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Chapter 32
Care of Patients with Noninfectious
Lower Respiratory Problems
Block 2 Concepts
1.
Asthma
2.
COPD
3.
Lung Cancer
4.
Pleural Effusion
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Prevalence of Asthma





Estimated 20 million (8.4%) Americans
affected
Estimated 300 million people affected
worldwide
More common in adult women than men
Slightly more prevalent among AfricanAmericans than Caucasians
Number of people with asthma continues to
grow
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
2
Asthma


Condition that occurs intermittently
Occurs in two ways:


Inflammation
Airway hyperresponsiveness leading to
bronchoconstriction
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3
Pathophysiology of Asthma


Intermittent and reversible airflow obstruction
affecting airways only, not alveoli
Airway obstruction:


Inflammation
Airway hyper-responsiveness
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
4
Pathophysiology of Asthma (cont’d)
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5
Etiology



Different types based on how attacks are
triggered
Caused by specific allergens, general
irritants, microorganisms, aspirin
Hyper-responsiveness caused by exercise,
URI, unknown reasons
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6
Etiology & Pathophysiology
Continued



Bronchospasm
Aspirin & NSAID triggers
GERD
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7
Collaborative Management

Assessment


History
Physical assessment/clinical manifestations
• Audible wheeze, increased respiratory rate
• Increased cough
• Use of accessory muscles
• “Barrel chest” from air trapping
• Long breathing cycle
• Cyanosis
• Hypoxemia
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8
Laboratory Assessment



ABGs
Arterial O2 may decrease in acute asthma
attack
Arterial CO2 may decrease early in attack and
increase later (indicating poor gas exchange)
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9
Laboratory Assessment (cont’d)


Allergic asthma with elevated serum
eosinophil count , immunoglobulin E levels
Sputum with eosinophils, mucous plugs, with
shed epithelial cells
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10
Pulmonary Function Tests

Most accurate with use of spirometry



Forced vital capacity (FVC)
Forced expiratory volume in first second (FEV1)
Peak expiratory flow rate (PEFR)
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
11
Interventions



Teaching for self-management
Use of peak flowmeter twice daily
Personal drug therapy plan
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12
Peak Flow Meters




Green Zone
Yellow Zone
Red Zone
Teaching Technique
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13
Peak Flow Technique
Set the peak flowmeter at zero
Use a standing position, without leaning or supporting yourself
Take as deep a breath as you can.
Place the mouthpiece of the meter in your mouth-wrap lips tightly
Blow your breath out through the mouthpiece as hard and as fast as you are
able. (If you cough, sneeze, or have any type of interruption while you exhale,
reset the meter and perform the test again.)
Reset and perform the test two additional times.
Use the highest reading of the three to determine your current peak flow rate.
Keep a record or graph of your peak flow rates and examine these for trends.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
14
Drug Therapy

Bronchodilators


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Short- and long-acting beta2 agonists
Cholinergic antagonists
Methylxanthines
Anti-inflammatory agents




Corticosteroids
NSAIDs
Leukotriene antagonists
Immunomodulators
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15
Drug Therapy


Based on step category for severity and
treatment
Preventive therapy (controller drugs)



Change airway responsiveness to prevent asthma
attacks
Used every day, regardless of symptoms
Rescue drugs

Actually stop attack once it has started
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16
Other Treatments for Asthma


Exercise and activity to promote ventilation
and perfusion
Oxygen therapy via mask, nasal cannula, ET
tube (acute asthma attack)
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17
Status Asthmaticus




Severe, life-threatening, acute episode of
airway obstruction
Intensifies once it begins, often does not
respond to common therapy
Patient can develop pneumothorax and
cardiac/respiratory arrest
Treatment—IV fluids, potent systemic
bronchodilator, steroids, epinephrine, oxygen
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18
Critical Thinking
A patient with a history of asthma is having shortness of
breath. The nurse discovers that the peak flowmeter
indicates a peak expiratory flow (PEF) reading that is in
the red zone. The nurse should immediately:
A.
B.
C.
D.
Repeat the PEF reading to verify the results.
Take the patient’s vital signs.
Administer the rescue drugs.
Notify the patient’s prescriber.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
19
Decision-Making Challenge
Patient-Centered Care
Evidence-Based Practice: Safety

The patient is a 22-year-old college student who has had asthma
since childhood. She is being managed with fluticasone (Flovent)
50 mcg/puff, 2 puffs twice daily; salmeterol (Serevent) 1 puff twice
daily; albuterol (Ventolin) 1-2 puffs every 4-6 hours as needed for
wheezing. She reports that she is using the fluticasone and
salmeterol as prescribed but needs to use the albuterol about every
2 hours. She also tells you that she is having difficulty sleeping and
feels “like my heart is skipping some beats.” Her vital signs are BP,
136/88; P, 96 and irregular; R, 30, with slight wheezing on
exhalation. Her oxygen saturation is 92%, and you notice that she
has a slight tremor in both hands.
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20
COPD
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21
Chronic Obstructive Pulmonary
Disease (COPD)

Includes:




Emphysema
Chronic bronchitis
Characterized by bronchospasm and
dyspnea
Tissue damage not reversible; increases in
severity, eventually leads to respiratory failure
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22
Emphysema



Loss of lung elasticity and hyperinflation of
lung
Dyspnea; need for increased respiratory rate
Air trapping caused by loss of elastic recoil in
alveolar walls, overstretching and
enlargement of alveoli into bullae, collapse of
small airways (bronchioles)
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23
Interaction of Chronic Bronchitis and
Emphysema in COPD
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Chronic Bronchitis




Inflammation of bronchi and bronchioles caused by
chronic exposure to irritants, especially cigarette
smoke
Inflammation, vasodilation, congestion, mucosal
edema, bronchospasm
Affects only airways, not alveoli
Production of large amounts of thick mucus
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25
Complications




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Hypoxemia/tissue anoxia
Acidosis
Respiratory infections
Cardiac failure, especially cor pulmonale
Cardiac dysrhythmias
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Right-Sided HF Caused by
Chronic Bronchitis or COPD
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Cor Pulmonale or Right –Sided HF
Hypoxia and hypoxemia
Increasing dyspnea
Fatigue
Enlarged and tender liver
Warm, cyanotic hands and feet, with bounding pulses
Cyanotic lips
Distended neck veins
Right ventricular enlargement (hypertrophy)
Visible pulsations below the sternum
GI disturbances, such as nausea or anorexia
Dependent edema
Metabolic and respiratory acidosis
Pulmonary hypertension
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27
Physical Assessment & Clinical
Manifestations




History
General appearance
Respiratory changes
Cardiac changes
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28
Dyspnea Assessment Tool
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Laboratory Assessment



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



ABG values for abnormal oxygenation,
ventilation, acid-base status
Sputum samples
CBC
Hemoglobin and hematocrit
Serum electrolytes
Serum AAT
Chest x-ray
Pulmonary function test
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30
Interventions





Improve oxygenation and reduce carbon
dioxide retention
Prevent weight loss
Minimize anxiety
Improve activity tolerance
Prevent respiratory infection
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31
Drug Therapy






Beta-adrenergic agents
Cholinergic antagonists
Methylxanthines
Corticosteroids
NSAIDs
Mucolytics
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32
Nursing






The patient with COPD is expected to
attain and maintain gas exchange at a
level within his or her usual baseline
values. Indicators include that the patient:
Maintains SpO2 of at least 88%
Is not cyanotic
Maintains cognitive orientation
Coughs and clears secretions effectively
Maintains a respiratory rate and rhythm
appropriate to his or her activity level
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33
Nursing Management-Fatigue






The patient with COPD often has chronic fatigue.
While in the acute phases of the illness, he or she may need
extensive help with the ADLs of eating, bathing, and
grooming.
As the acute problem resolves, encourage the patient to
pace activities and provide as much self-care as possible.
Teach to not rush through morning activities, because
rushing increases dyspnea, fatigue, and hypoxemia.
As activity gradually increases, assess the patient's
response by noting skin color changes, pulse rate and
regularity, blood pressure, oxygen saturation, and work of
breathing.
Supplemental oxygen during periods of high energy use,
such as bathing or walking.
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34
Expected Outcomes







Maintains his or her baseline SaO2 with activity
Performs ADLs with no or minimal assistance
Performs selected activities with minimal dyspnea or
tachycardia
When discharged, participates in family, work, or social
activities as desired
Nursing Interventions Review
As activity level increases, assess the patient's response by
noting skin color changes, pulse rate and regularity, blood
pressure, oxygen saturation, and work of breathing.
Use of supplemental oxygen during periods of high energy
use, such as bathing or walking.
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35
Surgical Management




Lung reduction surgery
Preoperative care and testing
Operative procedure by median sternotomy
or VATS
Postoperative care and close monitoring for
complications
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36
Dyspnea Management


Needed during mealtime; can be reduced by
resting before meals
4 to 6 small meals a day
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37
Community-Based Care

Home care management



Long-term use of oxygen
Pulmonary rehabilitation program
Teaching for self-management




Drug therapy
Manifestations of infection
Breathing techniques
Relaxation therapy
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38
COPD Anxiety




Patients with COPD often have increased anxiety during acute
dyspneic episodes, especially if they feel as though they are
choking on excessive secretions. Also, anxiety has been shown to
cause dyspnea.
Help the patient understand that anxiety can increase dyspnea,
have a plan for dealing with anxiety. that states exactly what he or
she should do if symptoms flare.
Anxiety plan provides confidence and control in knowing what to
do, which often helps reduce anxiety. Stress the use of pursed-lip
and diaphragmatic breathing techniques during periods of anxiety
or panic.
Family, friends, and support groups can be helpful. Recommend
professional counseling, if needed, as a positive suggestion.
Stress that talking with a counselor can help identify techniques to
maintain control over the dyspnea and feelings of panic.
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39
Critical Thinking

A client with moderate chronic obstructive
pulmonary disease (COPD) is preparing to
go home and has thrown away the
information regarding smoking cessation.
He states, “Why should I quit now after I
have already caused this disease.” What is
the nurse's best response?
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40
(cont’d)
Based on the patient’s diagnosis, which clinical
manifestations would you expect to see when assessing
this patient? (Select all that apply.)
A. Concave chest appearance
B. Sitting in a forward posture
C. Shortness of breath
D. Bradycardia
E. Use of accessory muscles
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41
CASE STUDY
The patient is a 55-year-old woman with a long
history of COPD and 40 years of smoking
cigarettes. She is being admitted to the
pulmonary stepdown unit from the ED. The ED
nurse tells you that the patient is on oxygen at 2
L per nasal cannula. She had a bronchodilator
respiratory treatment in the ED as well. She has
bilateral expiratory wheezes and crackles both
anteriorly and posteriorly. A saline lock was
placed in her right forearm for intermittent
medications.
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42
(cont’d)
When the patient arrives to the unit, you
complete her assessment and find her to be in
acute respiratory distress. Her respirations are
labored and her respiratory rate is 34. She
states that she is severely short of breath. Her
oxygen saturation is 82% on O2 at 2 L via nasal
cannula.
Based on these findings, what should you do
next?
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43
(cont’d)
While the Rapid Response Team is at the bedside, the
patient’s health care provider arrives. The provider
writes several orders.
Which order is most important for you to implement
immediately?
A. Transfer to ICU
B. Increase O2 to 3 L per nasal cannula
C. ABGs 30 min after oxygen is increased
D. Methylprednisolone sodium succinate (Solu-Medrol)
40 mg IVP
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44
(cont’d)
The patient is in the ICU for 3 days and then transferred
back to the pulmonary stepdown unit. She is still slightly
short of breath with exertion. Her O2 saturation is 99%
on oxygen at 2 L per nasal cannula. She denies any
shortness of breath during your assessment. The
provider plans to discharge the patient on home oxygen
in the morning.
What should you include in this patient’s discharge
teaching?
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45
Lung Cancer
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46
Lung Cancer





Leading cause of cancer deaths worldwide
Poor long-term survival due to late-stage
diagnosis
Bronchogenic carcinomas
Staged to assess size/extent of disease
Etiology and genetic risk
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47
TNM Staging



Staging of lung cancer is performed to assess the
size and extent of the disease. These factors are
related to survival.
Lung cancer staging is based on the TNM system
(T, primary tumor; N, regional lymph nodes; M,
distant metastasis)
Refer to textbook for cancer staging system.
Higher numbers represent later stages and less
chance for cure or long-term survival.
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48
Lung Cancer (cont’d)


Health promotion and maintenance
Assessment





History
Pulmonary manifestations
Nonpulmonary manifestations
Psychosocial assessment
Diagnostic assessment
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49
Assessment
Hoarseness
Change in respiratory pattern
Persistent cough or change in cough
Blood-streaked sputum
Rust-colored or purulent sputum
Frank hemoptysis
Chest pain or chest tightness
Shoulder, arm, or chest wall pain
Recurring episodes of pleural effusion, pneumonia, or
Bronchitis
Dyspnea
Fever associated with one or two other signs
Wheezing
Weight loss
Clubbing of the fingers
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50
Diagnosis

Diagnostic Assessment

The diagnosis of lung cancer is made by examination of cancer
cells. Cytologic testing of early-morning sputum specimens may
identify tumor cells; however, cancer cells may not be present in
the sputum. When pleural effusion is present, fluid is obtained by
thoracentesis for cytology

Most commonly, lung lesions are first identified on chest x-rays.
Computed tomography (CT) examinations are then used to identify
the lesions more clearly.

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51
Nonsurgical Management




Chemotherapy
Targeted therapy
Radiation therapy
Photodynamic therapy
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52
Surgical Management




Lobectomy
Pneumonectomy
Segmentectomy
Wedge resection
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53
Chest Tube Placement
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54
Nursing Care After Thoracotomy



Chest Tube Management
Pain management
Respiratory management
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55
Chest Tube Chambers



Chamber 1: collects fluid draining from
patient
Chamber 2: water seal prevents air from reentering patient’s pleural space
Chamber 3: suction control of system
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56
Chest Tube Drainage System
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57
Interventions for Palliation







Oxygen therapy
Drug therapy
Radiation therapy
Thoracentesis and pleurodesis
Dyspnea management
Pain management
Hospice care
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58
Question for Students
Which risk factor is responsible for the majority
of deaths from lung cancer?
A. Cigarette smoking
B. Occupational radiation exposure
C. Chronic exposure to asbestos
D. Air pollution
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59
Nurse Assessment
Oxygenation Review







Respirations rapid and shallow
Decreased oxygen saturation by pulse oximetry
Skin cyanosis or pallor (in lighter-skinned
patients)
Cyanosis or pallor of the lips and oral mucous
membranes (in patients of any skin color)
Tachycardia
Patient appears to work hard to inhale and exhale
Patient is restless or anxious
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60
Nurse Assessment Oxygenation
Continued






Patient's general appearance is thin compared
with height
Muscles of the neck appear thick
Arm and leg muscles appear thin
Fingers are clubbed
Chest is barrel-shaped (has a round rather than
an oval shape with the front to back depth
increased)
Ribs are spaced more than a fingerbreadth apart
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61
Nursing Management








Assisting the patient to an upright position, with arms resting on a
table or armrests
Performing or assisting the patient to perform chest
physiotherapy/pulmonary hygiene
Ensuring that oxygen delivery is kept low enough to maintain
respirations of no fewer than 16 breaths per minute or per order
Prioritizing and pacing activities to prevent fatigue
Administering prescribed inhaled drugs
Administering respiratory therapy treatments or collaborating with
the respiratory therapist to administer these treatments
Re-assessing respiratory status after respiratory therapy treatment
Ensuring a fluid intake of at least 3 liters per day or per order
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