0133427269 Module15 Oxygenation LectureOutline

Module 15 Oxygenation The Concept of Oxygenation Definitions Oxygenation (mechanisms that facilitate or impair bodys ability to supply oxygen to all cells Respiration ( act of inhaling and exhaling air to transport oxygen to the alveoli so that oxygen may be exchanged for carbon dioxide, and carbon dioxide expelled from body Ventilation( the actual exchange of oxygen and carbon dioxide Upper respiratory tract ( nose to pharynx Lower respiratory tract ( epiglottis to alveoli Alveoli ( functional portion of respiratory system where exchange of oxygen and carbon dioxide occurs by diffusion at alveolipulmonary capillary bed interface Breathing ( often unnoticed ( contributes to vital oxygenation of cells and tissues Normal oxygenation Physiology review Adequate oxygenation of body depends on healthy intact respiratory system Upper respiratory system ( inlet for air into the body Inlet ( typically nose ( warms, humidifies, and filters air Upper respiratory tract protective functions ( sneezing and cilia Breathing also happens through mouth ( shared with GI system Epiglottis reflexively closes during swallowing ( protects from aspiration Lower respiratory tract ( enclosed in neck, thoracic cavity Muscular structures relaxed during breathing Eupnea ( breathing within expected respiratory rates Auscultation( listening to bodys sounds with stethoscope ( trachea creates a tubular sound of air movement Trachea ( bifurcates ( two bronchi ( access to right, left lungs See Figures 151 ANATOMY OF THE RESPIRATORY SYSTEM, p. 954, and 152 ANTERIOR VIEW OF THORAX AND LUNGS, p. 955 Trachea, bronchi supported by C-shaped cartilage rings, smooth muscle Bronchioles supported by smooth muscle ( deliver air to alveoli Movement of air ( bronchovesicular sound Lungs ( lobes ( right has three lobes, left has two lobes Inferior lobes largest Pleural lining has two layers ( structures glide across one another Air sacs ( final portion ( alveoli Surfactant( produced by specialized cells in alveoli ( keeps from collapsing and sticking to itself Produced with adequate oxygenation Alveoli interface with pulmonary capillaries ( oxygen (carbon dioxide diffusion Hypercarbia ( increased level of carbon dioxide in blood ( drives breathing Normal respiratory rate in adult ( 1020 breaths per minute See Table 151 RESPIRATIONS THROUGHOUT THE LIFE SPAN, p. 956 Requires patent airway Receptor sited in aortic arch, carotid arteries monitor oxygen ( induce inspiration with low enough levels of oxygen Ability of respiratory system to deliver oxygen to blood ( depends on inflated, well-oxygenated alveolus associated capillary with freely flowing blood at adequate BP Lifespan considerations Childs airway is shorter and narrower than adults ( creates greater potential for obstruction See Figure 15-4 CHILDRENs AIRWAYS ARE SMALLER , p. 956 Trachea primarily increases in length rather than diameter during first 5 years of life See Figure 15-6 IN CHILDREN, THE TRACHEA IS SHORTER , p. 957 Infants airway is approximately 4 mm in diameter adults is 20 mm At birth, lungs contain only 25 million alveoli, which are not fully developed After age 8, the alveoli begin increasing in size and complexity, reaching 300 million by adulthood Alterations to oxygenation Mild impairments ( fatigue, irritability, discomfort Severe alterations ( tissue hypoxia, life threatening See CONCEPTS RELATED TO OXYGENATION, p. 958 Alterations and manifestations Drive to breathe typically hypercarbia ( sometimes decreased oxygen levels drive breathing Commonly seen in COPD Hypoxemia decreased level of oxygen Cyanosis late sign of hypoxemia Loss of airway patency can result Increased sputum production from upper and lower respiratory tract infection Irritation Respiratory rate, rhythm, depth and quality determine adequate oxygenation Tachypnea ( respiratory rate greater than 20 breaths per minute in adults Bradypnea ( respiratory rate less than 10 breaths per minute in adults Apnea ( absence of breathing Dyspnea ( shortness of breath Orthopnea ( difficulty breathing when supine Irregular breathing patterns Kussmaul breathing Cheyne-Stokes respirations Biot respirations Abnormalities in alveolar-capillary bed system alter V-Q ratios See Figure 157 VENTILATION-PERFUSION RELATIONSHIPS, p. 960 Airflow in alveolus blocked Blood flow in capillary blocked Alterations Acute respiratory distress syndrome Asthma Chronic obstructive pulmonary disease Respiratory syncytial virus/bronchiolitis Sudden infant death syndrome Fractured pleural rib Sickle cell disease Pneumothorax Prevalence Inability to oxygenate properly can occur at any point in the life span Those less than 1 year and over 65 years are at increased risk Genetic considerations and nonmodifiable risk factors Genetic link seems to be associated with alterations in oxygenation Significant inherited patter of variation in hemoglobin concentration Case Study Part 1 ( Melissa Dawson is a 30-year-old Caucasian female who was diagnosed with severe persistent asthma as a young child , p. 961 Prevention Factors that affect a healthy respiratory system Management of environmental air quality Vaccination Modifiable risk factors Remediating any alteration that affects the hearts ability to pump and circulate blood throughout the body Hypertension Atherosclerosis Other modifiable risk factors include Obesity Type 2 diabetes Smoking Stress and anxiety Assessment Nursing assessment See ASSESSMENT INTERVIEW Oxygenation, p. 962 See OXYGENATION ASSESSMENT, p. 963 Systematic approach ( all five senses Observe Palpation ( symmetry Percussion Auscultation See Box 151 ADVENTITIOUS BREATHING SOUNDS, p. 963 Client presentation Posture Difficulty breathing, raspy voice Impairment at or near respiratory failure ( will not be able to respond to questions Immediate interventions may be required Notify clients physician Adrenaline if due to anaphylaxis Chest tube or ventilators Support for family Lifespan and cultural considerations See LIFESPAN CONSIDERATIONS RESPIRATORY DEVELOPMENT, p. 965 For pregnant clients, assess for Rhinitis of pregnancy and epistaxis due to increased amounts of estrogen Emphysema, asthma, or COPD due to increased AP diameter Tactile fremitus due to respiratory distress Low-pitched resonance due to high diaphragm Vesicular breath sounds with longer inspiratory phase Diagnostic tests Sputum culture Arterial blood gas (ABG) ( see Table 15-2 ABG Values, p. 966 Pulse oximetry Pulmonary function tests (PFTs) ( see Box 15-2 PULMONARY FUNCTION TESTS, p. 967 Case Study Part 2 ( Ms. Dawson is prescribed Advair Diskus to replace her Flovent Diskus , p. 967 Interventions and therapies Independent Deep breathing exercises Diaphragmatic or abdominal breathing Expansion causes negative pressure within the chest and forces air into the lungs Positioning Fowler position High-Fowler position Encouraging smoking cessation Tobacco smoke exposure ( increased mucus production, reduced cilia action Cessation contributes to overall health See Table 153 INTERVENTIONS FOR TOBACCO CESSATION, p. 969 Monitoring activity tolerance Alterations in respiratory system can affect activity levels Fatigue, weakness from too many activities too close together Adapt schedules Promote secretion clearance Deep breaths and coughing Suctioning Postural drainage Suctioning Use sterile technique Upper respiratory tract ( oral and oropharyngeal suctioning Trachea ( nasopharyngeal and nasotracheal suctioning See LIFESPAN CONSIDERATIONS SUCTIONING, p. 970 Techniques to minimize complications ( hyperinflation, hyperoxygenation Assisting with activities of daily living (ADLs) Poor endurance for ADLs Provide personal care, encourage individual to do as much as possible Collaborative Improving nutrition Nutritionist to aid clients in choosing foods and supplements Pharmacologic therapy Therapeutic management focus on individuals ability to maintain a patent airway Individual whose lung sounds indicate narrowing of airways ( benefits from bronchodilator, possibly anti-inflammatory Short-acting beta-agonist (SABA) ( levalbuterol Corticosteroids Long-acting beta-agonist (LABA) ( chronic respiratory problems in combination with inhaled corticosteroid (ICS) Symbicort, Advair (combinations) ICS without LABA ( Pulmicort, Asmanex Anticholinergics ( relax smooth muscles of airway, decrease mucous secretions by blocking parasympathetic effect Ipratropium bromide inhaler (Atrovent) Xanthines ( cause small airway dilation, increase heart rate and renal blood flow ( theophylline (Slo-Bid) Immunotherapy Medication compliance with chronic, recurring respiratory impairment critical Medications may be costly Teenagers ( embarrassed Older adults ( forgetful, complicated regimen Nonpharmacologic therapy Oxygenation administration Decreased oxygen saturation in arterial blood indicated need for supplemental oxygen Most common, comfortable ( nasal cannula ( 24 L Oxymizer Vapotherm Simple mask Nonrebreather Venturi mask See Table 154 OXYGEN DELIVERY SYSTEMS, p. 973 Nursing care ( ensure flow is sufficient, client comfortable, indwelling lines clear Clients with oxygen ( may feel have lost quality of life Thoracic catheter Chest tube ( used to treat conditions in which fluid enters pleural cavity ( causing lung collapse In place 25 days Nursing actions Ensure oxygen therapy immediately available at all times Monitor dressings for drainage, air leakage Monitor tubing to make sure it is free of kinks or other impediments Monitor and record client vital signs Monitor for and report any decrease in oxygen saturation, changes in breath sounds Assess for pain Monitor and report any changes in respiration or excessive bleeding Review The Concept of Oxygenation Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Part 3 ( Ms. Dawson has been hospitalized for 10 days , p. 974 Exemplar 15.1 Acute Respiratory Distress Syndrome Overview Acute respiratory distress syndrome (ARDS) ( rapid onset characterized by noncardiac pulmonary edema and progressive refractory hypoxemia Extensive lung tissue inflammation and small blood vessel injury occur ( malfunction of other organs following Pathophysiology and etiology Acute lung injury from unregulated systemic inflammatory response to acute injury or inflammation Damaged capillary membranes allow plasma and blood cells to escape into interstitial space ( damage to alveolar membrane ( fluid enters alveoli See Figure 1520 PATHOGENESIS OF ARDS, p. 975 See Figure 1521 PATHOPHYSIOLOGY OF ARDS, p. 976 As ARDS progresses ( significant tissue hypoxia results ( metabolic acidosis Etiology Mortality rate 2545 ( men women ARDS from sepsis ( poorer outcomes Risk factors Direct insults Pulmonary infection, aspiration, inhalation injuries, pulmonary contusions, fat emboli Indirect insults Sepsis, trauma, GI infections, drug overdoses, multiple blood transfusions Prevention Prevention is determined by risk factors Aspiration is prevented by elevating the head of the bed Clinical manifestation Initial manifestations ( 2448 hours after initial insult Progressive respiratory distress See CLINICAL MANIFESTATIONS AND THERAPIES Adult Respiratory Distress Syndrome, p. 978 Collaboration Seriously ill ( require multiple members of healthcare team Role of nurse ( monitor clients condition, respond to subtle cues indicating a change ( react appropriately Diagnostic tests Arterial blood gases analysis Chest x-ray or CT CBC, blood chemistries, blood cultures Sputum culture Pharmacologic therapy No definitive drug therapy Inhaled nitric oxide ( reduces intrapulmonary shunting Surfactant therapy may be described NSAIDs, corticosteroids ( under investigation Nonpharmacologic therapy Includes several different types of therapy ( mechanical ventilation, artificial airways, proper nutrition, adequate fluids, suctioning Mechanical ventilation Mainstay of ARDS management ( endotracheal intubation, mechanical ventilation Percentage of oxygen inspired (FIO2 ) set at lowest level possible Maintain PaO2 higher than 60, oxygen saturation approx 90 Higher percentages may lead to oxygen toxicity ( accentuate ARDS Add positive end-expiratory pressure (PEEP) Types of ventilators Negative-pressure ventilators ( create negative pressure externally to draw chest outward, air into lungs Iron lung, cuirass ventilator, PulmoWrap Positive-pressure ventilators ( used more often Push air into lungs Amount of air delivered in milliliters or until specific pressure reached Noninvasive ventilation Tight-fitting face mask Respiratory failure, obstructive sleep apnea, neuromuscular disease Client tolerance main factor in success Modes of ventilation See Table 156 MODES OF POSITIVE-PRESSURE VENTILATOR OPERATION, p. 981 Continuous positive airway pressure (CPAP) ( applies positive pressure to the airways of a client who is breathing spontaneously Bilevel ventilator (BiPAP) ( provides positive airway pressure as well as airway support during expiration Assist-control mode ventilation (ACMV) ( frequently used to initiate mechanical ventilation when the client is at risk for respiratory arrest assisted breaths triggered by inspiratory effort Synchronized intermittent mandatory ventilation (SIMV)( allows client to breathe spontaneously between delivered ventilator breaths PEEP ( requires intubation, can be applied to any of the previously described ventilator modes ( positive pressure maintained in airways during exhalation and between breaths Pressure-support ventilation (PSV) ( delivers ventilator-assisted breaths when client initiates an inspiratory effort Pressure-control ventilation (PCV) ( controls pressure within airways to reduce the risk of airway trauma Ventilator settings See Table 157 VENTILATOR SETTINGS, p. 982 Most important ( rate, tidal volume, oxygen concentration Rate initially set ( 1215 ventilator breaths per minute Tidal volume ( control amount of gas delivered with each breath ( normal adult tidal volume at rest 7 mL/kg body weight ( 400550 mL Set slightly higher on ventilator to compensate for tubing dead space Percentage of oxygen ( adjusted to maintain oxygen saturation and PaO2 within acceptable ranges Complications Can be lifesaving ( but risks involved Hospital-acquired pneumonia Infection ( normal respiratory tract defense mechanisms bypassed Oral hygiene important Barotrauma Lung injury caused by alveolar overdistention Subcutaneous emphysema Pneumothorax Pneumomediastinum Pneumothorax Identified by signs of unequal chest expansion Rapid chest tube insertion is required Pneumomediastinum ( presence of air in mediastinum Pneumopericardium ( air in the pleural sac Cardiovascular effects Can interfere with venous return to heart, ventricular filling Gastrointestinal effects Stress ulcers Vomiting Weaning from ventilator support Removing ventilator support and reestablishing spontaneous, independent respirations ( begins after underlying process causing respiratory failure corrected Following brief period of mechanical ventilation a T-piece unit or CPAP See Figure 1522 A T-PIECE, OR BLOW-BY, UNIT, p. 982 SIMV and PSV used for weaning ( reconditioning of respiratory muscles necessary Primary use of PCV Terminal weaning ( gradual withdrawal of mechanical ventilation when survival without assisted ventilation in not expected Artificial airways Inserted to maintain a patent air passage for client with obstructed, potentially obstructed airway Oropharyngeal and nasopharyngeal airways Used to keep upper air passages open ( easy to insert, low risk of complications Oropharyngeal ( stimulate gag reflex ( clients with altered LOC See Figure 1523 AN OROPHARYNGEAL AIRWAY IN PLACE, p. 983 Nasopharyngeal ( tolerated better by alert clients See Figure 1524 A NASOPHARYNGEAL AIRWAY IN PLACE, p. 983 Frequent oral care Endotracheal tubes Commonly inserted in clients who have general anesthesia, emergency situations Inserted by primary care provider, nurse, respiratory therapist with specialized educations Inserted into mouth or nose with guide of laryngoscope See Figure 1525 AN ENDOTRACHEAL TUBE, p. 983 Client unable to speak while tube in place Tracheostomies Client who needs long-term airway support Opening into the trachea through the neck Percutaneous or surgical insertion See Figure 1526 A TRACHEOSTOMY TUBE IN PLACE, p. 984 Tracheostomy tubes have outer cannula that is inserted into trachea, flange rests against neck ( tube secured in place with tape or ties See Figure 1527 A TRACHEOSTOMY TUBE WITH A LOW-PRESSURE CUFF, p. 984 See Figure 1528 A TRACHEOSTOMY TUBE WITH A FOAM CUFF, p. 984 Cuffed tracheostomy tubes are surrounded by inflatable cuff that produces airtight seal between tube, trachea Low-pressure cuffs commonly used to decrease risk of tracheal necrosis Nurse provides tracheostomy care for client ( maintains patency, reduces risk of infection Air no longer filtered, humidified ( humidity with mist collar Nutrition and fluids Monitoring fluid, electrolytes, nutrition vital to outcomes Renal perfusion may be decreased ( fluid retention Swan-Ganz catheter Arterial line Other clinical therapies Atelectasis ( prone positioning Careful fluid replacement Infections treated with IV antibiotics Low-molecular-weight heparin ( prevents thrombophlebitis, possible pulmonary embolism, DIC Nursing process Assessment Health history Previous respiratory alterations, illnesses, surgeries, injuries Physical assessment Respiratory LOC Diagnosis Risk for Acute Confusion Ineffective Airway Clearance Ineffective Breathing Pattern Impaired Spontaneous Ventilation Impaired Gas Exchange Decreased Cardiac Output Dysfunctional Ventilatory Weaning Response Risk for Imbalanced Fluid Volume Imbalanced Nutrition Less Than Body Requirements Risk for Infection Acute Pain Anxiety Planning Client will be oriented to name, place, time with each healthcare personnel individual interaction Client will receive adequate ventilatory support to maintain oxygenation of body cells Client will not have pulmonary tissue damage Client will maintain patent airways Client will maintain cardiac output adequate to perfuse all body systems Client will receive adequate nutrition to maintain body process Client will not have signs or symptoms of infection Client will not develop thrombosis Client will manage pain successfully Client will cope with or be free from anxiety Implementation Common interventions CBC, chemistry panel, ABG, blood cultures, sputum cultures, and gastric and stool cultures as indicated by symptoms Monitor vital signs at least hourly continual monitoring may be required Monitor oxygenation status with ABG and pulse oximetry Monitor neurological status, including orientation and LOC Auscultate lung and heart sounds Provide analgesia, anxiolytics, and sedation medications as ordered Provide beta-agonist to maintain patent airways as ordered Maintain head of bed at 30 degrees or higher Position the individual prone for 3060 minutes as tolerated three or four times a day Suction airways as needed Monitor hemodynamic status with central venous catheters or pulmonary artery catheter as ordered Monitor renal function by intake and output as well as blood urea nitrogen and creatinine levels Place Foley catheter Administer intravenous fluids as needed, but avoid fluid overload Monitor glucose levels, and maintain levels within normal limits Assess peripheral pulses Maintain a patent airway c Suction as needed to maintain patent airway Obtain sputum for culture if it appears purulent or is odorous Perform percussion, vibration, postural drainage as ordered Firmly secure the ET or trach tube Assess fluid balance and maintain adequate hydration Promote spontaneous ventilation Assess and document respiratory rate, vital signs, oxygen saturation every 1530 minutes Promptly report worsening ABG and oxygen saturation levels Administer oxygen as ordered, monitoring response Place in Fowler or high-Fowler position Minimize activities and energy expenditures by assisting with ADLs, spacing procedures and activities, allowing uninterrupted rest Enhance cardiac output Monitor and record vital signs, including apical pulse at least every 2 hours Assess LOC at least every 4 hours Monitor pulmonary artery pressures, CVP, and cardiac output readings every 14 hours Assess heart and lung sounds frequently Weigh daily at the same time Frequently provide skin care Maintain IV fluids as ordered Administer analgesics, sedatives, neuromuscular blockers Monitor for dysfunctional ventilatory weaning response Findings Dyspnea, apprehension, agitation Decreasing oxygen saturation level Cyanosis or pallor, diaphoresis Increased blood pressure, pulse, respiratory rate Diminished or adventitious breath sounds, use of accessory muscles Decreased LOC Deteriorating ABG values Shallow, gasping breaths or paradoxic abdominal breathing Interventions Assess vital signs every 1530 minutes Place in Fowler or high-Fowler position Fully explain all weaning procedures, along with expected changes in breathing Remain with client during initial periods following changes of ventilator settings or T-piece trials Limit procedures and activities during weaning periods Provide diversion Begin weaning procedures in the morning, when client is well rested, alert When SIMV used for weaning, decrease SIMV rate by increments of two breaths per minute Avoid administering drugs that may depress respirations during weaning process Keep oxygen at bedside following weaning and extubation Provide pulmonary hygiene with percussion and postural drainage Relieve anxiety Remain with client as much as possible Explain all monitors, procedures, unusual sounds, and machinery Provide simple means of communication Encourage frequent family visits Explain to family that client can hear and understand Provide distraction with radio, television Reassure that intubation, mechanical ventilation is temporary Prepare for discharge ARDS is consequence of serious illness, not of family action/inaction Maximal respiratory function following ARDS usually achieved within 6 months ( may remain significantly impaired Avoid smoking, exposure to secondhand smoke Obtain immunization of pneumococcal pneumonia and annual influenza immunization Evaluation Client maintains oxygen saturation greater than 90 Vital signs remain within acceptable limits Clients airway remains clear ABG results indicate acidbase balance maintained Review ARDS Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Student Nursing Resources Reflect Case Study Exemplar 15.2 Asthma Overview Asthma ( chronic inflammatory disease of lungs characterized by recurrent episodes of wheezing, breathlessness, chest tightness, coughing Mild, brief episodes may resolve spontaneously( most require treatment Asthma early in life ( can cause permanent structural changes called airway remodeling Pathophysiology and etiology Airways ( persistent state of inflammation ( edema may be present Acute inflammatory response may be triggered by variety of factors Trigger occurs ( acute, early response develops in airways Asthma attack prolonged by late-phase response ( develops 412 hours after exposure to trigger See Figure 1529 PATHOGENESIS OF AN ACUTE EPISODE OF ASTHMA, p. 991 Asthma attack untreated ( limited expiratory airflow traps air distal to spastic, narrowed airways ( hypoxemia Hyperventilation ( causes PaCO2 to fall ( respiratory alkalosis Inflammatory mediators released from sensitized airways ( causing activation of inflammatory cells ( bronchoconstriction, airway edema, impaired mucociliary clearance ( airway narrowing limits airflow, increases work of breathing ( trapped air mixes with inhaled air, impairing gas exchange Etiology Triggered by allergies ( 50 of asthma attacks in U.S. May occur from exposure to aspirin and other nonsteroidal drugs Other triggers (exercise, cold or hot air, viral infections, stress Stimuli result in airway hyperresponsiveness, airway overproduction of mucus, edema, of airway mucosa Status asthmaticus ( severe prolonged form of asthma that is difficult to treat Affects 5 million children in U.S. Pediatric differences Narrower airway causes greater increase in airway resistance Edema and swelling ( further narrowing Children under age 6 use diaphragm to breathe ( intercostal muscles immature Ribs flexible ( respiratory distress ( retractions See Figure 1531 RETRACTION SITES, p. 992 Oxygen consumption higher in children than in adults ( higher metabolic rates ( fewer muscle glycogen reserves Risk factors Genetic factors See Table 158 COMMON CAUSES OF ASTHMA, p. 992 Prevention Avoid allergies and environmental triggers Modify home environment Remove pets from household Eliminate all tobacco smoke Comply with medication regimens Clinical manifestations Coughing, wheezing, shortness of breath, chest tightness, tachypnea, tachycardia, anxiety, and apprehension Abrupt or insidious onset Frequency of attacks, severity of symptoms varies Certain audible manifestations may offer clue to airway obstruction See CLINICAL MANIFESTATIONS AND THERAPIES Asthma, p. 994 Disease monitoring Peak expiratory flow reading (PEFR) ( objective measure of lung functions Inexpensive PEFR meter ( monitor self Green ( yellow ( red Asthma in children Frightening for child and parents Interferes with child and family functioning Written asthma action plan for parents and caregivers Smokers need to be aware of danger of secondhand smoke to those with asthma Asthma and pregnancy Improves in 1/3, maintains in 1/3, and worsens in 1/3 Prematurity, low birth weight more common in women who have asthma Multidisciplinary care ( pulmonologist, daily monitory of PEFR Collaboration Diagnostic tests PEFR reading Allergic asthma ( scratch, patch testing CBC with diff ABG Pulmonary function study Chest x-ray Oxygenation saturation monitoring Transcutaneous oxygen and carbon dioxide monitoring Pharmacologic therapy Prevent and control symptoms, reduce frequency and severity of exacerbations, reverse airway obstruction Stepwise approach See Table 159 STEPWISE APPROACH TO ASTHMA MANAGEMENT FOR ADULTS, p. 996 SABA ( quick relief of acute symptoms Metered-dose inhaler, dry powder inhaler, nebulizer Bronchodilators Relax smooth muscles of airway Adrenergic stimulants Anticholinergic agents Methylxanthine See MEDICATIONS Asthma, p. 998 Corticosteroids and NSAIDs Corticosteroids ( block the late response to inhaled allergens and reduce edema and bronchial hyperresponsiveness NSAIDs ( cromolyn sodium, nedocromil Leukotriene modifiers Oral medications that reduce inflammatory response in clients with asthma Montelukast (Singulair) Zafirlukast (Accolate) Complementary and alternative therapy Herbals ( Atropa belladonna, ephedra should NOT be used Biofeedback, yoga, breathing techniques, acupuncture have been found to alleviate or help control asthma symptoms Nursing process Assessment Health history current symptoms, history, controller medications, acute care Physical examination level of distress, color, vital signs Diagnosis Ineffective Breathing Pattern Ineffective Airway Clearance Impaired Gas Exchange Activity Intolerance Anxiety Ineffective Therapeutic Regimen Management Planning Client will experience decreased number and frequency of exacerbations Client will require fewer unscheduled visits to primary care provider or emergency department Client will reduce exposure to irritants that aggravate asthma control Client will experience improved quality of life Implementation Promote airway clearance Monitor skin color and temperature and LOC Assess ABG results, pulse oximetry readings Place in Fowler, high-Fowler or orthopneic position to facilitate breathing and lung expansion Administer oxygen as ordered Administer nebulizer treatments and provide humidification as ordered Increase fluid intake Enhance breathing pattern Monitor vital signs and laboratory results Assist with ADLs as needed Provide rest periods between scheduled activities and treatments Administer medications, including bronchodilators and anti-inflammatory drugs Help relieve anxiety Assess level of anxiety Assist client to identify coping skills that have been successful in the past Listen actively to concerns Include client in care planning, decisions as appropriate, without making excessive demands Reduce excessive environmental stimuli and maintain calm demeanor Allow supportive family members to remain with the client Assist client to use relaxation techniques Promote adherence to therapeutic regimen management Assess clients level of understanding about asthma, treatment regimen Discuss clients perception of illness and effect on his or her lifestyle Assist client and significant others to identify problems or difficulties integrating treatment regimen into lifestyle Assess knowledge and understanding of prescribed medications and use of over-the-counter preparations Provide verbal and written instructions at the clients level of understanding Refer to counseling, support groups, self-help organizations Provide education regarding activity intolerance Teach client to monitor cardiopulmonary response to activity by taking his or her own pulse and BP Teach client how to monitor, record peak flow rates before and after activities Help client assess his or her capacity to sustain activities and determine activities in which the client can participate Assess the need for short-acting bronchodilators before activity or exercise Teach client to space periods of activity with periods of rest Assist client with ADLs as needed Evaluation Client maintains oxygen saturation greater than 90 Client demonstrates proper use of inhalant medications Client lists common triggers for asthmatic exacerbation, strategies to avoid triggers Client, family list symptoms requiring immediate notification of primary provider Client responds appropriately to asthma flare-up Client maintains optimal nutrition to promote health Client describes appropriate follow-up care to control condition Review Asthma Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Student Nursing Resources Reflect Case Study Exemplar 15.3 Chronic Obstructive Pulmonary Disease Overview Diseases that cause obstruction of airways ( combination of bronchoconstriction and inflammation Include asthma, bronchitis, emphysema Chronic obstructive pulmonary disease (COPD) is a specific progressive disorder ( slowly alters structures of respiratory system over time ( irreversibly affecting lung function Periodic exacerbations ( with increased symptoms of dyspnea, sputum production Demonstrate progressive destructive changes Not curable ( manageable Typically includes components of chronic bronchitis and emphysema See Figure 1533 PATHOGENESIS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE, p. 1006 Pathophysiology and etiology COPD results from repeated exposure to respiratory irritants that begin to damage structure within lungs Fluid ( causes edema ( narrowing of airway passages ( airflow limitation ( air trapping ( hyperinflation of lungs ( bronchitis Chronic bronchitis ( disorder of excessive bronchial mucus secretion Recurrent infection common Emphysema ( characterized by destruction of walls of alveoli, with resulting enlargement of abnormal air spaces See Figure 1535 EMPHYSEMA, p. 1007 Inflammatory cells collect in distal airway tissues ( alveolar wall destruction ( alveoli and air spaces enlarge ( surface area for alveolar-capillary diffusion reduced ( reducing volume of air that is passively expired Asthma often exists as comorbid disease in client with COPD Summary three separate processes typically are involved Chronic bronchitis with persistent airway edema, excessive mucus production, and impaired airway clearance Emphysema with loss of interstitial membranes and airway support tissue, resulting in airway collapse and loss of alveolar surface area for gas exchange Small airways disease with bronchoconstriction Etiology A leading cause of death, illness disability Not curable, manageable Preventable ( cigarette smoking greatest risk factor ( 80 of cases Environmental exposures Risk factors Smoking Short-term exposure to high levels of highly irritating substances may result in impairment of lung function Prevention Key to preventing COPD is not engaging in behaviors linked to etiology Dont smoke or quit smoking Decrease exposure to secondhand smoke, occupational respiratory irritants, air pollutants Clinical manifestations Presentation varies from simple chronic bronchitis without disability ( chronic respiratory failure and severe disability Forced expiratory volume in 1-second reading combined with symptoms manifestations determine clients level of COPD severity See Box 15-4 CLASSIFICATION OF COPD BY SEVERITY, p. 1008 Manifestations typically mild, absent early in disease ( chronic cough, sputum production Initially dyspnea ( only on exertion Manifestations of chronic bronchitis ( cough that produces copious amounts of thick tenacious sputum, cyanosis, evidence of right-sided heart failure, adventitious lung sounds prominent on auscultation Manifestation of emphysema insidious ( dyspnea with exertion, minimal cough, barrel chest due to air trapping and hyperinflation, breath sounds diminished, pursed-lip breathing Client often thin, tachypneic, uses accessory muscles, assumes tripod position Prolonged impairment of gas exchange eventually results in cardiac dysfunction Clients need to be seen at least every 6 months Caloric demand increases as effort to breathe increases Anxiety Collaboration Diagnostic tests Pulmonary function testing Ventilation-perfusion scanning Serum (1-antitrypsin levels Arterial blood gas Pulse oximetry Exhaled carbon dioxide CBC with WBC differential Chest x-ray Surgery Lung transplantation when medical therapy is no longer effective Lung reduction surgery is experimental Pharmacologic therapy Immunizations ( pneumococcal pneumonia, yearly influenza Antibiotics if infection suspected Bronchodilators ( MDI, DPI, nebulizer, orally Corticosteroid therapy ( with major asthma component Research indicating use of statins may also target airway inflammation Oxygen therapy Improves exercise tolerance, mental functioning, reduces rate of hospitalization Intermittent, at night, continuous Home oxygen With caution in client with chronic elevated carbon dioxide levels in blood Percussion, vibration, and postural drainage Percussion ( clapping, forceful striking of skin with cupped hands Vibration ( series of vigorous quiverings produced by hands placed flat against clients chest wall Postural drainage ( drainage by gravity of secretions of various lung segments Wide variety of positions necessary to drain all segments of lungs ( not all positions required for all clients Evaluate tolerance of postural drainage Sequence ( positioning ( percussion ( vibration ( removal of secretions by coughing or suction Auscultate clients lungs ( compare to baseline Other interventions Smoking cessation Avoid exposure to other airway irritants, allergens Pulmonary hygiene measures Exercise Improving exercise tolerance Enhancing ability to perform ADLs Preventing deterioration of physical condition Hydration Humidifiers Complementary and alternative therapy Dietary measures ( reduce dairy, sodium intake Acupuncture for smoking cessation Hypnotherapy and guided imagery Nursing process Assessment Health history Physical examination Diagnosis Ineffective Breathing Pattern Ineffective Airway Clearance Activity Intolerance Imbalanced Nutrition Less Than Body Requirements Compromised Family Coping Decisional Conflict Smoking Planning Client will adapt breathing patterns to meet oxygenation demands adequately Client will experience ease of respirations by using positioning, pursed-lip breathing Client will maintain a patent airway, allowing adequate oxygenation Client will maintain oxygenation saturation levels above 90 Client will tolerate activity levels, allowing completion of ADLs Implementation Promote airway clearance Assess respiratory status every 12 hours or as indicated Monitor ABG results Weigh daily monitor intake, output assess mucous membranes and skin turgor Encourage a fluid intake of at least 2,0002,500 mL/day unless contraindicated Place in Fowler, high-Fowler, or orthopneic position Assist with coughing and deep breathing at least every 2 hours while awake Provide tissues and a paper bag to dispose of expectorated sputum Refer to a respiratory therapist and assist with or perform percussion and postural drainage as needed Administer expectorant and bronchodilator medications as ordered Provide supplemental oxygen as ordered Enhance breathing pattern Monitor vital signs and laboratory results Assist with ADLs as needed Provide rest periods between scheduled activities and treatments Teach and assist to use techniques to control breathing pattern Administer medications as ordered Promote activity Assess at each healthcare interaction how the client is meeting ADLs Discuss importance of spacing periods of activity with periods of rest Design, together with physician, physical therapist and client, an exercise plan that meets clients current level of performance but helps build the clients stamina and strength Promote balanced nutrition Assess nutritional status Observe and document food intake, including types, amounts, and caloric intake Monitor lab values, including serum albumin, electrolyte levels Consult with dietitian to plan meals, nutritional supplements to meet caloric needs Provide frequent small feedings with between-meal supplements Place client in a seated or high-Fowler position for meals Assist to choose preferred foods from the menu Keep snacks at the bedside Provide mouth care before meals If unable to maintain oral intake, consult with physician about enteral or parenteral feedings Promote family coping Assess interactions between client and family Assess the effect of the illness on the family Help the client and family identify strengths for coping with the situation Provide information and teaching about COPD Encourage expression of feelings Help family members recognize behaviors and attitudes that may hinder effective treatment, such as continuing to smoke in the house Encourage family members to participate in care Initiate a care conference involving the client, family, and healthcare team members from a variety of disciplines If dysfunctional family relationships interfere with measures to enhance coping, advocate for client, reaffirming his or her right to make decisions Refer client and family to support groups and pulmonary rehabilitation programs as available Arrange a social services consultation Refer to community agencies or services such as home health, homemaker services, or Meals-on-Wheels as appropriate Encourage smoking cessation Assess clients knowledge and understanding of the choices involved and the possible consequences of each Acknowledge concerns, values, beliefs listen without making judgments Spend time with the client, encouraging expression of feelings Help plan a course of action for quitting smoking and adapt it as necessary Demonstrate respect for decisions and the right to choose Provide referral to a counselor or other professional as needed Evaluation Client consistently maintains oxygen saturation greater than 90 Client demonstrates appropriate modifications to ADLs as required based on activity tolerance Client is able to maintain a patent airway adequate to allow for sufficient oxygenation Family is able to describe resources available to reduce caregiver role strain and improve family coping Review COPD Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Student Nursing Resources Reflect Case Study Exemplar 15.4 Respiratory Syncytial Virus/Bronchiolitis Overview Respiratory syncytial virus (RSV) ( highly contagious respiratory infection that affects almost all children before 2 years of age Bronchiolitis ( lower respiratory tract illness that occurs when an infecting agent causes inflammation and obstruction of the small airways Most common cause of RSV Reinfection common Pathophysiology and etiology RSV infects squamous epithelial cells of bronchioles and alveoli Cells merge with adjacent cells, creating large masses of cells, or syncytia that subsequently burst and die ( resulting debris clogs minute airways( irritating airways ( resulting in edema and mucosal secretions ( partial airway obstruction and bronchospasms follow Cycle repeated throughout both lungs Wheezing, crackles in airways, acute rhinorrhea, atelectasis, hypoxemia May lead to apnea and pulmonary edema Highly contagious spread by direct physical contact with respiratory secretion or individual Etiology RSV ( primary cause of respiratory infections among children 2 years and older adults Worldwide ( RSV causes more than 150,000 deaths each year Risk factors Higher with infants, toddlers not breastfed, live in homes with secondhand smoke, attend day care, live in crowded conditions, are socioeconomically disadvantaged Prematurity, chronic lung disease, congenital heart disease, reduced immunity Prevention Good thorough hand hygiene and infection control measures Infants at high risk may be given palivizumab ( offers protection for 30 days Clinical manifestations 35 days after exposure ( rhinorrhea, cough, irritability, low-grade fever for 13 days ( copious mucous secretions occur in lung fields and nasal passages, usually green in color More serious signs and symptoms ( increased irritability, excessive coughing, wheezing, observable retractions of rib cage Call EMS ( marked retractions of rib cage, nasal flaring, rapid respiratory rate, blue skin, listlessness, periods without breathing Collaboration Infants who demonstrate signs of respiratory distress while infected with RSV ( hospitalization Respiratory therapist Nurse Nutritionist Play therapist Diagnostic tests Lab tests Immunofluorescent or enzyme immunoassay techniques from posterior nasopharyngeal specimen Viral cell culture Chest x-ray ABGs Pharmacologic therapy Few medications prescribed ( most studies have not demonstrated improvement Ribavirin ( antiviral drug ( marginal benefit, expensive Infants with complicated congenital heart disease, immunocompromised Nonpharmacologictherapy No effective therapy Hospitalized children ( isolated, roomed together, place on same unit Humidified oxygen using a hood, face tent, mask, nasal cannula ( maintain oxygen saturation readings at greater than 90 Supportive care ( hydration, suctioning CPAP ( moderate to severe bronchiolitis Intubation with apnea, respiratory failure Nursing process Assessment Health history symptoms, behaviors Physical examination Diagnosis Ineffective Breathing Pattern Ineffective Airway Clearance Impaired Gas Exchange Fluid and Electrolyte Imbalance Less Than Body Requirements Impaired Nutrition Less Than Body Requirements Activity Intolerance Planning Clients breathing patterns will remain or return to regular rate, rhythm and quality for the individuals group Clients airways will remain clear of secretions Clients fluid intake will meet daily requirements for individuals age group If a child, client will return to play activities as expected for individuals age group Implementation Promote airway clearance Monitor temperature, pulse, respiration, blood pressure and pulse oximetry Auscultate lung sounds Encourage oral fluids to maintain thinned pulmonary secretions Suction mouth and nose Teach parents the procedure to clear oral and nasal passages with a bulb syringe Teach parents and caregivers the signs and symptoms that indicate the need to return the child to the primary healthcare provider or hospital Teach parents and caregivers the signs and symptoms that indicate the need to call EMS to transport the child to the hospital Teach parents not to smoke around infants and children Administer medications as ordered Promote effective breathing pattern Continue to monitor breathing pattern, including rate, rhythm, and quality Teach parents or caregiver how to observe breathing patterns Inspect and palpate chest for use of accessory muscles Assess for self-posturing Administer bronchodilators and oxygen therapy as ordered Promote adequate nutrition Monitor dietary intake Take daily weight measurements Offer foods that client prefers Offer small, frequent feedings Encourage parents to continue to feed child and provide liquids as normal Monitor fluid balance Assess for poor skin elasticity, dry mucous membranes, decreased urinary output Record intake and output Weigh each diaper for accurate output Teach parents to count diapers per day Encourage oral intake Monitor IV fluid rate if ordered Reduce fatigue Assess capacity to play Organize care to allow for rest periods Evaluation Rate, rhythm, quality of breathing patterns Airway remains clear Fluid and caloric intake monitored to meet needs of age of individual Review RSV/Bronchiolitis Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Student Nursing Resources Reflect Case Study Exemplar 15.5 Sudden Infant Death Syndrome Overview Sudden infant death syndrome (SIDS) is sudden death of apparently healthy infant that remains unexplained after all other possible causes ruled out Third leading cause of infant mortality in the U.S. Pathophysiology and etiology No confirmed causative factor or pathophysiology for SIDS Etiology SIDS ( syndrome ( many and varied autopsy and clinical findings Recent theory Three factors occur simultaneously Infant has brainstem abnormality Significant stressors ( prone, side-lying sleeping positions vulnerable Infants in critical developmental period Covert homicide Respiratory illness Cardiac dysrhythmia Risk factors Infants placed prone ( greatest risk ALWAYS placed supine to sleep Side-lying position increases risk Premature and low-birth-weight infants Maternal smoking Previous SIDS in family Environmental factors See Box 15-6 RISK FACTORS FOR SUDDEN INFANT DEATH SYNDROME, p. 1025 Clinical manifestations No warning signs Most deaths unobserved Typically parents find infant dead in crib Collaboration Education ( back to sleep Assessing older cribs Modeling protective behaviors Protective behaviors modeled and taught Neonatal workers, nursery and pediatric healthcare workers ( conscious of positioning behaviors Addressing the psychosocial needs of the family SIDS may occur despite following precautions Interdisciplinary team to support family through grief Empathetic, provide support Reassure parents they are not responsible for death Direct family to a support group for those who have suffered the death of a child When a death occurs Assessment in the home is completed by the medical examiner and law enforcement Families are interviewed Collaborative care for families includes grief counselors, chaplains, religious leaders, nurse, school nurse, psychotherapists Nursing process Assessment Health history Smoking Sleep positioning Physical examination Diagnosis Risk for SIDS Knowledge Deficit related to risk factors associated with SIDS Enhanced Parenting related to preventive measures associated with SIDS Grieving Compromised Family Coping Risk for Spiritual Distress Planning Parents and other adults living in household will describe appropriate habits to lower the risk for SIDS Any adult in household who smokes will participate in smoking cessation program Parents who lose a baby to SIDS will participate in grief counseling or support group Implementation Reduce risk for SIDS Back to sleep Tummy for play time while awake Cuddle time for loving, upright position on lap or chest Cease smoking during pregnancy and around infant Use bedding that is firm Crib or cosleeper in parents room Sleeper or warm pajamas Blankets secured lower than infants chest Avoid overheating sleeping room Parents need to tell caregivers back to sleep only Evaluation Discuss protection at follow-up visits Review SIDS Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Student Nursing Resources Reflect Case Study 2015 by Education, Inc. 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