Adult Nursing – I Topic: Care of clients with Asthma, COPD & Bronchiectasis, Pulmonary Infections

1. Adult Nursing – ITopic: Care of clients with Asthma, COPD & Bronchiectasis, Pulmonary Infections Prepared by: Ms. HepsibahKirubai

2. 1. Asthma What is Asthma? • Asthma is a chronic inflammatory disease of the airways that causes airway hyper responsiveness, mucosal edema & mucus production • These pathophysiological changes ultimately  Recurrent episodes of asthma symptoms • Cough particularly at night & early morning • Chest Tightness • Wheezing and Dyspnea/breathlessness Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

3. 1. Asthma • Airway obstruction may reverse spontaneously or with treatment (Rx). • Experience symptom-free periods alternating with acute exacerbations, which lasts from minutes to hours or days • Incidence of asthma has increased 60% since 1980s and it affects school attendance; occupational choices, physical activity and other aspects of life. • Occurs at any age – childhood disease • Strongest predisposing factor is ALLERGY Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

4. 1. Asthma… Triggers of Asthma attacks: • Allergens: In some persons with asthma, an exaggerated IgE response to certain allergens (e.g. dust, pollen, grasses, animal dander) • Respiratory Infections: (especially viral infections) are one of the most common precipitating factors of an acute asthma attack. Bacterial infections except sinusitis play a major role in exacerbations of asthma. Avoid people with colds or flu, get yearly influenza vaccinations and avoid taking over-the-counter (OTC) cold remedies unless prescribed Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

5. 1. Asthma… Triggers of Asthma attacks… c) Nose and Sinus Problems: Approximately 30% of asthmatics have chronic sinus problems and more have nasal problems that include allergic rhinitis (seasonal or perennial, & nasal polyps). Either allergic sinusitis or bacterial sinusitis may occur. Sinusitis must be treated and large nasal polyps removed for asthma patients to have a good control. d) Exercise: Asthma that is induced or exacerbated during physical exertion is called exercise-induced asthma (EIA) like jogging, aerobics, walking briskly, climbing stairs  bronchospasms, dyspnea, cough & wheezing. Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

6. 1. Asthma Triggers of Asthma attacks… e) Drugs and Food Additives: Sensitivity to drugs may occur in some asthmatic persons especially those with polyps. In 12 – 25% of people with asthma have what is termed the asthma triad – nasal polyps, asthma and sensitivity to aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) like ibuprofen or indomethacin. Betablockers (propranolol & timolol) can trigger asthma. Angiotensin converting enzyme inhibitors (ACEI) may produce cough in susceptible individuals making symptoms worse. Others are tartrazine, vitamins and sodium metabisulfite can trigger asthma. Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

7. 1. Asthma… Triggers of Asthma attacks… f) Gastroesophageal Reflux Disease (GERD): Exact mechanism causing asthma is unknown. Patients with hiatal hernia, excessive stress, and a prior history of (h/o) reflux or ulcer disease may have acid reflux as an asthma trigger. g) Emotional Stress: Psychological or emotional stress like panic or anxiety. Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

8. Common asthma triggers Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

9. 1. Asthma… (Pathophysiology) • Triggers • Infection • Allergens • Exercise • Irritants IgE-mast cell mediated response Release of mediators from mast cells, eosinophils, macrophages, lymphocytes Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

10. Early Phase Response Late Phase Response • Bronchial smooth muscle constriction • Mucus secretions • Vascular leakage • Mucosal edema • Infiltration with eosinophils and neutrophils • Inflammation • Bronchial hyperactivity • Infiltration with monocytes & lymphocytes • Obstruction of large & small airways • Air trappings • Respiratory acidosis • Hypoxemia Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

11. 1. Asthma: Pathophysiology Inflammation  Obstruction  Swelling of the membranes of airway Mucosal Edema  Reducing the airway diameter  Contraction of the bronchial smooth muscles/bronchospasms (wheezing)  Further narrowing & ↑ mucus production Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

12. Normal & Asthmatic Bronchiole Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

13. 1. Asthma: Clinical Manifestations Three most common symptoms are: • COUGH particularly at night and early morning • DYSPNEA & • WHEEZING: Wheezing first on expiration & then inspiration with chest tightness & dyspnea • Expiration is prolonged. • Instead of a normal inspiratory-expiratory ratio of 1:2., it may be prolonged to 1:3 or 1:4 • As a result of bronchospasm, edema and mucus in bronchioles  wheezing, air trapping and hyperinflation Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

14. 1. Asthma: Clinical Manifestations • Cough may be non productive. Secretions may be thick, tenacious, white, gelatinous mucus. • Feeling of suffocation. The person sits upright or slightly bent forward using the accessory muscles of respiration to get enough air. • The more difficult the breathing becomes, the more anxious the patient feels. • During acute attack, the patient reveals signs of hypoxemia: restlessness, increased anxiety, inappropriate behaviour, increased pulse and BP and pulsus paradoxus greater than 12 mmHg. RR is usually >30 bpm. Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

15. 1. Asthma: Classification Step-4: Severe Persistent Symptoms: continual symptoms, limited physical activity, frequent exacerbations Pulmonary Function: FEV1/PEFR is no greater than 60% of predicted. PEFR variability exceeds 30% (FEV1: Forced Expiratory Volume in one second; PEFR: Peak Expiratory Flow Rate) Long-Term control: Two daily medications: Antiinflammatory agent (high-dose inhaled corticosteroid) and long acting bronchodilator (inhaled or oral ᵝ2-agonist or theophylline) and Oral corticosteroid Quick relief: Short-acting inhaled ᵝ2-agonist Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

16. 1. Asthma: Classification Step-3: Moderate Persistent Symptoms: Daily symptoms; daily use of inhaled short-acing ᵝ2-agonist; exacerbations affect activity, exacerbations at least twice weekly and may last for days. Pulmonary Function: FEV1/PEFR is greater than 60% but is less than 80% of predicted. PEFR variability exceeds 30% Long-Term control: One to Two daily medications: Antiinflammatory agent (medium-dose inhaled corticosteroid) and or medium-dose inhaled corticosteroid plus long -acting bronchodilator Quick relief: Short-acting inhaled ᵝ2-agonist Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

17. 1. Asthma: Classification Step-2: Mild Persistent Symptoms: Symptoms more frequent than twice weekly but less than once a day. Exacerbations may affect activity. Pulmonary Function: FEV1/PEFR is at least 80% of predicted. PEFR variability is between 20 % and 30% Long-Term control: One daily medications: Antiinflammatory agent (low-dose inhaled corticosteroid, cromolyn, or nedocromil) or sustained release theophylline. Leukotreine modifiers may be considered. Quick relief: Short-acting inhaled ᵝ2-agonist Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

18. 1. Asthma: Classification Step-1: Mild Intermittent Symptoms: Symptoms no more frequent than twice weekly. Asymptomatic and with normal PEFR between exacerbations. Exacerbations are brief (hours to days) Intensity of exacerbations varies. Pulmonary Function: FEV1/PEFR is at least 80% of predicted. PEFR variability is less than 20 %. Long-Term control: No daily medications Quick relief: Short-acting inhaled ᵝ2-agonist . Use more than twice weekly may indicate need to initiate long-term therapy. Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

19. 1. Asthma: Assessment & Diagnostic Finding: • Complete family, environmental & occupational history is essential • A positive family history & environmental factors including seasonal changes, high pollen counts, mold, climate changes etc • Ask for occupational history Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

20. 1. Asthma: Assessment & Diagnostic Finding: • Ask for comorbid conditions like GERD, drug induced asthma & allergic bronchopulmonary aspergillosis • Ask for allergic reactions like eczema, rashes & temporary edema • Blood test & sputum: ↑eosinophils • Serum immunoglobulin E may be elevated if allergy is present Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

21. 1. Asthma: Assessment & Diagnostic Finding: • ABG  Initially hypocapnia & respiratory alkalosis & later ↑ PCO2 • A normal PCO2 signals respiratory failure • Pulse oximetry • FEV1 & FVC are markedly decreased but can improve on bronchodilators • PFT are usually normal between exacerbations Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

22. 1. Asthma: Complications • Status Asthmaticus • Respiratory failure • Pneumonia • Atelectasis Medical Management: • Pharmacology: • Long-acting medications: To achieve & maintain control of persistent asthma • Quick-relief medications for immediate treatment of asthma symptoms & exacerbation Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

23. 1. Asthma: Pharmacology • Route of choice is Metered Dose Inhaler (MDI) as it allows for topical administration • Success depends on proper use of MDI • If difficulty, use spacer device I. Long-Acting Control Medications: • Corticosteroids: Most potent & effective anti-inflammatory drug • Rinse mouth after inhaling corticosteroid to prevent oral thrush Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

24. 1. Asthma: Long-Acting Control Medications • Systemic corticosteroids to gain rapid control of the disease, to manage severe & persistent asthma Eg: Beclomethasone, budesonide, flunisolide, fluticasone, triamcinolone, prednisolone • Mast cell stabilizers: Cromolyn Sodium (Intal) & Nedocromil (Tilade) are mild to moderate anti-inflammatory agents used in children or on prophylaxis basis for exercise-induced asthma or unavoidable exposure to triggers. Contraindicated in acute asthma exacerbation Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

25. 1. Asthma: Long-Acting Control Medications • Long acting beta2-adrenergic agonists are used with anti-inflammatory. Eg: Salmeterol, albuterol (ventolin), formoterol • Methyl Xanthines: Relief of night time asthma symptoms (aminophylline, theophylline) • Leukotriene modifiers: Zafirlukast, zileuton, montelukast • Mucolytics: Acetylcysteine, Guaifenesin Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

26. 1. Asthma: Other Treatment • If attack caused by exertion, have the patient sit down, rest, and sip warm water • If severe breathing difficulty, reassure and place him in semi-Fowler’s position, encourage diaphragmatic breathing, and urge him to relax • Know that status asthmaticus unrelieved by epinephrine is a medical emergency. Give humidified oxygen by nasal cannula at 2 L/mt to ease dyspnea and increase O2 saturation • Administer drug and IV fluids Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

27. 1. Asthma: Respiratory care modalities: MDI Nebulizer Spacer Spirometry Hepsibah RN; RM; MSN School of Nursing-CPN-UoN Peak Flow Meter

28. 1. Asthma: Quick-Relief Medications • Short-acting beta2 adrenergic agents: Albuterol, levalbuterol etc • Anticholinergics: Ipratropium bromide (Atrovent) Management of Asthma Exacerbation: • Quick acting beta-adregenic agonists are first used for airflow obstruction. • Systemic corticosteroids • Oxygen supplementation • Written action plan Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

29. 1. Asthma: Nursing Management Depends upon severity of symptoms • Patient & family are often frightened & anxious – use calm approach • Assess respiratory status by monitoring severity of symptoms, breath sounds, peak flow, pulse oximetry & vital signs • Obtain h/o allergic reactions to medications & identify current use of medication • Administer medications as prescribed & monitor patients response Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

30. 1. Asthma: Nursing Management • Fluids may be administered • Antibiotics agents may be administered • Nurse assists in intubation procedure if acute respiratory failure occurs Patient Teaching: • Multiple inhalers & different types • Antiallergy therapy • Antireflux medications • Avoidance measures • Nature of asthma & its effect Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

31. 1. Asthma: Nursing Care Plan Nursing Diagnosis-1: Ineffective breathing pattern related to increased airway resistance caused by bronchospasm, mucosal edema and mucus production as manifested by dyspnea, wheezing, rapid respiratory rate, use of accessory muscles Nursing Interventions: • Assess heart rate, respiratory rate, lung sounds, decreased airflow, accessory muscle use and color of mucus membrane and lips to identify acute dyspnea • Provide comfortable position (bed rest in high Fowler’s position or recliner chair) to maximize chest expansion and promote prolonged expiratory phase to reduce trapped air • Administer bronchodilators as ordered to treat bronchospasms • Administer oxygen as ordered to increase oxygen saturation • Auscultate breath sounds to monitor effectiveness of treatment and patient status Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

32. 1. Asthma: Nursing Care Plan Nursing Interventions: • Monitor ABGs or pulse oximetryto monitor oxygen saturation, PaO2 and PaCo2 • Premedicate with bronchodilators before deep-breathing and coughing exercises or chest physiotherapy to open airways for more efficient movement of sputum toward mouth • Evaluate effectiveness of nebulizer treatment by assessing lung sounds, secretion clearance, PEFR and oximetryto assess need for increase or decrease in frequency of treatment • Teach patient to breathe deeply through the nose and exhale 2-3 times as long through pursed lips to increase vital capacity and increase PaO2 and decrease respiratory rate (RR) Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

33. 1. Asthma: Nursing Care Plan Nursing Diagnosis-2: Ineffective airway clearance related to bronchospasm, ineffective cough, excessive mucus production, tenacious secretions and fatigue as manifested by ineffective cough, inability to raise secretions, adventitious breath sounds. Nursing Interventions: • Monitor and control environment for possible allergens to reduce exacerbating asthma attacks • Teach effective coughing so patient can clear airways by propelling secretions toward mouth for expectoration • If patient is unable to cough or expectorate secretions, (fatigue, pain, thick secretions, severe bronchospasm…) so appropriate intervention can be initiated Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

34. 1. Asthma: Nursing Care Plan • As ordered, assist in and evaluate administration of bronchodilator drugs, mucolytic drugs, corticosteroid therapy, chest physiotherapy to improve respiratory status • Observe and note character and quantity or coughed or suctioned sputum and secretions to determine presence of infection • If ordered, send sputum for Gram’s stain and culture and sensitivity Nursing Diagnosis-3: Anxiety related to difficulty breathing, perceived or actual loss of control, and fear of suffocation as manifested by restlessness, elevated pulse and BP Nursing Intervention: • Give simple, concise explanations demonstrating and repeating to increase understanding and foster cooperation Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

35. 1. Asthma: Nursing Care Plan Nursing Intervention… • Stay with the patient to provide reassurance and reduce anxiety. • Anticipate patients needs • Provide anticipatory guidance for patients to prevent exacerbation • Promptly treat any exacerbations of an attack to prevent development of status asthmaticus • Place in room near nurses’ station to provide reassurance & frequent observation. • Teach relaxation techniques to reduce anxiety. 1/29/2012 Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

36. 1. Asthma: Nursing Care Plan Nursing Diagnosis-4: Risk for infection related to decreased pulmonary function, ineffective airway clearance and possible corticosteroid therapy. Nursing Interventions: • Assess for respiratory infections such as elevated temperature, pulse and respiration; increased coughing; change in color, consistency or amount of sputum; adventitious breath sounds • If sputum is mucopurulent, obtain sputum gram’s stain and culture and sensitivity to determine infecting organisms • Administer antibiotic as ordered to treat infection • Monitor temperature q4h and prn, sputum character and quantity to assess for signs of infection • Monitor for localized decrease in breath sounds, decreased PaO2, inability to raise secretions to determine worsening of the condition • Provide deep-breathing and coughing exercises to improve breathing and raise secretions 1/29/2012 Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

37. 1. Asthma: Nursing Care Plan*** Nursing Diagnosis-5: Ineffective management of therapeutic regimen related to lack of knowledge about asthma and its treatment as manifested by frequent questioning regarding all aspects of long-term management • Help the patient identify asthma triggers • Explain how to recognize and prevent respiratory tract infection • Teach how to control an asthma attack • Discuss prescribed drugs and how to use them. Teach how to use a oral inhaler • Tell the patient if asthma support groups are available 1/29/2012 Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

38. End of Asthma! Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

39. Chronic Obstructive Pulmonary Disease (COPD) Prepared By: Ms. Hepsibah, RN; RM; MSN

40. 2. COPD Description: Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. It may include diseases that cause airflow obstruction (emphysema, chronic bronchitis) or any combination of these disorders. The WHO estimates that in 2000, 2.74 million people died of COPD worldwide. Although cigarette smoking is the primary cause of COPD, the WHO estimates that there are 400,000 deaths per year from exposure to biomass fuels.

41. Pathophysiology of COPD The airways and air sacs lose their elasticity (like an old rubber band). The walls between many of the air sacs are destroyed. The walls of the airways become thick and inflamed (swollen). Cells in the airways make more mucus (sputum) than usual, which tends to clog the airways.

42. Pathophysiology of COPD Hepsibah RN; RM; MSN School of Nursing-CPN-UoN

43. Risk factors for COPD Exposure to tobacco smoke accounts for an estimated 80-90 % of COPD cases Passive Smoking Occupational Exposure Ambient Air Pollution Genetic Abnormalities: Deficiency of alpha1-antitrypsin

44. A. Chronic Bronchitis Description: The presence of a cough and sputum production for at least 3 months in each of 2 consecutive years Irritation of airways results in inflammation and hypersecretion of mucus. Mucus-secreting glands and goblet cells increase in number. Ciliary function is reduced, bronchial walls thicken, bronchial airways narrow, and mucus may plug airways. Alveoli become damaged and fibrosed, and alveolar macrophage function diminishes. The patient is more susceptible to respiratory infections.

45. Pathophysiology of Bronchitis Smoke or environmental pollutants irritate the airways ↓ Hypersecretion of mucus & inflammation ↓ Constant irritation ↓ ↑ mucus-secreting glands & goblet cells and ↓ ciliary function ↓ Mucus is produced

46. ↓ Bronchial walls become thickened ↓ Bronchial lumen narrows & mucus may plug the airway ↓ Alveoli adjacent to the bronchioles may become damaged and fibrosed ↓ Altered function of alveolar macrophages ↓ Susceptible to respiratory infection

47. Causes of Bronchitis A wide range of • Viral, Bacterial, Mycoplasmal infection  Bronchitis • Exacerbations of chronic bronchitis is most likely to occur during winter.

48. PATHOPHYSIOLOGY OF CHRONIC BRONCHITIS

49. B. Emphysema Description: Abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli  It is an end stage of a process that has progressed slowly for many years.

50. Pathophysiology of Emphysema  Abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli  ↓ alveolar surface area causes an ↑ in “dead space” and impaired oxygen diffusion.  ↓ of the pulmonary capillary bed ↑ pulmonary vascular resistance and pulmonary artery pressures.  Hypoxemia is the result of these pathologic changes.  ↑ pulmonary artery pressure may cause right-sided heart failure (corpulmonale).