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General Nursing Care for Airway Clearance
Incentive Spirometry
Coughing and Deep Breathing (C & DB)
Chest Physiotherapy (CPT)
- Suctioning of Airway only as needed
- *Nasopharyngeal
- *Oropharyngeal
- *Artificial airways if in place (Tracheostomy, Endotracheal Tube)
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Acute Bronchitis
Inflammation of the bronchi
Usually due to infection
One of most common illnesses in primary care
Etiology: viral, bacterial
Most cases are viral
Usually precipitated by upper respiratory infection
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Manifestations with Acute Bronchitis
- Cough
- Sputum production
- Fever
- Headache
- Malaise
- Shortness of breath on exertion
- Rhonchi, wheezing
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Collaborative Care for Acute Bronchitis
Supportive treatment: fluids, rest,
antiinflammatory agents
Antitussives
Bronchodilators
Teach for s/s of complications
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Asthma
A clinical syndrome characterized by increased responsiveness of the tracheobronchial tree to a variety of stimuli.
A disease of INFLAMMATION.
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Extrinsic asthma has an
Allergic Cause
examples: dust, pollen, animal dander
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Intrinsic or Idiopathic Asthma has a
Non-allergic cause
Examples: respiratory infection, exercise, cold air, cigarette smoke
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Parasympathetic Dominance (Pathophysiology of Asthma)
Mucosal inflammation
Constriction of bronchial smooth muscles
Excess production of mucus
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Stages of Asthma
Step 1 – Mild Intermittent
Step 2 – Mild Persistent
Step 3 - Moderate Persistent
Step 4 – Severe Persistent
Treatment based upon stages
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Diagnosis of Asthma
Primarily on history and physical exam
- History
- Physical examination
- Pulmonary function tests (more chronic)
- Increase IgE levels and eosinophil levels
- ABG/CBC
- Pulse Oximetry
- CXR
- Allergy Skin Testing Sputum Culture if s/s infection is present
- Sputum Specimen for Gram Stain & Culture
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Beta Agonist Medication for Asthma
- activate the beta-2 receptor on the muscles surrounding the
- airways→ relaxes the muscles surrounding the airways→ opens the airways
(Albuterol, Xopenex, Terbutaline)
P.O. & Inhaler
Long acting – (Salmeterol)
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Xopenex
newer drug, tried to reduce tachycardia so pts on this don’t complain as much of tachy and jitteriness
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Anticholinergics (meds for Asthma)
relax and dilate the airways in the lungs; protect the airways from spasms
Atrovent; Spiriva; Combivent
Inhaler & Nebulizer
Used for more chronic conditions
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Methylxanthines
Slightly relax the airways in the lungs through bronchodilation
- Increases the strength of the diaphragm by
- stimulating the breathing control centers in the brain
Aminophylline; Theophylline; Theodur; Slo-bid (side effects a lot jittery and HR goes up)
IV, PO
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Antiinflammatory Agents
- Many steroids, specifically glucocorticoids, reduce inflammation or swelling by binding to cortisol
- receptors.
Methylpredisolone; Solu-medrol; Prednisone; Flovent, Pulmacort
Advair (combined drug – Flovent and Serevent)
IV, PO, Inhaler
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Leukotriene Modifiers
(leukotriene antagonists)
work to block the effects of leukotrienes in our bodies by binding to receptors on smooth muscle and other tissue in the airways, as well as by preventing their release from mast cells
Singulair; Accolate;
PO
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Mucolytic Agents
help loosen and clear the mucus from the airways by breaking up the sputum\
Guiafenesin; Acetylcysteine
PO, Nebulizer
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Using an Inhaler
- Hold inhaler 2-3 cm from mouth; shake cannister;
- spray one puff and inhale; hold for 10 sec.
2 minutes in between each puff of the same type of inhaler.
5 minutes in between use of inhaler of a different medication.
Rinse mouth after use of steroid inhalers can get thrush
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Order of Use of Inhaler
- BAS
- Beta-agonist
- Atropine-based
- Steroid
- BAC
- Beta-agonist
- Atropine-based
- Cromolyn
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What does it mean when pt goes from wheezing to not wheezing ???
if pt was wheezing and now they are not, its saying the pt could be getting worse, theres less movement and less air, pulse ox would drop, grasp neck, Louder can mean they are getting better meaning airway is getting bigger and more air is going through
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Asthma Nursing Management
Assessment (esp. resp/cardiac status)
Bedrest-High Fowler's or Recliner
- C & DB time and place for both
- Chest Physiotherapy
Pursed Lip Breathing
Balance Activity & Rest
Fluids 3L/Day
Diet-Sm. Frequent Meals
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What are some Other Asthma Nursing Management
NO SEDATIVES
Relaxation Exercises
Patient Education
Preventive Measures
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What are some preventative measures for Asthma pts
Stay indoors when weather too hot or cold or high degree of pollution
Avoid OTC drugs containing ASA & Beta Blockers
Prompt diagnosis and treatment of URI
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What are some Complications of Asthma
Acute Respiratory Failure
Status Asthmaticus (more than just a nebulizer)
Ruptured Bleb---> pneumothorax
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COPD
(Chronic Obstructive Pulmonary Disease): disease state characterized by the presence of airflow obstruction
- Chronic Bronchitis
- Emphysema
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Chronic Bronchitis
presence of chronic productive cough for 3 months X 2 years
45-65 yrs of age
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Emphysema
– abnormal enlargement of airspaces accompanied by destruction of walls
A 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.
65-75 yrs of age
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COPD significance and etiology
Related primarily to smoking-20 year lag before signs of disease are apparent
- Etiology
- Three major irritants
- cigarette smoking
- infection
- inhaled irritants
- Heredity (AAT found in emphysema)
- Aging
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Chronic Bronchitis-Pathophysiology
A 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 years.
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Pathophysiology-Chronic Bronchitis
Hypertrophy & hyperplasia of bronchial glands
Increased # goblet cells--->increased mucus
Decreased cilia
Chronic Inflammation---> airway narrowing
Altered function of alveoli macrophages
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ATT in Normal individual
ATT is secreted from the liver into the blood stream which transport it to the lungs
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ATT in Emphysema
ATT's secretion from the liver is blocked
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Lungs with Emphysema is
Hyper-inflated and the Diaphragm is flattened
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Cor Pulmonale
right sided failure, bc pressure that builds up from chronic condition causing pressure in pulmonary circulation it has to pump harder as a result will develop right sided heart failure trying to get blood out. If you are suspecting this don’t increase fluids we don’t five extra fluid to pt with heart failure
- Alveolar hypoxia-->pulmonary capillary
- vasoconstriction-->increased pulmonary artery pressure (pulmonary hypertension)--> hypertrophy of right ventricle--> right-sided heart
- failure
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Polycythemia
compensation mechanism: body trys to do to deal with hypoxemia not really emphezemia
physiologic compensation for hypoxemia.
Increased RBC’s but not able to carry increased O2 as oxygen not available -->cyanosis.
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Polycythemia blood
- Blood becomes very viscous, not enough o2 to attach to cells and as a result the blood gets thick and slughish resulting in heart attack and if not going to the brain stroke, if not goin to kidney will
- continue to put out more eyrthropoetin
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Chronic Bronchitis Clinical Manifestations
BLUE BLOATERS
Cough-frequent, productive
Frequent respiratory infections
Dyspnea on exertion (DOE)
Hypoxemia & Hypercapnia
Edematous
Robust appearance
Finger clubbing
Coarse rhonchi & wheezing
blue pale overweight, bloated, barrel chest, rhonchi wheezing crackles
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Emphysema Clinical Manifestations
Pink Puffers
- have enough o2 to get out all that co2, thin bc
- they are using all their energy to breathe, cough is minimal, combo usually emphysema and bronchitis
Dyspnea
Cough-minimal
Barrel chest
Chest breather
Thin and underweight
Finger Clubbing
Pursed-lip breathing
Diminished breath sounds
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Pharmacotherapy for COPD
Beta-adrenergic Agents
Anticholinergic Agents
Methylxanthines
Corticosteroids
Expect them to be agonist
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COPD collaborative care
Smoking Cessation
Influenza & Pneumococcal Vaccinations
Avoid & Immediately Treat URIs
Should quit smoking to help celia to grow back
Flue and pneumonia
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Oxygen Treatment for COPD
Oxygen-Low Flow, <2L/min- safety
“O2 drive”
O2 toxicity – inactivates surfactant and can lead to ARDS
Less than 2 liters is safe don’t turn it up more than a liter per minute. Cant go from 1L to 5L
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What happens to a COPD pt concerning CO2 and O2
Pt will walk around with co2 levels and their body will not respond to changes in co2. so their primary mechanism is o2. o2 will slow down RR. So if you turn up the o2 you can make the pt stop breathing
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a pt with COPD encourage how many Liters per day
3 liters of fluid per day
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What kind of breathing exercises do you encourage for a pt with COPD
Pursed-lip breathing (releases trapped air)
Diaphragmatic breathing (abdomen protrudes on inhalation and contracts on exhalation)
Effective coughing exercise
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is Chest Physiotherapy appropriate for a pt with COPD
Yes , make sure pt has not had a meal before doing chest physiotherapy
Eating takes a lot of oxygenation
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What are some Nutritional Considerations for a pt with COPD
Sm. frequent meals; Fluids between meals
High calorie/protein for emphysematic
Low carbohydrate
Low carb bc by product is co2 so if high carb high co2
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Why should a pt avoid foods that promote bloading
Bloated pressure on diaphram and impact ability
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Collaborative Nutritional Care for pt with COPD
Rest 30 minutes before eating
Bronchodilator before eating
- Frozen & microwave foods – conserve energy
- in food preparation (be careful of sodium content-read labels)
Sodium restriction may be necessary
Avoid foods that cause bloating and gas (e.g. cabbage)
5-6 small meals/day
Liquid commercials diets
Avoid food that requires significant chewing
Avoid exercises for 1 hour after eating
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Activity Consideration for a pt with COPD
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 5-15 mins/day and slowly increase.
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What are complications that can occur for a pt with COPD
Cor-pulmonale
Respiratory Failure
Peptic Ulcer Disease and GERD
Pneumonia
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The nurse caring for a client with COPD recognizes which of the following as an early sign of possible respiratory failure
A. Restlessness
B. Deep coma
C. Hypotentsion and tachycardia
D. Decreases urinary output
A. Restlessness
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When teaching the use of a MDI containing flovent the nurse itstructs the clitnet to
Rinse the mouth after using the inhaler
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Isabella is instructed to take her asthma meds in which order
Albuterol atroven and cromolyn
remember BAC
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What action will most help a client obtain max benefits after postural drainage ( position to drain pt)
Encourage the client to cough deeply
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Which client should the charge nurse assign to a step down RN pulled to the intensive care unit for the day
A. 72 yearo old with COPD who is ventilator dependent
B. 68 yo pt on a ventilator with acute respiratory failure
C. 56 yo NEW ADMISSION client with ketoacidosis and on an insulin
drip
D. 38 yo client on a ventilator with
A. 72 yearo old with COPD who is ventilator dependent
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