Transcript Slide 1
Respiratory System 1 D.A. is a 78 year old male who states he cannot get rid of his “cold” He has a productive cough Sputum is white to grey He has a 31 pack year smoking history He uses Albuterol inhaler up to 6 times per day 2 What additional information do you need? Subjective information Objective information Psychosocial information 3 4 Controlled by respiratory muscles of the thorax Diaphragm Intercostal muscles Coordinated by respiratory centers of the brain and carotid arteries Respiratory centers respond to changes in: Blood levels of oxygen Carbon dioxide Blood pH 5 Stiffening of connective tissue of lungs Alteration in alveolar shape → increased alveolar diameter Decreased alveolar surface area Increased chest wall stiffness Stiffening of the diaphragm 6 Increased residual volume Decreased vital capacity Premature airway closure → air trapping in lower airways 7 8 Crackles—intermittent, nonmusical, caused by fluid filled alveoli popping open Wheezes—high pitched, occur when air flow is blocked Rhonchi—low pitched, snoring, rattling, occur when fluid partially blocks large airways 9 10 11 12 13 Pulmonary embolism? GERD? Obstruction? ACEi cough? Vocal cord dysfunction? Asthma COPD Chronic bronchitis 14 Symptom Asthma Wheezing Chest tightness Chronic productive cough Nocturnal dyspnea Smoking history Chronic bronchitis COPD Heart Failure Maybe Maybe 15 Airway inflammation Increased mucous secretion production Increased airway responsiveness/sensitivity Reversible airflow obstruction (usually) Eventually causes irreversible damage and scarring Often overlooked in the older client 16 17 Coughing Wheezing Shortness of breath Chest tightness Nocturnal dyspnea between 0400-0600 CHF nocturnal dyspnea occurs 1-2 hours after retiring 18 Mild Mild Intermittent Persistent Moderate Persistent Severe Persistent □ Sx ≤ 2 days □ Sx > 1 □ Symptoms per week times per daily week but < once per day □ Continuous daily symptoms □ Sx ≤ 2 nights per week □ Frequent nighttime symptoms □ Nighttime sx > twice per month □ Nighttime sx > one night per week 19 Prevent symptoms that interfere with quality of life Prevent exacerbations of asthma Minimize need for emergency department visits Maintain normal activity levels Maintain (nearly) normal pulmonary function Minimize use of “rescue” medication Minimize adverse effects of medication 20 Intermittent asthma Step 1 Preferred: short acting β-agonist (SABA) prn Example: Albuterol Persistent asthma with daily medication Step 2 Preferred: low dose inhaled corticosteroids (ICS) Example: Beclomethasone 21 Step 3 Preferred: Low dose ICS + LABA or medium dose ICS Example LABA: Advair Step 4 Preferred: Medium dose ICS + LABA 22 Step 5 Preferred: High dose ICS + LABA And consider Omalizumab for patients who have allergies Step 6 Preferred: High dose ICS + LABA + oral corticosteroid And consider Omalizumab for patients who have allergies 23 At each step… Patient education Environmental control Step up if needed Step down if possible and if asthma is well controlled for at least 3 months 24 Refer to video link in syllabus Spacers are useful for the elderly who have difficulty with coordination and timing (refer to link) Encourage to rinse with warm water and expectorate (“swish and spit ”) to minimize candidiasis, gum disease, tooth decay 25 Provides misted form of medication Easy to use at home Machine requires regular cleaning Breathe slowly, deeply Hold each breath 1-2 seconds before breathing out Important to continue until dose is complete 26 Measures movement of air out of lungs Helps patient anticipate asthmatic episode Patient finds best peak flow number Every day for 2 weeks On waking and between 1200-1400 Before inhaled β-agonist 27 Β-blockers—can induce bronchospasm NSAIDs—bronchospasm Diuretics—hypokalemia Antihistamines—prolonged QT interval ACEi—cough Antidepressants—symptoms of depression can be worsened by corticosteroids 28 COPD Chronic bronchitis Emphysema 29 Cough and sputum production on most days Minimum of 3 months for at least 2 successive years, or, For 6 months during 1 year 30 Acute inflammation of the bronchi Usually self-limiting Viral Similar to pneumonia: productive cough, chills, lethargy, low grade fever Negative chest xray Treatment: rest, humidification, cough suppressants, acetaminophen 31 Permanent destruction of the alveoli Collapse/narrowing of bronchioles Usually in older adults with long smoking history 32 33 COPD with chronic bronchitis Increased mucous production Normal to decreased lung capacity Increased residual lung volume with air trapping Cyanosis and right heart failure Body responds by decreasing ventilation and increasing cardiac output 34 35 COPD with severe emphysema Pink complexion Dyspnea Increased residual lung capacity Decreased elastic recoil High tidal volume Destruction of capillary bed Body compensates for destruction of pulmonary capillary bed by hyperventilation Retractions 36 37 38 Assessment, monitoring treatment of disease Reduce risk factors Prevent disease progression Assess, manage anxiety and depression Mucolytic therapy (e.g., Mucomyst) Rehabilitation Manage exacerbations 39 Bronchodilators Inhaled corticosteroids Antibiotics Flu vaccine annually Pneumococcal vaccine at age 65 Exercise training Mucolytics and expectorants (e.g., Mucomyst, Guaifenesin) 40 Continuous oxygen administration—low flow Postural drainage Chest percussion Controlled coughing Tracheal suctioning 41 Normal stimulus to breathe is rise in CO2 level In COPD, stimulus to breathe is a decrease in O2 level Oxygen flow that is too high will minimize or eliminate the stimulus to breathe in a COPD patient CO2 O2 42 Elderly the most vulnerable Drug resistant forms prevalent Vulnerability enhanced by multiple risk factors: Living in an institution, homeless Exposure to drug-resistant form Previous infection Diabetes Use of immunosuppresive drugs (including corticosteroids) Malnutrition Renal failure 43 Isoniazid—prevent active disease once infected Rifampin Side effects can be significant Interrupting treatment can create drug resistant form 44 More common in the young-old Initial symptoms are vague and mimic other pulmonary illnesses Chest xray initial diagnostic test Older, debilitated patients may not be surgical candidates Chemotherapy Radiation Palliative care 45 History nosocomial pneumonia COPD Recent hospitalization, insitutionalization Smoking Hyperglycemia Use of immunosuppressants and/or antibiotics and/or oxygen therapy Recent antibiotic use Eating dependency 46 Cough Fever Sputum production Prodromal headache, myalgia, lethargy Changes in behavior and mental status New onset tachycardia and tachypnea Change in function 47 48 Clotting disorders Immobility Dehydration Recent surgery Atrial fibrillation Obesity 49 Sudden onset Tachypnea Dyspnea Chest pain Hypoxia Hypotension Possible shock 50 Flu vaccination every year Pneumonia vaccination once if given after the age of 65 Revaccinate in 5 years once only if first vaccination given before the age of 65 51 What is your nursing diagnosis for RB? What is your desired outcome? What are appropriate interventions pertinent to your desired outcome? 52