Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Patients With Respiratory

Alterations VI

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Nursing Care of Clients with Chronic Obstructive Pulmonary Disease (COPD)

COPD is Characterized By: Airflow limitation that is not FULLY REVERSIBLE! :o o ASTHMA IS SEPRATED FROM COPD because it is REVERSIBLE RECURRENT OBSTRUCTION of airflow in the pulmonary airways Obstruction is usually PROGRESSIVE and May be accompanied by HYPERACTIVITY of GOBLET Cells / mucus secreting cells Problem with lung recoil / chronic inflammation

Topics Discussed Here Are: 1. Chronic Obstructive Pulmonary Disease a. COPD i. Emphysema ii. Chronic Bronchitis b. Bronchiectasis c. Bronchial Asthma 2. Vascular Disease a. Pulmonary Artery Hypertension b. Pulmonary Heart Disease c. Pulmonary Embolism

Mechanism: Involves multiple pathogenesis Includes INFLAMMATION and FIBROSIS (Stiffening) of the bronchial wall, hypertrophy of the submucosal glands and HYPERSECRETION of mucus There is a LOSS OF ELASTIC FIBER and ALVEOLAR tissue

Pathophysiology of COPD
Smoking

Types of COPD
1. Emphysema Characterized by: LOSS of lung elasticity and Abnormal ENLARGEMENT of the air spaces distal to the terminal bronchioles with DESTRUCTION of alveolar wall and capillary beds Etiology: Smoking Genetic: Absence of Alpha1 anti-trypsin
Responsible for synthesis of ELASTIC FIBER

Inflammation of the bronchial wall (Nicotine is irritating)

Fibrosis of the Bronchial Wall

Loss of elastic fiber that hold the airway open

PATHOPHYSIOLOGY of Emphysema
Hypertrophy of the submucosal gland Impairment of expiratory flow rate

Hypersecretion of mucus

Air Trapping!

Obstruction of airflow

Airway collapse

VQ Mismatch Ventilation / Perfusion

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Chronic Bronchitis Airway obstruction caused by INFLAMMATION of major or small airway Commonly seen on middle-aged men and associated with chronic irritation and recurrent infections Etiology or Risk Factors: Smoking, Gender, Age Viral / bacterial cause History of recurrent RTI Exposure to irritants Medical Management Depends on the stage of the disease Administration of PHARMACOLOGIC TREATMENTS 1. Bronchodilators 2. Adrenergic Drugs 3. Anticholinergics Drugs 4. Theophylline 5. Corticosteroids Administer Corticosteroids (Prednisone) Administer Antibiotics (INFECTIONS) Lung resection for distended areas of the lungs

LETS DIFFERENTIATE EMPHYSEMA and CHRONIC BRONCHITIS Characteristics Emphysema (Pink Puffer) Chronic Bronchitis (Blue Bloater) Smoking Usual Usual Age of Onset 40 50 30 40 Barrel Chest After Maybe present Weight Loss May be severe / advanced stage Infrequent SOB Absent in early stage Predominant early sign!! Breath Sounds Characteristic (Alveolar wall distention) Variable Wheezing ABSENT Variable Rhonchi Absent/minimal Other prominent Sputum May be absent / may develop Frequent early manifestation!! Cyanosis Advanced stage Often dramatic Blood Gases Relatively normal until later in the disease Hypercapnia! Cor Pulmonale Only in advanced stages Frequent in peripheral edema Polycythemia Advanced cases Frequent Prognosis Slowly debilitating case Life-threatening due to acute exacerbation IRREVERSIBLE MAY BE REVERSED??

Bronchiectasis
Chronic obstructive lung disease characterized by an ABNORMAL DILATION of the LARGE BRONCHI associated with DESTRUCTION of the BRONCHIAL WALLS Usually bilateral and most commonly affect the lower lobes Clinical Manifestations: o Fever, Recurrent Bronchopulmonary infection o Coughing, Production of copious (Foul smelling secretion) o Purulent sputum o Hemoptysis o Weight loss and anemia o Clubbing of fingers (Prolonged hypoxemia)

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NURSING MANAGEMENT FOR COPD

Identify factors that contributed to the development of the disease Assess for pulmonary function Conduct physical examination Provide health teaching of the disease process and management of care Encourage client to STOP or QUIT SMOKING! Monitor for signs and symptoms of infection Encourage client to EAT SMALL, FREQUENT NUTRITIOUS feedings Improve physical and psychosocial functioning Teach client to do DBE! (Coughing exercises, Pursed lip breathing) To remove air trapping Administer medications as ordered Administer low flow oxygen therapy o 0.5 1 or 2 L o WOF: Carbon dioxide Narcosis

Bronchial Asthma
Chronic inflammatory airway disease In a susceptible person, an asthma attack can be triggered by a VARIETY of stimuli that DO NOT NORMALLY cause symptoms IgE = Immunoglobulin for ALLERGIES Categories / Problems: Bronchospastic Inflammation Causes

Exposure to allergens or irritants Respiratory tract infection caused by viruses Exercise-induced asthma Use of aspirin and NSAID Drug Use of non-selective beta-blocking drug Emotional factors Changes in hormonal level

Clinical Manifestations: Expiratory wheezing Use of accessory muscle Dyspnea Productive cough (Whitish sputum) Prolonged expiration Tachypnea Tachycardia Pulsus Paradoxus Exaggeration of the normal variation in the pulse during the Inspiratory phase of respiration, in which the pulse becomes weaker as one inhales and stronger as one exhales o Normal: Systolic should be <10 mmHg o Abnormal: Systolic is >10 mmHg Diagnostic Procedure: Spirometry Pulmonary Function Test To Test for staging of asthma Chest x-ray Physical Examination

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Medical Management: Immune therapy such as allergy shots and monoclonal antibodies Short Relief medications: o Short-acting beta adrenergic agonists (Terbutaline) o Administration of metered dose inhaler / Nebulizer o Short course of corticosteroid and anticholinergic drug (Ipatroprium Bromide) O2 Therapy Long Term Medications: o Inhaled corticosteroids o Anti-inflammatory agents (Chromolyn Na) o Bronchodilators o Long-active Beta2-Agonist o Aerosol administration Nursing Management: Assess the factors that contributed to the development of the disease Obtain health history of allergic reactions to the medication Administer medication as prescribed Encourage client to OFI Referral to respiratory therapist and other members of the health team Administration of IV Fluids as ordered Health teaching on disease process and prevention of asthma attack

NURSING CARE OF CLIENTS WITH PULMONARY VASCULAR DISORDERS

1. Pulmonary Artery Hypertension (PAH) Defined as a mean pulmonary artery pressure 5 10 mmHg above normal or above 20 mmHg Classified as primary and secondary Risk Factors: HIV Infection Collagen vascular disease Use of appetite suppressants Congenital heart disease Portal hypertension Clinical Manifestations: Dyspnea MAIN SYMPTOM Weakness Fatigue syncope Occasional Hemoptysis Sign of right-sided heart failure Anorexia Abdominal Pain Diagnostic Procedures: ECG Pulmonary Function Test Echocardiogram VQ Scan Liver function testing Cardiac catheterization Pulmonary angiogram Medical Management: Goal is to TREAT the UNDERLYING CAUSE

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Administration of anti-coagulant (To prevent blood clotting!) O2 Therapy Administration of Ca+ Channel Blockers (For vasodilation to pressure) [Endothelin antagonist and protanoids] Oral Administration of sildenafil (Viagra) not only given for males

2.

Pulmonary Heart Disease (Cor Pulmonale) Condition in which the right ventricles of the heart enlarges as a result of the disease that affect the structure or function of the lungs or its vasculature Any condition affecting the lungs and accompanied by hypoxemia may result to cor pulmonale Clinical Manifestations: Clinical manifestation of underlying cause Right Ventricular Failure Edema of the leg, distended neck veins Medical Management: Goal is to improve ventilation o O2 Therapy o Chest physical therapy o Bronchial hygiene o ET Tube intubation o Administration of digitalis o ECG Monitoring o Treat other respiratory problems / infection o Bronchial Hygiene OFI Coughing exercises DBE

3.

Pulmonary Embolism Obstruction of the pulmonary artery or one or more of its branches by a thrombus, tissue fragment, lipids, fats, foreign body or and air bubble Causes/Etiology: Any condition that promotes blood clotting as a result of venous stasis, hypercoagulability and injuries to the endothelial cells that line the vessel o Geriatrics o Clients with spinal injury; immobile for a long time o DM which leads to thrombus formation o Post-op clients Clinical Manifestations: Sudden onset of pleuritic chest pain o VQ Mismatch = Problem in perfusion Dyspnea Tachypnea Tachycardia Unexplained anxiety Large Emboli: o Fainting o Pleural friction rub o Pleural effusion o Fever

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Leukocytosis Pulmonary hypertension Shock

Diagnostic Procedures: Chest x-ray Pulmonary function test Arterial Blood Gas VQ scan Pulmonary Angiogram Hemodynamic measurement Medical Management: Goal is to dissolve the existing emboli and PREVENT new one from FORMING o Anticoagulation Therapy (Prevents formation of NEW EMBOLUS) o Thrombolytic Therapy (Destroying clots Cl: CV disorders, Cerebrovascular disorders) o Surgical intervention (Big clots) Emergency Cases: o Nasal administration of O2 o Hypotension / Dobutamine o ECG Monitoring! o Digitalis = Contractility o Intubation o Morphine to alleviate anxiety and chest discomfort (To promote vasodilation) Nursing Management: Assess the general condition of the patient and presenting symptoms, family history and medication record Prevention of pulmonary embolism o Leg Exercises! o Early AMBULATION! o Use of anti-embolic stockings! Administer medication as ordered Administer O2 Therapy Elevate legs to venous flow = Above heart (But if with congestion, DO NOT ELEVATE!) Alleviate chest pain and anxiety Provide pre and post-op care for client who will undergo and has undergone surgery (Embolectomy) Systemic hydration Remove bubbles in IV

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