Download Asthma and COPD

Respiratory System
Assessment & Disorders
26/10/2009
1
Upper Respiratory System
Noses and Sinuses
Nose
Begin respiratory system
Filter and warm air
Sinuses
Openings in facial bones
Lighten skull
Assist in speech
Produce mucus
Pharynx and Larynx
Pharynx
Nasopharynx
Oropharynx
Laryngopharynx
Larynx
Connects laryngopharynx to trachea
Routes air and food to proper
passageway
Lower Respiratory system
Lungs
Separated by mediastinum
Composed of elastic connective
tissue
Divided into lobes which are further
divided into segments
Bronchi and Alveoli
Trachea divides into right and left
mainstem bronchi
Bronchi continue to branch and get
smaller (bronchioles) and end as
alveoli
Air moves through passageways to
alveoli where gas exchange occurs
Bronchioles and Alveoli
Pulmonary Circulation
Pulmonary arteries
Pulmonary veins
Pulmonary capillary network
Pleura
Double-layered membrane that
covers lungs
Parietal
Visceral
Hold lungs out to chest wall
Rib Cage and Intercostal
Muscles
Protect lungs
12 pairs ribs
Intercostal muscles are between ribs
Assist with process of breathing
Ventilation
Divided into inspiration and expiration
Normal is 12–20 breaths per minute
Inspiration
Lasts 1–1.5 seconds
Diaphragm contracts and flattens
Intercostal muscles contract
Increases size of chest cavity
Lungs stretch and volume increases
Pressure in lungs slightly less than
atmospheric
Causes air to rush in
Expiration
Lasts 2 to 3
seconds
Passive
Muscles relax
Diaphragm rises
Ribs descend
Lungs recoil
Pressure in chest
cavity increases
(compressing
alveoli)
Pressure in lungs
higher than
atmospheric
causes gases to
flow out of the
lungs
Factors Affecting Respiration
Respiratory center of the brain
Chemoreceptors in the brain, aortic
arch, and carotid arteries
Airway resistance
Compliance
Elasticity
Surface tension of alveoli
Respiratory Changes
Associated with Aging
Cartilage that connects ribs to
sternum and spinal cord calcifies
Anterior-posterior diameter of chest
increases
Respiratory muscles weaker
Cough and laryngeal reflexes less
effective
Respiratory Changes
Associated with Aging
Size of lungs decreases
Alveoli less elastic
Older client at greater risk for
developing respiratory infections
Assessment
Subjective
Current complaint or existing condition
Onset or duration of symptoms
Ability to maintain ADL
Nasal congestion, nosebleeds
Sore throat, difficulty swallowing
Changes in voice quality
Difficulty breathing, orthopnea
Pain on breathing
Assessment (continued)
Subjective
Presence of cough frequency, duration,
productive or unproductive
Sputum amount, color, and consistency
Exposure to infections (colds or
influenza)
History of chronic lung conditions
Occupational exposure to chemicals,
smoke, asbestos
Assessment (continued)
Subjective
History of previous respiratory problems
Allergies to medication or environmental
allergens
Use of tobacco, chewing tobacco,
marijuana, cocaine, injected drugs, and
alcohol
Assessment (continued)
Objective
Assess state of health
Color
Ease of breathing
Note respiratory rate and pattern
Observe nasal flaring
Use of accessory muscles for breathing
Listen for hoarseness in client’s speech
Assessment (continued)
Objective
Inspect mucosa of nose, mouth, and
oropharynx
Inspect neck, position of trachea
Inspect anterior/posterior diameter of
chest
Palpate lips for nodules, chest for
tenderness or swelling
Assessment (continued)
Objective
Auscultate breath sounds, note absence
or presence and quality
Note adventitious breath sounds
(wheezing or crackles)
Pulse Oximetry
Monitors oxygen saturation (SpO2)
Amount of arterial hemoglobin that is
combined with oxygen
Nursing Care
Apply to fingertip, forehead, earlobe, or
nose
Remove nail polish when using fingertip
Arterial Blood Gases
Nursing care
Apply pressure to site 2–5 minutes
following arterial puncture
Serum Alpha1-Antitrypsin
Deficiency in this serum protein
contributing factor in emphysema and
COPD
Normal value in adults 150–350
mg/dL
Fasting specimen obtained in client
with elevated cholesterol or
triglycerides
Sputum and Tissue
Throat or nose swab
Sputum specimen
Culture and sensitivity
Gram’s stain
Acid-fast stain
Cytology
Imaging Techniques
X-rays
CT scans
Ventilation perfusion scans
Nursing care and client teaching
If contrast used remember to ask
about allergies, especially iodine and
seafood
Pulmonary Function Tests
Measure lung volume and capacity
Smoking, caffeine, and
bronchodilators interfere with results
Nursing care and client teaching
Instruct client to stop bronchodilators 4–
6 hours prior to test
Instruct client not to smoke or drink
caffeinated drinks prior to test
Lung Volumes and Capacities
Direct Visualization
Direct or indirect laryngoscopy
Used to identify and evaluate laryngeal
tumors
Nursing care and client teaching
Make sure consent form has been
signed
Remove dentures, partial plates, bridges
prior to procedure
NPO before procedure
NPO after procedure until gag reflex
returns
Bronchoscopy
Visualize trachea, bronchi and
bronchioles
Tumors and structural disorders
Obtain tissue biopsy
Obtain sputum specimen
Removal of foreign body
Nursing care and teaching
Asthma and COPD
Dr Ibrahim Bashayreh, RN, PhD.
25/10/2010
34
Asthma
Asthma is a
chronic
inflammatory
pulmonary disorder
that is
characterized by
reversible
obstruction of the
airways
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Asthma
Asthma is a chronic (long-term)
disease that makes it hard to breathe.
Asthma can't be cured, but it can be
managed. With proper treatment,
people with asthma can lead normal,
active lives.
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Etiology
Cause of asthma is unknown but many
factors play a part:
Genetic factors: Asthma tends to run in
the family
Environmental factors: pollen, dust,
mold, tobacco smoke
Occupational exposure: chemicals and
gases
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Normal bronchiole/
Asthmatic bronchiole
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How asthma works
If you have asthma, your airways
(breathing passages) are extra sensitive.
When you are around certain things, your
extra-sensitive airways can:
Become red and swollen - your airways
get inflamed inside. They fill up with
mucus. The swelling and mucus make your
airways narrower, so it's harder for the air
to pass through.
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Cont.
Become "twitchy" and go into
spasm - the muscles around your
airways squeeze together and tighten.
This makes your airways narrower,
leaving less room for the air to pass
through.
The more red and swollen your
airways are, the more twitchy they
become.
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Symptoms
Hard breathing caused by irritants
Asthma inducers: If you breathe in
something you're allergic to- for
example, dust or pollen- or if you
have a viral infection- for example, a
cold or the flu- your airways can
become inflamed (red and swollen).
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Cont.
Asthma triggers: If you breathe in an
asthma trigger like cold air or smoke, or if
you exercise, the muscles around your
airways can go into spasm and squeeze
together tightly. This leaves less room for
air to pass through.
It's important for every person with asthma
to know what they triggers and inducers
are.
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What are the Triggering Factors?
Domestic dust
mites
Air pollution
Tobacco smoke
Occupational
irritants
Animal with fur
Pollen
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Triggering Factors ( cont.)
Respiratory (viral)
infections
Chemical irritants
Strong emotional
expressions
Drugs ( aspirin,
beta blockers)
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Asthma: Early Clinical
Manifestations
Expiratory & inspiratory wheezing
Dry or moist non-productive cough
Chest tightness
Dyspnea
Anxious &Agitated
Prolonged expiratory phase
Increased respiratory & heart rate
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Asthma: Early Clinical
Manifestations
Wheezing
Chest tightness
Dyspnea
Cough
Prolonged expiratory phase [1:3 or
1:4]
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Asthma: Severe Clinical
Manifestations
Hypoxia
Confusion
Increased heart rate & blood pressure
Respiratory rate up to 40/minute & pursed lip
breathing
Use of accessory muscles
Diaphoresis & pallor
Cyanotic nail beds
Flaring nostrils
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Classification
At risk- breathing test normal, mild
symptoms
Mild- breathing test shows mild limitation,
increasing symptoms
Moderate- person will typically seek care
for symptoms, shortness of breath with
significant exertion, lung tests abnormal
Severe- shortness of breath with limited
activity, lung tests abnormal
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Asthma: Diagnostic Tests
Pulmonary Function Tests
FEV1 decreased
Increase of 12% - 15% after bronchodilator indicative of
asthma
PEFR decreased
Symptomatic patient
eosinophils > 5% of total WBC
Increased serum IgE
Chest x-ray shows hyperinflation
ABGs
Early: respiratory alkalosis, PaO2 normal or near-normal
26/10/2009
severe: respiratory acidosis, increased PaCO2,
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Asthma: Nursing Diagnoses
Ineffective airway clearance r/t
bronchospasm, ineffective cough,
excessive mucus
Anxiety r/t difficulty breathing, fear of
suffocation
Ineffective therapeutic regimen
management r/t lack of information about
asthma
Knowledge deficit
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Medical Management of Asthmatic
Patient
Limit exposure triggering agents
Medications such as: inhaled
corticosteroids, inhaled beta2
adrenergic agonist, and cromolyn
sodium
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Asthma Medications: Antiinflammatory
Corticosteroids
Not useful for acute attack
Beclomethasone: vanceril,
beclovent, qvar
Cromolyn & nedocromil
Inhibits immediate response
from exercise and allergens
Prevents late-phase response
Useful for premedication for
exercise, seasonal asthma
Intal, Tilade
26/10/2009
Leukotriene modifiers
Interfere with synthesis or
block action of leukotrienes
Have both bronchodilation
and anti-inflammatory
properties
Not recommended for acute
asthma attacks
Should not be used as only
therapy for persistent
asthma
Accolate, Singulair, Zyflo
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Asthma Medications:
Bronchodilators
2-adrenergic agonists
Rapid onset: quick relief of bronchoconstriction
Treatment of choice for acute attacks
If used too much causes tremors, anxiety, tachycardia,
palpitations, nausea
Too-frequent use indicates poor control of asthma
Short-acting
Albuterol[proventil]; metaproterenol [alupent]; bitolterol [tornalate];
pirbuterol [maxair]
Long-acting
Useful for nocturnal asthma
Not useful for quick relief during an acute attack
Salmeterol [serevent]
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Asthma Medications:
Bronchodilators con’t
Methylxanthines
Less effective than betaadrenergics
Useful to alleviate
bronchoconstriction of
early and late phase,
nocturnal asthma
Does not relieve
hyperresponsiveness
Side effects: nausea,
headache, insomnia,
tachycardia, arrhythmias,
seizures
Theophylline,
aminophylline
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Anticholinergics
Inhibit parasympathetic
effects on respiratory
system
Increased mucus
Smooth muscle
contraction
Useful for pts w/adverse
reactions to betaadrenergics or in
combination w/betaadrenergics
Ipratropium [atrovent]
Ipratropium + albuterol
[Combivent]
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Management of Asthmatic Patient
Identify and assess status
Avoid precipitating factors
Bring inhaler for each appointment
Drug considerations: Avoid ASA, NSAIDs,
barbiturates, and narcotics
Drug interactions with asthmatic medications (ex.
Theophylline vs. Antibiotics, Cimetidine)
Chronic corticosteroid users may require steroid
supplementation
For sedation, nitrous oxide/oxygen and/or small
doses of oral diazepam is recommended
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Asthma: Client Teaching
Correct use of medications
Signs & symptoms of an attack
Dyspnea, anxiety, tight chest, wheezing, cough
Relaxation techniques
When to call for help, seek treatment
Environmental control
Cough & postural drainage techniques
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COPD
Chronic obstructive pulmonary
disease is a slowly progressive
disease that is characterized by a
gradual loss of lung function
COPD includes chronic bronchitis,
chronic obstructive bronchitis, or
emphysema, or combinations of these
conditions
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Epidemiology
20.3 million Americans report having
asthma
5,000 deaths annually from asthma
12.1 million Americans reported being
diagnosed with COPD
119,000 deaths annually from COPD
COPD is the 4th leading cause of
death in the U.S.
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Chronic Bronchitis
Inflammation of the
main airway passages
(bronchi) to the lungs,
which results in the
production of excess
mucous, a reduction in
the amount of airflow
in and out of the lungs,
and shortness of
breath
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Emphysema
A respiratory
disease
characterized by
breathlessness
brought on by the
enlargement, or
over-inflation of,
the air sacs
(alveoli) in the
lungs
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Signs and symptoms
Wheezing
Coughing
Sputum production
Shortness of breath
Chest tightness
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Diagnosis
Clinical symptoms
Chest x-ray
Lung function tests
ABGs
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Nursing diagnosis
Ineffective airway clearance r/t secretions
Impaired gas exchange r/t altered supply
O2
Altered health maintenance r/t ineffective
individual coping
Risk for infection r/t inadequate defense
system
Knowledge deficit of COPD
Altered role performance r/t changes in
role
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Nursing DX
Ineffective breathing pattern r/t
musculoskeletal impairment , decreased
energy
Inability to sustain spontaneous
ventilation r/t muscle fatigue
Activity intolerance r/t imbalance of O2
supply
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Clinical Features of COPD Patients
Mild COPD: no abnormal signs, smokers
cough, little or no breathlessness
Moderate COPD: breathlessness
with/without wheezing, cough with/without
sputum
Severe COPD: breathlessness on any
exertion/at rest, wheeze and cough
prominent, lung inflation usual, cyanosis,
peripheral edema, and polycythemia in
advanced disease
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Diagnosis
Spirometry
Breathing test which measures the amount and rate at
which air can pass through the airways
Bronchodilator Reversibility Testing
Relaxing tightened muscles around the airways and
opening up airways quickly to ease breathing
Other pulmonary function testing
Diffusion capacity
Chest X-ray
Arterial Blood Gas
Shows oxygen level in blood
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Medical Management of COPD
Patient
Smoking cessation and elimination of
environmental pollutants
Palliative measure such as regular
exercise, good nutrition, flu and
pneumonia vaccines
Bronchodilators, corticosteroids,
anticholinergics, and NSAIDs
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Management of COPD Patient
Review history for concurrent heart disease
Avoid treatment if upper respiratory tract infection is
present
Treat in upright position
Avoid rubber dam in severe cases
Use pulse oximetry (if pulse ox <91%, use low flow 23L/min)
Avoid Nitrous oxide/oxygen in severe cases
Avoid barbiturates, narcotics, antihistamines, and
anticholinergics
If patient is on steroid regimen, supplement as needed
Drug interactions with COPD medication
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