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Asthma: Nursing Management
- Assessment (especially respiratory/cardiac status) - auscultate the lungs, look for use of accessory muscles, coughing. Signs of a diminishing condition: drop in pulse ox, diminished lung sounds, agitation/restlessness. Ask yourself: are these things normal for the pt's condition? (e.g., someone on continuous albuteral will have a higher HR considered normal for their condition)
- Bedrest: High Fowler's or a recliner
- C & DB
- Chest PT
- Pursed lip breathing
- Balance activity & rest - conserves O2 and lessens demand
- Fluid 3L/day
- Diet: small but frequent meals - large meals increase O2 needs
- NO SEDATIVES
- Relaxation education: preventative measures
- * if pt is wheezing and then stops wheezing = pt is getting worse, airway is closing off and becoming tighter. Pt will displays signs of distress (mentioned above)
- * NO chest PT for pts while they are in an acute asthma attack - cough will be nonproductive because mucus is located below. Give chest PT after airway has been opened
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Patient Education: Preventative Measures for Asthma Patients
- Stay indoors when the weather is too hot or too cold
- Avoid OTC drugs containing ASA & Beta Blockers
- Prompt diagnosis and treatment of URI
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Complications of Asthma
- Acute Respiratory Failure
- Status Asthmaticus: condition where pt is severly affected by asthma; significant asthma complications; pt may require ICU
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COPD (Chronic Obstructive Pulmonary Disease): Disease state characterized by the presence of airflow obstruction
- Chronic Bronchitis: presence of chronic productive cough for 3 months X 2 years
- Emphysema: abnormal enlargement of air spaces accompanied by destruction of the lung walls * problem with the alveoli
* Patient can have both
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COPD Signifigance & Etiology
- Chronic bronchitis: 45 - 65 years of age
- Emphysema: 65 - 75 years of age
- Related primarily to smoking - 20 year lag before signs of disease are present
- Etiology
- 3 major irritants: cigarette smoking (* primary cause for both), infection, inhaled irritants
- Hereditary (AAT found in genetic emphysema - displays symptoms at an earlier age)
- Aging
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Chronic Bronchitis Pathophysiology
- Syndrome of excessive mucus production in the bronchi accompanied by a recurrent daily cough that persists for at least 3 months of the year during at least 2 consecutive yearsHypertrophy and hyperplasia of bronchial glands
- Incresed # of goblet cells = increased mucus
- Decreased cilia
- Chronic inflammation = narrowed airway
- Altered function of alveoli macrophages
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Emphysema Pathophysiology
- Condition of the lung characterized by abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls, and without obvious fibrosis
- Destruction of alveolar walls 2o proteolytic enzymes = destroys elastin and collagen
- Alveolar air trapping = hyperinflation = alveoli meld together = bleb/bullae
- Loose normal elastic recoil
- Stimulation of macrphages and neutrophils
- Problem with the ALVEOLI (as compared to the airway with bronchitis)
- Alveoli expand but do not recoil and eventually become distended
- Problem is with CO2 but not O2 - because these patients cannot get the air out of their lungs (bronchitis is a problem with both)
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Cor Pulmonale
- "right sided heart failure"
- Alveolar hypoxia
= pulmonary capillary vasoconstriction = increased pulmonary artery pressure (pulmonary HTN) = hypertrophy of right ventricle = RIGHT SIDED HEART FAILURE Complication that occurs with COPD - it is expected in these pts and must be watched for - Pressure build up in the lungs from air circulation of the condition - right side of the heart has to work harder than the left to pump blood
- DO NOT give extra fluids
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Polycythemia
- Complication that occurs with COPD - it is expected in these pts and must be watched for
- Physiologic compensation for hypoxemia
- Increased RBC's but not able to carry increased O2 as oxygen is not available = cyanosis
- Compensation mechanism that the body uses to deal with the hypoxia that has developed from the chronic condition
- Erythropoietin - kidneys pump out more to produce more RBCs but there is not enough O2 available to compensate for the increased RBCs
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Clinical Manifestations of Chronic Bronchitis
- Cough - frequent & productive
- Frequent respiratory infections
- Dyspnea on exertion (DOE)
- Hypoxemia & Hypercapnia
- Edematous
- "Blue Bloaters" - person appears blue and pale from the lack of O2, bloated, barreled chest, overweight
- Robust appearance
- Finger clubbing
- Coarse rhonchi & wheezing
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Clinical Manifestations of Emphysema
- Dyspnea
- Cough - minimal
- Barrel chest
- Chest breather
- "Pink puffer" - puff to try and get out CO2
- Thin & underweight - energy and O2 are used in an attempt to get out CO2
- Finger clubbing
- Pursed-lip breathing
- Diminished breath sounds
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COPD Diagnostic Studies
- History & physical exam
- Chest X-ray
- Pulmonary function studies
- ABG studies
- Electrocardiogram
- Sputum specimen for gram stain & culture
- Serum a1 - antitrypsin levels
- Exercise testing with Oximetry
- Echocardiogram or Cardiac nuclear scans
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COPD Collaborative Care
- Pharmacotherapy: Beta-adrenergic agents; Anticholinergic agents; Methylxanthines; CorticosteroidsSmoking cessation (will not fix damage done to alveoli but will help in cilia restoration)
- Influenza & pneumococcal vaccinations
- Avoid & immediately treat URIsOxygen: LOW flow, < 2L/min - safety"O2 Drive"
- O2 Toxicity: inactivates surfactant and can lead to ARDS
- Nebulizer Treatment: devices - Bronkosol and Bronchosaline .. given before cup treatment
- Encourage fluids - 3 L/day (not when patient have cor pulmonale)
- Pursed lip breathing
- Diaphragmatic breathing (abdomen protrudes on inhalation and contracts on exhalation)
- Chest PT (done before meals and not when pt is wheezing)
- Nutrition: small frequent meals, fluid between meals; high calorie/protein for emphysema; low carbohydrate
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COPD Nutrition
- Rest 30 minutes before eating
- Bronchodilator before eating
- Frozen and microwave foods - conserve energy in food prep (be cautious of sodium content!)
- Sodium restriction may be necessary
- Avoid foods that cause bloating and gas (e.g. cabbage)
- 5 - 6 small meals per day
- Liquid commercials diets
- Avoid food that requires significant chewing
- Avoid exercising for 1 hour after eating
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COPD Home Care
- Activity considerations: exercise training of upper extremities may reduce dyspnea. Pt may assume tripod position to conserve energy. Schedule periods of rest in between periods of activity. Walking 5 to 15 minutes a day, then slowly increase.
- Pulmonary rehabilitation
- Sexual Activity
- Psychosocial considerations - location of bedrooms/bathrooms, number of steps
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COPD Complications
- Cor pulmonale
- Respiratory failure
- Peptic Ulcer Disease and GERD
- Pneumonia
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