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Respiratory 2

  1. Asthma
  2. Definition/etiology
    1. reversible obstruction of airways
    2. inflammation of airways
    3. airways hypersensitive to variety of stimuli
    4. bronchospasm is a minor component
    5. disease waxes and wanes, remissions and exacerbations
  3. Findings
    1. orthopnea, expiratory wheezing
    2. barrel chest, cyanosis, clubbingof fingers
    3. distention of neck veins
    4. edema of extremities
    5. increased PCO2 and decreased PO2
    6. polycythemia
  4. Diagnostics
    1. physical examination with history of findings
    2. arterial blood gases
    3. chest x-ray
  5. Complications
    1. hypoxemia
    2. hypercapnia
    3. variety of respiratory infections
    4. cor pulmonale
    5. dysrhythmias
  6. Management for obstructive disease
  7. Antibiotics and corticosteroids for infection or chronic inflammation
  8. Bronchodilators
  9. Mucolytics
  10. Expectorants
  11. Respiratory program: postural drainage, exercise, nebulizer, high protein diet (illustration 1  illustration 2)
  12. Nursing interventions common to obstructive diseases
  13. Assess client's risk of respiratory failure
  14. Assess for degree of respiratory effort for an increased work of breathing or dyspnea
  15. Assess oxygenation with pulse oximeter if hemoglobin level is within normal limits
  16. Measure arterial blood gases (ABG) to evaluate gas exchange
  17. Administer oxygen as indicated
  18. If risk of respiratory failure, anticipate ventilation
  19. Assist with secretion removal as indicated
  20. Pace client activities to reduce oxygen demand
  21. Teach diaphragmatic breathing and pursed-lip breathing
  22. Position in a high Fowler's to ease breathing effort
  23. Provide for nutritional consults as indicated
  24. Reinforce the plan for small, frequent high carbohydrate meals
  25. Provide referrals for:
    1. depression associated with disease
    2. pulmonary rehabilitation
    3. stop smoking support groups
  26. For asthma, teach clients that aspirin or peanuts may stuimulate an asthma attack
    1. LRS Disorders: Restrictive
    2. In general: these disorders prevent full lung expansion via three mechanisms
      1. Lung stiffening
      2. External compression
      3. Muscle weakness
    3. Pulmonary fibrosis- lung stiffening
      1. Occupational lung diseases
        1. coal worker's pneumoconiosis- risk increases with length of exposure to coal dust (>15 years), intensity of exposure, and silica content of dust
        2. silicosis: workers who will have inhaled silica dust
      2. Asbestosis
        1. inhalation of asbestos fibers
        2. disease may develop 15 to 20 years after exposure
    4. Pulmonary sarcoidosis - lung stiffening
      1. Etiology
        1. unknown origin
        2. characterized by formation of tubercles, most often in the lungs
        3. may progress to fibrosis
      2. Findings
        1. dyspnea
        2. anxiety
      3. Diagnostics
        1. chest x-ray
        2. biopsy of affected tissue
      4. Management
        1. antitussives
        2. oxygen therapy
        3. removal of toxic substances
    5. Nursing interventions common to all types of pulmonary fibrosis
      1. Prevent infection or exposure to infection
      2. Pace clients' activities to reduce oxygen demands and dyspnea
      3. Reinforce the need for small, frequent meals
      4. Encourage daily activities within pulmonary tolerance
        1. provide referrals for:
          1. depression associated with disease
          2. stop smoking support groups
          3. occupational rehabilitatio
    6. Disorders of fluid in pleurae
      1. Pleural fluid disorders - all treated with water seal chest drainage systems

        1. Pneumothorax: air between the pleurae
          1. open pneumothorax: hole in the chest wall, communicates with the lung
          2. closed pneumothorax: hole in lung, chest wall intact
          3. tension pneumothorax - a nursing and medical emergency
            1. closed pneumothorax
            2. air is forced into the pleural space with a continued pressure build up
            3. shifts mediastinum away from affected side with results of a compressed heart
            4. treated with chest tube insertion
            5. cardiac and respiratory arrest if not treated
          4. examples of the above (illustration)
        2. Pleural effusion
          1. fluid (transudate or exudate) in the pleural space
          2. if small, no treatment
          3. if larger, treated with chest tube insertion
        3. Hemothorax
          1. blood in the pleural space
          2. treated with thoracentesis or chest tube
        4. Empyema
          1. purulent drainage in the pleural space
          2. often from a chronic condition such as lung cancer
          3. treated with chest tube inserton
        5. Chylothorax
          1. lymphatic fluid in pleural space
          2. treated with thoracentesis or chest tube
      1. Musculoskeletal diseases associated with difficulty breathing
        1. Guillain-Barre syndrome - follows a viral infection
          1. ascending paralysis that may affect muscles of respiration as paralysis ascends
          2. muscles so weak that client cannot breathe deeply, a nursing and medical emergency
          3. may progress to respiratory failure
            1. may require intubation
            2. mechanical ventilation
            3. course of illness varies from a few months to years
        2. Myasthenia gravis
          1. sporadic, progressive weakness of skeletal muscle
          2. cause: lack of acetylcholine with results of a myoneural junction malfunction
          3. may not be able to chew and swallow well
            1. may aspirate
            2. may lose protective airway reflexes
          4. repeated muscle movements, especially towards days end, can exacerbate acute respiratory failure
        1. Poliomyelitis
          1. viral infection
          2. if disease strikes the respiratory muscles the result may be respiratory failure
          3. may not swallow well
            1. may aspirate
            2. may lose protective airway reflexes
        2. Amyotrophic lateral sclerosis (ALS; Lou Gehrig's Disease)
          1. affects motor neurons; autonomic, sensory and mental function unchanged
          2. manifests as a chronic, progressive irreversible disorder
          3. begins usually in distal ends of upper extremities
          4. often leads to respiratory failure within two to five years
          5. results in ethical issue
            1. whether clients want mechanical ventilation
            2. whether nutritional support is desired
            3. if they would rather die when disease becomes this severe
          6. results in clients' inability to communicate or physically move from voluntarily and/or clients lack involuntary reflexes, such as blinking or gag reflex
        3. Muscular dystrophies
          1. progressive symmetrical wasting of voluntary muscles with no nerve effect
          2. as thoracic muscles weaken, breathing becomes more difficult
          3. may not swallow well; risk for aspiration with loss of protective airway reflexes
        1. Interventions common to musculoskeletal disorders
          1. monitor carefully for changes in condition
          2. assess regular swallowing and ability to protect the upper airway
          3. discuss chances of mechanical ventilation or nutritional support: does client wish it?
          4. assist with coughing and secretion clearance as indicated
          5. prevent infection
          6. assess for with appropriate referrals for depression that is often associated with these diseases
          7. administer medications specific to the disease condition
          8. assist/provide occupational or/and physical rehibilitation as indicated
          9. maintain adequate nutrition
          10. with terminal disorders, provide for referrals for family
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