Download 401-Chronic-Resp

Care of the Chronic
Respiratory Client
Keith Rischer RN, MA, CEN
1
Todays Objectives
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Compare & contrast pathophysiology and clinical
manifestations of asthma, emphysema, bronchitis &
lung cancer.
Identify the diagnostic tests, nursing priorities, and client
education with asthma, emphysema, bronchitis, & lung
cancer.
Describe the mechanism of action, side effects and
nursing responsibilities with pharmacologic
management of asthma, emphysema & bronchitis.
Contrast and compare medical vs. surgical
management for treatment of lung cancer.
Identify nursing priorities and care of the client with a
chest tube.
Identify nursing priorities and care of the client on a
mechanical ventilator.
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3
Obstructive Airway Disorders
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
COPD
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Increase resistance to airflow
Bronchi smooth muscle
innervated by autonomic
nervous system
• Parasympathetic stimulation
• Sympathetic stimulation
• Inflammatory mediator
response
COPD
• Chronic-recurrent
obstruction
 Emphysema
 bronchitis
4
Obstructive Disorders:Asthma

Patho
• Intermittent & reversible airway obstruction
 INFLAMMATION-Chronic
– Antibody molecules (IgE)
– Mast cells>histamine>WBC
– Physiological response to inflammation
» Vessel dilation>capillary leakage>tissue
swelling>incr. secretions
 Airway hyper-responsiveness
 Childhood
– Allergens
– smoking
– Cold/dry air
– Bacteria
 Bronchospasm
– edema & mucous
5
What is a Mast Cell?
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Bag of Granules
Located in connective
tissue
• close to blood vessels
Histamine released
• Increase blood flow
• Increase vascular
permeability
• Binds to H1, H2
receptors
6
Etiology of asthma

Intrinsic etiologies
•
uncertain causes
• physical or psychological stress
• exercise-induced

Extrinsic etiologies
•
antigen-antibody (allergic) reaction to specific irritants
 air pollutants
 sinusitis
 cold and dry air
 Meds-ASA
 food additives
 hormonal influences
 GE reflux
7
Clinical manifestations of Asthma
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Severe dyspnea
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wheezing with expiration or inspiration
Which is worse…
Tachypnea
Cough
Feelings of chest tightness
Prolonged expiration
Diminished breath sounds
Increased heart rate and blood pressure
Restlessness, anxiety, agitation
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Asthma: Lab & Dx Findings
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Decreased pO2
Decreased pCO2
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Forced vital capacity (FVC)
Peak flow meter
ABG’s
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•
Early
Late findings
Elevated eosinophil count
CXR
Pulmonary Function Test
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pH 7.28
pO2-55
pCO2-60
HCO3-22
O2 sats-86% RA
ABG’s
•
•
•
•
•
pH 7.35
pO2-75
pCO2-30
HCO3-22
O2 sats-90% RA
9
Pharmacologic Treatment Options
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Relievers = short-acting
bronchodilators
•
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quickly relieves
bronchoconstriction and
symptoms
Controllers = daily
medications taken on a
long-term basis
•
•
useful for controlling
persistent asthma
includes anti-inflammatory
agents and long-acting
bronchodilators
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Beta-2 agonists
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chart 33-5 p.590-592
Mechanism
• bronchodilation through bronchial smooth muscle
relaxation mediated by beta-2 receptors in the lung
Short Acting
• albuterol (Proventil, Ventolin)
 Xopenex
• Pirbuterol (Maxair autoinhaler)
• Terbutaline (Brethaire)
Long acting
• Salmeterol-Serevent
Onset: 5-15 minutes
Duration: 4-6 hours
11
Beta-2 agonists
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Uses:
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Rescue medication to relieve acute symptoms
& prevention of bronchospasms prior to a
precipitating event (e.g. exercise)
Adverse effects:
•
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•
•
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Tachycardia
Restlessness
Tremors
Palpitations
paradoxical bronchoconstriction
12
Anticholinergics
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Mechanism
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block parasympathetic nervous system influence
SNS dominates
Ipratropium (Atrovent)
Onset: 3-30 minutes, peak: 1-2 hours
Duration: 4-8 hours
Adverse effects
•
•
drying of mouth and respiratory secretions
increased wheezing in some individuals
13
Inhaled Corticosteroids
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Mechanism
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•
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Decrease inflammation
block late reaction to allergens and reduce
airway hyperresponsiveness
inhibit microvascular leakage
Common Meds…used qd
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•
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budesonide (Pulmocort)
fluticasone (Flovent)
triamcinolone (Azmacort)
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Inhaled Corticosteroids (cont.)
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Uses:
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long-term prevention of symptoms
(suppression, control, and reversal of
inflammation)
reduce/eliminate oral steroid use
Adverse effects:
•
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oral candidiasis
??systemic effects at high doses
15
Oral Corticosteroids
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Common agents
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Prednisone
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Uses
•
short term (3-10 days) “burst therapy” to gain prompt control of
asthma
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•
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methylprednisolone (Medrol, Solu-Medrol)
to prevent progression of exacerbation, speed recovery, and reduce
relapse
long-term prevention of symptoms in severe persistent asthma
LT Side Effects
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HTN
Peptic ulcers
Skin fragility
Impaired immunity
Thromboembolism
Cushingoid appearance
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Asthma:Combination Inhalers
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Advair Diskus
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Fluticasone
Salmeterol (serevent)
Frequency
1
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inhalation q12 hours
Combivent MDI
•
•
•
Ipratropium (atrovent)
Albuterol
Frequency
2
puffs 4 times daily
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Asthma: Other Medications
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Leukotriene Antagonists
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anti-inflammatory
Montelukast (Singulair)
Therapeutic response
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Decreased frequency & severity of attacks
Decreased exercise induced bronchoconstriction
Mast cell stabilizers
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Mechanism
Cromolyn sodium (Intal)
Frequency
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1-2 inhalations 4 times daily
18
Asthma:Regimen by Severity
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Mild
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Moderate
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Short-acting beta-agonist inhaler
Anti-inflammatory inhaler used for mild symptoms
occurring daily
Anti-inflammatory inhaler plus medium-dose
corticosteroid inhaler
used for moderate symptoms occurring daily or more
often
Severe
•
•
Anti-inflammatory inhaler plus long-acting
bronchodilator plus oral corticosteroid
used for severe symptoms occurring daily or more
19
Priority Nursing Diagnoses for Asthma
Impaired gas exchange r/t…
 Ineffective breathing pattern r/t…
 Ineffective airway clearance r/t…
 Anxiety r/t…
 Deficient knowledge
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Asthma:Critical Care Management
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Status asthmaticus/severe
asthma
Physical assessment
• Dyspnea/tachypnea
• Wheezing I/E
• Diminished aeration to no air
movement
• Accessory muscles
Medical management
…remember A,B,C,s
• O2
• Albuterol neb
• Epinephrine subq
• Establish IV
• IV steroids (solumedrol)
• Prepare for possible
21
intubation
Planning and implementation for Asthma
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Assess respiratory and oxygenation status
Administer supplemental oxygen as needed
Administer broncholdilators as prescribed
Observe characteristics of sputum
Identify/avoid/remove precipitating factors
Teach patient relaxation techniques
Prepare for IV access
Be prepared for intubation
Diagnostic studies
Emotional support for patient and family
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Expected outcomes/evaluation
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Absence of dyspnea, chest tightness, wheezing
Respiratory rate 12-20 breaths per minute
Pulse oximetry/arterial blood gas values within
normal range for client
Bilaterally clear and equal breath sounds
Afebrile
Adequate airway clearance
Absence/resolution of anxiety
Clear chest x-ray or return to patient’s baseline
Normal or improved peak flow
23
Asthma: Patient Education
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Identify asthma triggers
Teach patient/family proper used of metereddose inhaler
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Chart 33-6 p.593
Rescue inhalers!
Instruct client regarding the use of peak flow
meter for self-assessment of asthma status
Asthma symptoms requiring emergency
intervention
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Emphysema
25
Emphysema: Patho
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Loss of lung elasticity
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Alveolar destruction
Excessive enlargement
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Loss of “curves” impairs gas exchange
Compensation…
Hyperinflation of lung
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Secondary to air trapping
“barrel chest” appearance
“Pink puffer
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O2 diffused easier than CO2
CO2 accumulates causing chronic resp. acidosis
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Emphysema: Causes &
Complications
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Cigarette smoking
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•
•
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Chronic respiratory inflammation
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Pack years required
Smoke>enzyme elastase protease>destroys alveoli
Destroys cilia
air pollution
Complications
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Hypoxemia & acidosis
Resp. infections/pneumonia
Cur pulmonale
Cardiac dysrhythmias
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Emphysema:
PhysicalAssessment…A,B,C’s
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General appearance
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Emaciated
Barrel chest
Airway/breathing
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Dyspnea
Tachypnea
Accessory muscle use
Pursed lip breathing
Lung sounds
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overall diminished, and wheezes or crackles may be present
Dry cough more so than productive
O2 sats…
Circulation
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tachycardia (inadequate oxygenation)
Arrythmias
28
Emphysema: Diagnostic Tests
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ABGs
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Chronic resp. acidosis
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Compensation w/HCO3
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Assess pO2, pCO2 and HCO3
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CBC
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WBC
Hgb
Hct
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ABG’s
polycythemia
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pH 7.35
pO2-55
pCO2-60
HCO3-22
O2 sats-86% RA
ABG’s
pH 7.35
 Chest x-ray
• pO2-55
• hyperinflated lungs with a flattened•diaphragm
pCO2-60
• HCO3-35
• O2 sats-86% RA
•
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ED COPD Case Study
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84yr female
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PMH: COPD, asthma, HTN, anxiety, mitral stenosis
HPI: productive cough of green phlegm the last 4
days. Primary MD started on po Prednisone and Abx.
Developed incr. SOB through the night with
pronounced fever/chills w/left shoulder pain that
increases w/movement. Denies CP
VS: T-103.2 P-122 (ST) R-36 BP-202/105 sats 88%
RA
Assessment:
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Neuro-a/o notably anxious
Resp-diminished bilat w/exp. Wheezing
CV-2/6 murmur
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ED COPD Case Study
Medical Priorities…
 Nursing priorities
 Nursing assessments…
 Nursing interventions…
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ED COPD Case Study
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CXR
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Large left lower lobe infiltrate
Labs
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BMP
 Na
•
138, K+ 3.9, creat. 1.16, gluc 112
CBC
 WBC
•
7.0, Hgb 13.3, Hct 39.9, plat. 217
UA
 neg
32
Chronic Bronchitis
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A disorder of chronic airway inflammation
Major & small bronchioles
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Chronic productive cough lasting at least 3 months
during 2 years
Chronic exposure to irritants
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•
smoking
An inflammatory response in the small & large
airways resulting in…
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Vasodilation
Congestion
mucosal edema
broncospasm
33
Chronic Bronchitis: Patho
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Etiology
• Smoking
Chronic inflammation
• Increase in # and size of mucous glands
More mucous
• bronchial walls thicken/edema
 airflow is impeded
• Smaller airways are blocked
 Airflow and gas exchange impacted
 pO2…
 pCO2…
• Cilia disappear, and the airway clearance function is lost
• Unlike emphysema, cannot increase breathing efforts to maintain
blood gases
• “blue bloater”
• Polycythemia
34
Chronic Bronchitis: Clinical Manifestations
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Productive cough
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•
Primarily occurring during winter season
foul-smelling sputum
Dyspnea and activity intolerance
 Frequent pulmonary infections
 “Blue bloater”
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•
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bluish-red skin discoloration from cyanosis
and polycythemia
Barrel chest
35
Emphysema/Bronchitis:Medical
Management
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Goals
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improve ventilation
promote patent airway by removal of secretions
Remove environmental pollutants
O2 and neb therapy
Chest physiotherapy
Mechanical ventilation
Surgical procedure
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•
•
bullectomy
lung volume reduction
lung transplantation
36
Emphysema/Bronchitis: Medications
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Beta-adrenergic agonists
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Anticholinergics
•
•
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may be beneficial for pts. w/asthma history
Immunizations
•
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may be beneficial to strengthen diaphragm
contractility and decrease work of breathing
Corticosteroids
•
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Atrovent administered as maintenance by inhaler
most effective bronchodilators for COPD
Theophylline
•
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bronchodilators in COPD by nebs or MDI
flu and pneumonia
Abx
37
Emphysema/Bronchitis: Priority Nursing
Dx p.600-606
Impaired gas exchange r/t…
 Ineffective breathing pattern r/t…
 Ineffective airway clearance r/t…
 Imbalanced nutrition r/t…
 Anxiety r/t…
 Activity intolerance r/t…
 Fatigue r/t…
 Deficient knowledge

38
Emphysema/Bronchitis: Nursing Care
Priorities remember A,B,C’s…
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Administer low-flow O2 as needed
Position patients to maintain effective breathing
Closely monitor & assess resp. status
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Provide education and referrals for pts. w/risk behaviors
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Auscultation
O2 sats
Response to acute interventions/O2
Referral to smoking cessation
Pulmonary conditioning program
Develop appropriate nutritional plans
Energy conservation
Exercise conditioning
Assess understanding to education
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Emphysema/Bronchitis: Patient Education
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Smoking cessation
Teach clients how to avoid occupational or
environmental pollutants
Pursed lip breathing
Maintain adequate nutrition with emphasis on
higher calorie intake
Nutrition may be optimal with frequent small
meals, and 1000-2000cc of fluid daily
Teach energy conservation techniques
40
Emphysema/Bronchitis: Expected
Outcomes
Activity tolerance is optimized
 Pulmonary irritants such as smoking, air
pollution, or occupational exposure are
avoided
 Pulmonary infections are reduced in
number and severity
 Nutritional intake is adequate but not
excessive for individual energy needs

41
Pulmonary Tuberculosis
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Patho
•
•
•
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Mycobacterium
tuberculosis (bacillus)
Most common bacterial
infection globally
Aerosolized
Susceptible host
•
•
•
Nonspecific pneumonitis
alveoli or bronchus
5-15% ultimately develop
Cell mediated immunity 210 weeks later w/+
mantoux
42
Pulmonary Tuberculosis: Infection
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Inflammation in lungs
surrounded by
lymphocytes, collagen
Caseation necrosis
•
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Necrotic tissue turned into
granular mass that become
calcified
Seen in low to middle
lobes
Can spread systemically
to brain, liver , kidneys,
bone marrow
43
Incidence
HIV
 Immigrant populations
 Crowded areas
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•
LTC, prison,
Elderly
 Homeless
 Poverty
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Physical Assessment/Diagnosis
Fatigue, lethargy, nausea, weight loss
 Fever…night sweats
 Persistent cough…productive streaked
w/blood
 Decreased aeration, crackles
 Diagnosis
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•
•
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Positive smear acid-fast bacillus
+ sputum culture…takes 1-3 weeks to confirm
Mantoux 5-10mm induration
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Treatment
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Combination
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•
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chart 34-7 p.643
Isoniazid (INH)
Rifampin
Pt. education
•
•
•
•
Compliance! 6 months treatment required
Sputum specimens q2-4 weeks during therapy
No longer contagious after 2-3 weeks of treatment
Once negative x3 cured
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Nursing Priorities
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Airborne precautions
Ventilated room
N-95 mask or PAPR
for any staff entering
room
TB drugs can cause
nausea-anticipate
Nutrition
47
Lung Cancer: Patho
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Bronchial epithelium
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•
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90% primary
Obstruction
Histologic cell type
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Small cell vs. non small cell
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•
Adenocarcinoma
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Small cell 20% of all lung
CA
99% correlation
w/smoking
35% of all lung CA
Spread between smokers
and non smokers
Metastasis
•
Circulatory & lymphatic
48
Lung Cancer: Clinical Manifestations
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Non-specific & occur late
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Bronchitis/pneumonitis secondary to obstruction
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•
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Depend on type & location of tumor
Chills
Fever
Cough
Bloody sputum
Dyspnea
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•
Use of accessory muscles
Wheezing-diminished aeration
49
Lung Cancer: Diagnostic
CXR
 CT
 Bronchoscopy
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•
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Bronchial washing
Needle/surgical biopsy
50
Lung Cancer:Medical Management
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Non-surgical
•
Chemotherapy
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N&V
Mucositis
Alopecia
Immunosuppression
Pan cytopenia
Radiation
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Best results when used w/surgery or chemo
Daily for 5-6 weeks
Esophagitis…esophagus proximal to lungs
Side effects
–
–
–
–
Skin irritation & peeling
Fatigue
Nausea
Taste changes
51
Lung Cancer:Medical Management
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Surgical
•
Thoracotomy
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Lobectomy
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•
Tumor removal
Removal lobe of lung
Pneumonectomy
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Entire lung
52
Lung Cancer: Thoracotomy-Postop
p.618-622
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Chest tube
•
•
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Drain placed in pleural
space to restore intrapleural
pressure
Chest tube banded &
connected to Pleurovac
collection chamber w/several
feet tubing
Drainage system
•
First chamber

•
Second chamber
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•
Drainage from client
Water seal
Third chamber

suction
53
Chest Tube: Nursing Priorities
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Assess resp. status
closely
Check water seal for
bubbling
Milk NOT strip every 2
hours
Assess color-amount
drainage
•
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Call MD if >100cc/hr x2
hours first 24 hours
Sterile guaze/occlusive
dressing at bedside 54
Mechanical Ventilation
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The use of an ET and
POSITIVE pressure to deliver
O2 at preset tidal volume
Modes
•
Assist Control (AC)
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•
Synchronized Intermittent
Mandatory Ventilation (SIMV)
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•
•
TV & rate preset
Additional resp. receive preset
TV
Additional resp. receive own TV
Used for weaning
Continuous Positive Airway
Pressure (CPAP)
Bi-pap


Non-mechanical
receive both insp. & exp.
Pressures w/facemask
55
Mechanical Ventilation
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Terminology
•
•
Rate
Tidal volume

•
Fraction of inspired O2
concentration (FiO2)

•
•
Use lowest possible to maintain
O2 sats
Positive End Expiratory
Pressure (PEEP)
Minute volume


10-15cc/kg
RR x TV
AC12-TV 600-50%-+5
56
Mechanical Ventilation: Adverse
Effects
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Complications
•
•
•
•
•
•
Aspiration
Infection-VAP
Stress ulcer of GI tract
Tracheal damage
Ventilator dependancy
Decreased cardiac
output

•
Positive pressure decr.
venous return & CO
Barotrauma

pneumothorax
57
Mechanical Ventilation:Nursing Priorities
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Monitor VS-breath sounds
closely
Assess ET
securement/length at lip
Clearance of secretions
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•
•
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Sedation
•
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
Closed suction-maintains
sterility
Do not do routinely
Pre-oxygenate
Propofol
Oral care
Nutritional support
58
Mechanical Ventilation:Nursing Priorities

Ventilator Alarm
Troubleshooting
• High pressure
 Secretions-needs sx
 Tubing obstructed or
kinked
 Biting ET
•
Low pressure
 Disconnection of tubing
 Follow tubing from ET to
ventilator
59
Oxygen Delivery
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Atmospheric room air %.......???
Nasal cannula
• Add 3% for each liter of flow to
FiO2
• 1-6 liters
Oxymizer
• Reservoir to increase FiO2 per liter
delivery
• 6-12 liters
Face mask
• 40-50% FiO2
• 8-15 liters
Face mask w/non-rebreather
• 90-100% FiO2
60
Respiratory Case Study
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

Darrell Johnson is a 62-year-old male who comes
to the Emergency Room with a 4-day history of
increased sputum production, a change in the
character of sputum, increased shortness of
breath, and a fever of 101° F
He has a smoking history of 2 packs a day for the
past 20 years, and he smoked 1 pack a day prior
to that beginning at the age of 14.
He reports that he had asthma as a child, and
that he has been treated with Albuterol inhalers
from time to time as an adult. Mr. Johnson has
been hospitalized twice with pneumonia, most
recently 2 years ago.
61
Respiratory Case Study
Physical exam reveals the following:
Vital signs: T 101° F, P 115, R 30, BP 120/80
O2 sats 90% on room air


Respirations shallow and labored, with use of
respiratory accessory muscles.

Increased anteroposterior (AP) diameter of the
chest.

Skin dry and warm to touch, with inelastic skin
turgor, and fingernail clubbing present.
62
Respiratory Case Study

Which assessment is most important for the nurse to
complete next?

A) Auscultate breath sounds.
B) Determine pupillary response to light.
C) Observe for jugular vein distention.
D) Palpate pedal pulses.

Which assessment finding supports Mr. Johnson's
diagnosis of pneumonia?

A) Pulse rate of 115.
B) BP of 120/80.
C) Increased AP diameter of the chest.
D) Fingernail clubbing.
63
Respiratory Case Study

Arterial Blood Gases were obtained with the following
results:
•
•
•
•

pH 7.28.
pCO2 55.
HCO3 25.
pO2 89.
Based on these ABG results, which acid base imbalance is
Mr. Johnson experiencing?
•
A) Metabolic acidosis.
B) Metabolic alkalosis.
C) Respiratory acidosis.
D) Respiratory alkalosis.
64
Respiratory Case Study

Which nursing diagnosis has the highest
priority when planning care for Mr. Johnson?
•
A) Altered nutrition, less than body requirements.
B) Activity intolerance.
C) Anxiety related to increased shortness of
breath.
D) Ineffective airway clearance.
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Respiratory Case Study

Mr. Johnson is admitted to his room on the Medical
Nursing Unit.
The healthcare provider prescribes the following:
•
•
•
•
•
•
•
Bedrest with bedside commode.
O2 at 2 L/minute via nasal cannula.
Diet as tolerated.
Continuous O2 saturation monitoring via pulse oximeter.
IV fluid of 5% Dextrose and 0.45 Normal Saline at 3 liters per day.
Obtain a sputum culture.
Medications include:





Ampicillin (Unasyn) 1 gm IVPB every 6 hours.
Nebulizer treatments every 4 hours and PRN with saline and
albuterol (Ventolin).
Triamcinolone (Azmacort) inhaler, 2 puffs twice a day.
Albuterol (Ventolin) inhaler, 2 puffs 4 times a day.
Methylprednisolone (Solu-Medrol) 125 mg IVPB every 8 hours.
66
Respiratory Case Study

Which nursing action should be implemented before
administering the prescribed Unasyn?
•

A) Assess the apical heart rate.
B) Obtain O2 saturation recording.
C) Obtain a sputum culture.
D) Record Mr. Johnson's weight.
Which assessment is most important for the nurse to
perform while Mr. Johnson is receiving Ventolin?
•
A) Monitor temperature.
B) Measure intake and output.
C) Monitor pulse and BP.
D) Measure central venous pressure (CVP).
67
Respiratory Case Study

The nurse observes Mr. Johnson as he uses his inhalers. Using a
spacer, he takes 2 puffs of the Ventolin, followed a minute later by 2
puffs of the Azmacort.
After observing Mr. Johnson, what client teaching should the nurse
initiate?
•

A) "Administer the Azmacort first, followed by the Ventolin."
B) "Using a spacer reduces medication absorption."
C) "Inhale deeply before sealing the mouthpiece."
D) "Wait at least one minute between each puff of the same medication."
Which instruction should the nurse provide Mr. Johnson for an acute
episode of asthma?
•
A) "Administer the Azmacort as soon as possible."
B) "Use the Ventolin inhaler for acute asthma attacks."
C) "Call your healthcare provider before administering any medication."
D) "You will need IV Solu-Medrol for your next acute attack."
68
Respiratory Case Study


Continuous monitoring of Mr. Johnson's oxygen saturation indicates
readings ranging between 90%-91%.
After checking the sensor site to make sure the readings are
accurate, which intervention should the nurse initiate next?
•

A) Increase the oxygen to 6 L/minute per nasal cannula.
B) Elevate the head of the bed to a high-Fowler's position.
C) Remove the pulse oximeter to reduce anxiety.
D) Obtain and administer a prescription for pain relief.
Which action should the nurse implement to ensure accurate oxygen
saturation readings via a pulse oximeter?
•
A) Elevate the extremity to which the sensor is attached.
B) Assess adequacy of circulation prior to applying the sensor.
C) Keep the sensor exposed to adequate lighting.
D) Remove the sensor when taking the B/P.
69
Respiratory Case Study



During the night, Mr. Johnson calls the nurse to report a
sudden inability to catch his breath.
Upon assessment, the nurse notes that Mr. Johnson's
respiratory rate has increased to 40 with obvious dyspnea,
and his O2 saturation reading is 55. His pulse is 110, weak,
and thready, and his blood pressure is 70/40.
Which interventions should the nurse initiate immediately?
•
A) Place resusitation equipment in the room.
B) administer high flow O2
C) establish IV access and initiate IV fluid resuscitation
D) Initiate CPR.
70
Respiratory Case Study


The remainder of Mr. Johnson's hospital stay is uneventful and is
transferred back to the floor
Which outcome statement is the best indicator that Mr. Johnson's
pneumonia is resolved and he is ready to be discharged?
A) Sputum culture is negative.
B) Unasyn peak and trough levels are within normal limits.
C) Oxygen saturation level is 92%.
D) Temperature is 98° F.

Which additional discharge instruction should the nurse include in the
teaching plan to promote optimal health for Mr. Johnson?

A) Avoid physical exertion.
B) Avoid crowds and people with infections.
C) Limit intake of oral fluids.
D) Stay indoors except in the early morning.
71