiveness of the cilia | | | decreases.\ | | | \ | | | \* Immunoglobulin A decreases.\ | | | \ | | | \* Alveolar macrophages are | | | altered. | | | | | | **Q. What are some nursing | | | interventions for age related | | | changes in Susceptibility to | | | Infection?** | | | | | | \* Encourage pulmonary hygiene, | | | and help patient actively | | | maintain health and fitness. | | | Rationale: Regular pulmonary | | | hygiene and overall fitness help | | | maintain maximal functioning of | | | the respiratory system and | | | prevent illness. | | | | | | **Chest Wall** | | | | | | - \* Anteroposterior diameter | | | increases.\ | | | \ | | | \* Thorax becomes shorter.\ | | | \ | | | \* Progressive kyphoscoliosis | | | occurs.\ | | | \ | | | \* Chest wall compliance | | | (elasticity) decreases.\ | | | \ | | | \* Mobility may decrease. | | | | | | **Q. What are some nursing | | | interventions for age related | | | changes in the Chest Wall?** | | | | | | - Discuss the normal changes of | | | aging. Rationale: Patients | | | may be anxious because they | | | must work harder to breathe. | | | | | | - Discuss the need for | | | increased rest periods during | | | exercise. Rationale: Older | | | patients have less tolerance | | | for exercise. | | | | | | Top of Form | | | | | | Bottom of Form | | +===================================+===================================+ | **Pathophysiologic process of | **The following lung diseases are | | asthma (obstructive pulmonary | categorized as obstructive:** | | disease):** | | | | - Chronic obstructive pulmonary | | 1. Chronic airflow obstruction | disease (COPD) | | of the bronchi and | | | bronchioles d/t inflammation | - Chronic bronchitis. | | that causes | | | hyperresponsiveness, mucosal | - Asthma. | | edema, and mucous production. | | | | - Bronchiectasis. | | 2. Antigen/allergen binds to | | | dendritic cell→Dendritic cell | - Bronchiolitis. | | present antigen to type 2 | | | helper cells (Th2), but they | - Cystic fibrosis. | | have an excessive | | | response→T2h cells produce | **Asthma** is a chronic lung | | cytokines, like interleukin 4 | disease (no cure) that causes | | and 5→IL-4 eads to production | narrowing and inflammation of the | | of IgE antibodies (Type 1 | airways ([bronchi and | | hypersensitivity reaction), | bronchioles](https://www.register | | which coat mast cells Mast | ednursern.com/lung-anatomy-and-ph | | cells release histamine, | ysiology-review-notes/)) | | leukotrienes, prostaglandins | that leads to difficulty | | IL5 activate eosinophils, | breathing. | | which release more cytokines | | | and leukotrienes | **How does it happen?** | | | | | 3. In a type 1 hypersensitivity | First, let's talk about what | | reaction (IL-4 response), | should happen normally with | | smooth muscle around | breathing! Normally, when you | | bronchioles spasm and there | breathe in air, it travels down | | is increased mucous | through your upper airway to your | | secretion. Also, vascular | lower airway, which is the | | permeability increases, and | trachea, bronchi, bronchioles, | | more eosinophils enter from | and alveoli (where gas exchange | | the blood. The chemical | happens). The oxygen you breathe | | mediators from the immune | in crosses over into your blood | | cells that damage lung | stream and the carbon dioxide in | | endothelium. | your blood crosses over into the | | | airway to be exhaled. | | **How to use a peak flow meter to | | | help monitor the status of their | ***What is happening in patients | | asthma:** | with asthma?*** | | | | | - Patients should perform daily | In patients with asthma, the | | peak flow meter assessments | bronchi and bronchioles | | to self-manage their asthma | are ***chronically | | | inflamed*** and can become so | | - Peak flow meter assessments | inflamed that it leads to | | measure the amount of air you | an **[asthma | | can blow out in one fast | attack]**. This will | | breath | cause the patient to experience | | | wheezing, chest tightness, | | **Pharmacological interventions | shortness of breath, and | | for asthma:** | coughing. An asthma attack occurs | | | due to a trigger of some type | | - **Bronchodilators** | (discussed later). | | | | | : Short-acting beta2 agonists -- | **[Key Players of an Asthma | | albuterol | Attack:]** | | | | | -Rapid relief and prevention of | ***Bronchi and Bronchioles*** | | exercise-induced asthma | | | | - **What surrounds these | | -Watch for tachycardia and | structures?** Surrounding the | | tremors | bronchi and bronchioles **are | | | smooth muscles** that wrap | | :**Anticholinergic medication -- | around the airway. This | | ipratropium** | muscle helps with *dilating | | | and constricting* the airway. | | - Can provide rapid relief, but | | | also is long-acting and used | | | to prevent bronchospasms | | | | - **During an asthma attack, | | - Blocks the PNS, allowing the | these smooth muscles | | SNS to bronchodilate and | constrict. This causes chest | | decrease pulmonary secretions | tightness and difficulty | | | breathing.** | | - Watch for dry mouth increase | | | fluid intake, suck on hard | | | candies | | | | - **What is inside these | | - Monitor heart rate | structures?** Inside these | | | structures is a mucosa lining | | - Report headache, blurred | which contains special cells | | vision, or palpitations | called *goblet cells*. Goblet | | (signs of toxicity) | cells *produce mucous,* which | | | helps trap the irritants and | | :**Methylxanthines -- | bacteria we breathe in and | | theophylline** | prevent these substances from | | | entering further into our | | -Only used when other methods are | respiratory system. | | ineffective because there is a | | | narrow therapeutic range | | | | | | -Monitor blood levels | - During an asthma attack, the | | | mucosa becomes very inflamed | | -Adverse effects -- tachycardia, | (this narrows the | | nausea, diarrhea | airway...decreasing air flow | | | and air becomes trapped in | | :**Long-acting beta2 agonists -- | the alveoli). The goblet | | salmeterol** | cells (due to the | | | inflammatory response) | | -Prevention of asthma attacks | produce excessive amounts of | | | mucous. Hence, leading to | | :**Anti-inflammatory agents used | further decrease in air | | to decrease airway inflammation | flow: *coughing, | | and for prevention** | wheezing* (as air tries to | | | flow through the narrow | | -For anti-inflammatory agents, | airway and around the mucous | | watch for decreased immunity | it makes a musical whistling | | function and poor wound healing, | sound). | | hyperglycemia, fluid retention | | | and weight gain, aphthous lesions | - During this, air is becoming | | (canker sores); report black, | trapped in the alveoli. | | tarry stools | Therefore, gas exchange is | | | not taking place and low | | -Corticosteroids -- fluticasone, | amounts of oxygen are | | prednisone, budesonide | entering the blood (the | | | patient will have decreased | | -Take prednisone with meals | oxygen saturation) and carbon | | | dioxide is staying in the | | -Use spacer to prevent thrush; | blood (patient will have the | | oral rinse with baking soda and | buildup of | | water, then swallow QID | CO2.....[respiratory | | | acidosis](https://www.registe | | -Leukotriene antagonists -- | rednursern.com/respiratory-acidos | | montelukast | is-nclex-review-notes-with-mnemon | | | ic-quiz-acid-base-imbalance-notes | | -Mast cell stabilizers -- | /)). | | cromolyn | The patient will feel like | | | they can't exhale all the | | -Monoclonal antibodies- | way. | | omalizumab | | | | Now asthma attacks vary in | | (Can cause anaphylaxis) | severity among patients. It is | | | important for the patient to | | | recognize | | | the **triggers** and **early | | | signs and symptoms of a pending | | | asthma attack (discussed | | | below)**. These early signs and | | | symptoms are different for every | | | patient, but as the nurse you | | | will need to teach the patient | | | how to recognize them. They will | | | usually have these signs and | | | symptoms 1 to 2 days before an | | | attack. In addition, the patient | | | will need to follow an asthma | | | action plan created by the MD and | | | the patient. | | | | | | ***What is an asthma action | | | plan?*** It is a plan created to | | | help the patient control their | | | asthma based on the patient's | | | current signs and symptoms, along | | | with using a peak flow meter. The | | | asthma action plan has three | | | zones (green, yellow, and red) | | | and based on the patient's signs | | | and symptoms, they will treat | | | their asthma with the prescribed | | | medications. See a sample action | | | plan below. | | | | | | The cause of asthma is unknown | | | (may be genetic or environmental) | | | but certain "triggers" can lead | | | to an asthma attack: | | | | | | **What can trigger asthma?** | | | | | | - Environment: smoke, pollen, | | | pollution, perfumes, dander, | | | dust mites, pests | | | (cockroaches), cold and dry | | | air, mold | | | | | | - Body Issue: respiratory | | | infection, GERD, hormonal | | | shifts, exercise-induced | | | | | | - Intake of Certain Substances: | | | drugs (beta adrenergic | | | blockers that are | | | nonselective), NSAIDS, | | | aspirin, preservatives | | | (sulfites) | | | | | | ***How is it | | | diagnosed?*** pulmonary function | | | test (PFT) | | | | | | Another thing is to educate the | | | patient about **[early warning | | | signs:]** | | | | | | - - - - - - - | | | | | | **Signs and Symptoms of Asthma | | | Attack ** | | | | | | - - - - - | | | | | | Can progress to: where rescue | | | inhaler won't work, can't talk | | | easily, chest retractions | | | (stomach sucked in, chest | | | sticking out along with | | | collarbone with each | | | breath...this means the patient | | | is not getting enough air into | | | the lungs), cyanosis of the lips | | | and skin, sweaty...need medical | | | intervention fast!! | | | | | | **Nursing Interventions for | | | Asthma** | | | | | | **Presenting with an asthma | | | attack:** | | | | | | - - - - - - - - - | | | | | | | | | What is a **Peak Flow Meter:** it | | | shows how controlled a patient's | | | asthma is and if it is getting | | | worse (lets a patient know if an | | | attack is pending...several hours | | | to days before one) | | | | | | **How does the patient use a peak | | | flow meter?** As represented in | | | the picture above, the patient | | | will exhale as hard as they can | | | onto the device. The device will | | | then measure how much air was | | | exhaled out of the lungs. | | | | | | - - - How is | | | the ***[personal best peak | | | flow | | | meter]*** reading | | | figured out? The patient will | | | use the peak flow meter to | | | figure out their best peak | | | flow reading when their | | | asthma is**[ under good | | | control]**, and | | | measure it [once in the | | | morning and once at night for | | | 3 weeks | | | usually] and | | | record the numbers BEFORE | | | TAKING MEDICATION. ***The | | | highest number they obtain | | | over this period of time will | | | be their personal best | | | reading. *** | | | | | | - Then they will need to | | | continue to use the peak flow | | | meter at the same time every | | | day, either in the morning or | | | at night BEFORE TAKING | | | MEDICATION, and compare it | | | with the personal best | | | reading. If the reading is | | | 80% or less than their | | | personal best, they need to | | | follow the action plan | | | created with their doctor. | | | | | | You will be providing them with | | | education on how to follow their | | | prescribed asthma action plan | | | (quiz the patient to ensure they | | | understand how to follow the | | | plan). | | | | | | Help the patient identify | | | triggers (educate them on the | | | triggers), how to avoid (except | | | exercise-induced) and those early | | | warning signs. | | | | | | ***What if a trigger is | | | exercised-induced?*** The patient | | | doesn't need to quit exercising | | | (important for overall health). | | | To help decrease the chances of | | | an attack they can: | | | | | | - - - - | | | | | | **Medications used to treat | | | Asthma** | | | | | | **[Bronchodilators: ] | | | **opens | | | the airways to increase air | | | flow....different types | | | | | | ***Bronchodilators types used for | | | Asthma***: Beta-agonists\* and | | | Anticholingerics\*, Theophylline | | | | | | \*commonly given as inhaled | | | routes for asthma...theophylline | | | is oral | | | | | | [*Short-acting beta agonist | | | (Albuterol*):] | | | | | | - - | | | | | | *[Long-acting beta agonists | | | (Salmeterol, | | | Symbicort]...this | | | drug is a combination of a | | | long-acting beta agonist AND | | | corticosteroid*)*:* | | | | | | - | | | | | | \*\*\*\*Side effects of these | | | medications: tachycardia, feeling | | | nervous/jittery, monitor heart | | | rhythm for dysrhythmia | | | | | | *[Anticholinergics:]* | | | | | | - - - | | | | | | *[Theophylline:]* giv | | | en | | | PO | | | | | | - - | | | | | | \*\*\*\*\*Always administer | | | the **bronchodilator FIRST** and | | | then **5 minutes later the | | | corticosteroid.** | | | | | | If not responding to treatment, | | | may need intubation and | | | mechanical ventilation. | | | | | | **[Anti-inflammatories:]{.underli | | | ne}** decreases | | | swelling and mucus | | | production...used as long-term | | | treatment to control asthma not | | | an acute attack. | | | | | | **Anti-inflammatories used to | | | treat asthma | | | include:** "Corticosteroids, | | | Leukotriene Modifiers, | | | Immunomodulators, Cromolyn" | | | | | | *[Inhaled | | | corticosteroids:]* "F | | | luticasone", | | | "Budesonide", "Beclomethasone" | | | | | | - - - | | | | | | *[Leukotriene Modifiers | | | (oral):]* "Montelukas | | | t" | | | | | | - | | | | | | *[Immunomodulator | | | (subq):]* "Omalizumab | | | " | | | | | | - - - - - | | | | | | *[Nonsteroidal | | | Anti-Allergy:]* "Crom | | | olyn" | | | (inhaled) | | | | | | - - - | +-----------------------------------+-----------------------------------+ | | | +-----------------------------------+-----------------------------------+ | **Identify risk factors for COPD | | | when obtaining a history from a | | | patient:** | | | | | | 1. 2. 3. 4. 5. 6. 7. | | +-----------------------------------+-----------------------------------+ | **Clinical manifestations of | **What is happening in | | emphysema:** | emphysema?** | | | | | 1. 2. 3. 4. 5. | Main issue is with **damage to | | | the alveolar sac** (loses | | | elasticity...becomes floppy and | | | doesn't inflate and deflate | | | properly) leading to | | | "air-trapping". | | | | | | This condition also leads | | | to **hyperventilation** (puffing | | | to breathe...compensatory | | | mechanism) and pink | | | complexion (they maintain a | | | relatively normal oxygen level | | | due to rapid breathing) rather | | | than cyanosis as in chronic | | | bronchitis. Patients with | | | emphysema are sometimes | | | called **"pink puffers"**. | | | | | | **Major Signs & Symptoms:** | | | | | | - - - - - | | | | | | **Pathophysiology of Emphysema:** | | | | | | In emphysema, the ***alveoli sacs | | | lose their ability to inflate and | | | deflate*** due to an inflammatory | | | response in the body. Due to the | | | damage to the alveoli sac, there | | | is *[**damage to the capillary | | | bed** ]*so there will | | | a** matched V/Q | | | defect** (ventilation and | | | perfusion both poor...hence they | | | match). So, areas of low | | | ventilation (V) have poor | | | perfusion (Q). | | | | | | Because the sac cannot deflate or | | | inflate, inhaled **air starts to | | | get trapped** in the sacs and | | | this | | | causes major **hyperinflation of | | | the lungs** because the patient | | | is retaining so much volume. | | | | | | Hyperinflation causes | | | the **diaphragm to flatten**. The | | | diaphragm plays a huge role in | | | helping the patient breathe | | | effortlessly in and out. | | | Therefore, in order to fully | | | exhale, the patient starts to | | | hyperventilate and use accessory | | | muscles to get the air out now. | | | This leads to the **barrel chest | | | look** and during inspection it | | | may be noted there is | | | an**[ INCREASED | | | ANTEROPOSTERIOR] [DIA | | | METER]**[.]{.underlin | | | e} | | | | | | The damage in the sacs cause the | | | body to keep **high carbon | | | dioxide levels and low blood | | | oxygen levels (respiratory | | | acidosis)**. Inhaled oxygen will | | | not be able to enter into the | | | sacs for gas exchange and carbon | | | dioxide won't leave the cells to | | | be exhaled. | | | | | | The body tries to **compensate by | | | causing | | | hyperventilation** (increasing | | | the respiratory rate...hence | | | puffing) and the patient will | | | have less hypoxemia "pink | | | complexion" than chronic | | | bronchitis (who have the | | | cyanosis) because pink | | | puffers keep their oxygen level | | | just where it needs to be from | | | hyperventilation. | +-----------------------------------+-----------------------------------+ | **Cor pulmonale (complications of | **Nursing Interventions: Cor | | COPD):** | Pulmonale** | | | | | Because of the decreased alveolar | 1. 2. 3. 4. 5. 6. 7. 8. 9 | | surface area, pulmonary |. 10. | | arterioles vasoconstrict to | | | divert blood flow away from the | | | impaired areas. The | | | vasoconstriction of these | | | pulmonary arterioles causes | | | increased resistance and | | | pulmonary HTN. The RV struggles | | | to pump blood into the pulmonary | | | circulation causing RV | | | hypertrophy and the thick muscle | | | wall of the RV decreases the | | | amount of space for filling the | | | RV leading to diastolic HF. | | | | | | or pulmonale is a disorder of the | | | structure and function of the | | | right side of the heart caused by | | | a disease of the respiratory | | | system, primarily pulmonary | | | hypertension. Cor pulmonale is | | | estimated to cause approximately | | | 5% to 7% of all types of heart | | | disease in adults, and chronic | | | obstructive pulmonary disease | | | (COPD) due to chronic bronchitis | | | or emphysema is the causative | | | factor in more than 50% of people | | | with cor pulmonale. While it is | | | difficult to know how many people | | | in the United States have cor | | | pulmonale, experts estimate that | | | 15 million people have the | | | condition. The right ventricle is | | | a thin-walled chamber as compared | | | to the left ventricle and is more | | | responsive to volume changes. | | | With increased resistance in the | | | pulmonary system, the right side | | | of the heart works harder, the | | | systolic pressure rises, the | | | right ventricle dilates, and | | | ultimately, right-sided heart | | | failure occurs. | | | | | | A number of physiological changes | | | lead to poor gas exchange. | | | Alveolar wall damage results in | | | anatomic reduction of the | | | pulmonary vascular bed as the | | | number of pulmonary capillaries | | | are reduced and the vasculature | | | stiffens from pulmonary fibrosis. | | | Constriction of the pulmonary | | | vessels and hypertrophy of vessel | | | tissue are caused by alveolar | | | hypoxia and hypercapnia. | | | Abnormalities of the ventilatory | | | mechanics bring about compression | | | of pulmonary capillaries. Cor | | | pulmonale accounts for | | | approximately 25% of all types of | | | heart failure. Complications of | | | cor pulmonale include | | | biventricular heart failure, | | | hepatomegaly, pleural effusion, | | | and thromboembolism related to | | | polycythemia. | | | | | | **Causes** | | | | | | In addition to COPD, acute cor | | | pulmonale is produced by a number | | | of other pulmonary and pulmonary | | | vascular disorders but primarily | | | by acute respiratory distress | | | syndrome (ARDS) and pulmonary | | | embolism. Two factors in ARDS | | | lead to right ventricular | | | overload: the disease itself and | | | the high transpulmonary pressures | | | that are needed to treat ARDS | | | with mechanical ventilation. In | | | the United States, approximately | | | 25,000 sudden deaths occur per | | | year from heart failure | | | associated with pulmonary emboli. | | | Other conditions can also lead to | | | cor pulmonale. Respiratory | | | insufficiency---such as chest | | | wall disorders, upper airway | | | obstruction, obesity | | | hypoventilation syndrome, and | | | chronic mountain sickness caused | | | by living at high altitudes---can | | | also lead to the chronic forms of | | | the disease. It can also develop | | | from lung tissue loss after | | | extensive lung surgery. A | | | contributing factor is chronic | | | hypoxia, which stimulates | | | erythropoiesis, thus increasing | | | blood viscosity. Cigarette | | | smoking is also a risk factor. | | +-----------------------------------+-----------------------------------+ | 1. 2. 3. 4. 5. 6. 7. | | | | | | | | | | | | 1. 2. 3. 4. | | | | | | | | | | | | 1. 2. 3. 4. 5. 6. | | | | | | | | | | | | 1. 2. 3. 4. 5. 6. 7. 8. | | | | | | | | | | | | 1. 2. 3. 4. 5. 6. 7. | | | | | | | | | | | | 5. | | +-----------------------------------+-----------------------------------+ | **Introduction to Tuberculosis** | | | | | | Mycobacterium is an acid-fast, | | | aerobic, slow-growing bacillus | | | that is resistant to drying and | | | many disinfectants. However, the | | | microbes can survive in dried | | | sputum for weeks. | | | | | | The TB bacterium is spread from | | | person to person through droplets | | | from coughing or sneezing. People | | | who live with or spend time with | | | an infected person may be at risk | | | for developing TB. The bacteria | | | then travel from the lungs | | | through the bloodstream to other | | | organs, where they can cause | | | damage over time if not | | | appropriately treated with | | | antibiotics. | | | | | | There are two stages of | | | tuberculosis: primary and | | | secondary (or reinfection). | | | Primary occurs when the | | | microorganisms first enter the | | | lungs. The TB may spread to other | | | organs with the bacilli migrating | | | to lymph nodes, which can rapidly | | | disseminate into the circulation | | | and to other tissues, such as | | | bone or kidney. | | +-----------------------------------+-----------------------------------+