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Obstructive Pulmonary Diseases

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Nursing Management

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LEARNING OBJECTIVES1.Describe the etiology, pathophysiology, clinical mannifestation, and

collaborative care of asthma.

2. Describe the nursing management of the patient with asthma.

3. Diffrentiete between the etiology, pathophysiology, clinical manifestation, and collaborative care of the patient with chronic obstructive pulmonary disease (COPD).

4. Describe The effects of cigarettes smoking on lungs.

5. Identify the indication for O2 therapy, methods of delivery, and complication of O2 administration.

6. Explain the nursing management of the patient with the COPD.

7. Describe the pathophysiology, clinical manifestations, collaborative care and nursing management of the patient with cystic fibrosis.

8. Describe the pathophysiology, clinical manifestations, collaborative care, and nursing management of the patient with Bronchiectasis.

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Obstuctive pulmonary disease

“when you can’t breath , nothing else matters,” is the mantra of the American lung Association. More than 35 million Americans are living with chronic lung disease. Obstructive pulmonary diseases , the most common chronic lung disease, Include diseases characterized by increase to air flow as a result of air way obstruction or air way narrowing. Airway obstruction may result from accumulate secretion, edema, and swelling of the inner lumen of airways. Bronchospam, or destruction of lung tissue. Type of the obstructive lung disease are asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis, and bronchiectatis.

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Asthma Asthma is the chronic inflammatory disorder of the

airway. The chronic inflammation causes an increase in airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night or in the early morning.

Asthma affect an estimated 20 million America. Women are 30% greater prevalence of asthma then

men. Asthma affects school attendance, occupational

choices, physical activity, and other quality-of-life issues.

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TRIGGER OF ASTHMA ATTACKS Allergens: Approximately 40% of all cases asthma

related to an allergic response. Allergic asthma may be seasonal and related to allergies such as tree or weed pollen. Nonseasonal forms of asthma may be year round (perennial) and related to allergens such as dust mites, mold animals, feather, and cockroaches.

Exercise: Asthma that is include or exacerbated during physical exertion is call exercise- induced asthma (EIA). Airway obstruction may occur due to change in the airway mucosa cause by hyper ventilation occurring during exercise with either cooling or rewarming of air and capillary leakage airway wall.

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TRIGGER OF ASTHMA ATTACKS (CON) Air Pollutants: Various air pollutants, cigarette or

wood smoke, vehicle exhaust, elevated ozone level, sulfur dioxide, and nitrogen dioxide can trigger asthma attack.

Occupational Factors: Occupational asthma is the most common form of occupational lung disease. These exposure in the workplace can also aggravate preexisting asthma. These agent are diverse, such as wood and vegetable dusts(flour), pharmaceutical agent, laundry detergents, animal and insect dusts, secretions and serum(e.g., chicken and crabs), metal salts, chemicals, paints, solvent, and plastics.

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TRIGGER OF ASTHMA ATTACKS (CON)• Respiratory Infection: Respiratory infection (i.e., viral and not bacterial) or allergy to microorganisms is the major precipitating factor of an acute asthma attack. Infections cause inflammatory changes in the tracheobronchial system and alter the mucociliary mechanism.

The patient with asthma should avoid people with cool or flu, get yearly influenza vaccinations, and avoid taking over counter (OTC) cold remedies unless approved by health care provider.• Nose and sinus problems: Some patients with asthma have chronic sinus and nasal problem , Nasal problem include allergic rhinitis, which can be can be seasonal or perennial, and nasal polyps. Treatment of allergic rhinitis may reduce the frequency of asthma exacerbation. Sinus problems are usually related to inflammation of the mucous membranes, most commonly from noninfectious causes such as allergies.

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TRIGGER OF ASTHMA ATTACKS (CON) Drug and food Addictives: sensitivity to specific

drugs may occur in some asthmatic person, especially those with nasal polyps and sinusitis. Some people with asthma have what is termed the asthma traid-nasal polyps, asthma and sensitivity to non steroidal inflammatory drugs (NSAIDs).

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TRIGGER OF ASTHMA ATTACKS (CON) Gastroesophageal Reflux Disease: The exact

mechanism by which gastroesophageal reflux disease (GERD) triggers asthma is unknown. It is postulate that reflux of stomach acid to the esophagus can be aspirated in to the lungs, causing reflex vagal stimulation and bronchoconstriction.

Psychologic Factor : Another factor often in relationship to the etiology of asthma is psychology or emotional stress. Emotional expressing like Crying, laughing, anger and fair can lead to hyperventilation and hypocapnia. Which can cause airway narrowing.

(See Table 29-1)

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TABLE 29-1 Triggers of Acute Asthma AttacksAllergen inhalation• Animal dander (e.g., cat, mice, guinea pig)• House dust mite• Cockroaches • Pollen• Mod Air pollutants• Exhaust fumes• Perfumes• Oxidants• Sulfur dioxides• Cigarette smoke• Aerosol SpraysViral upper respiratory infection Sinusitis Exercise and cold, dry airStressDrugs• Aspirin• Nonsteroidal antiinflammatory drugs• β-Adrenergic blockersOccupational exposure• Metal salts• Wood and vegetable dusts• Industrial chemical and plastics• Pharmaceutical agentsFood additives• Sulfites ( bisulfites and metabisulfites )• Beer, wine, dried fruit, shrimp, processed potatoes• Monosodium glutamate• TartrazineHormones/mensesGastroesophangeal reflux disease (GERD)

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PATHOPHYSIOLOGY The primary pathophysiology of asthma is chronicle

inflammation. Lead to airway hyperresponsiveness and acute airflow limitation. Example of cell in asthma are mast cell, macrophage, eosinophils, neutrophils , T and B lymphocytes and epithelia cell of airway.

The inflammatory process begins, mast cells (found beneath the basement membrane of the bronchial wall) degranulate and release multiple inflammatory mediators.

See Fig. 29-1 and 29-2

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Triggers• Infection• Allergic• Exercise • Irritants

Immune activation(IL-4, IgE production)

Mast cell degranulation

Inflammatory mediators

VasodilationIncrease capillary permeability

Cellular infiltration(neutrophils, lymphocyte, eosiniphils)

Bronchospam Vascular congestion

Mucus secretionImpaired Mucociliary functionThickening of airway walls

Bronchial hyperresponsivenessAirway obstruction

Autonomic nervousSystem effects

Airway remodeling

FIG.29-1 Pathophysiology of asthma. IL, Interleukin

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FIG. 29-2

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CLINICAL MANIFESTATION The characteristic clinical manifestations

of asthma are wheezing, cough, dyspnea, and chest tightness.

Difficulty with air movement in the out of lung.

Reveals sigh of hypoxemia during acute attacks.

Some patients with asthma, cough is usually symptom and this termed cough variant asthma.

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CLASSIFICATION OF ASTHMAAsthma can be classification as mild intermittent, mild persistent, moderate persistent , or severs persistent, (See Table 29-2)

TABLE 29-2 Classification of Asthma Severity

Cassification Symptoms Nighttime Symptom Pulmonary Function*

Step1 Mild intermittent Symptom≤2 times/wk ≤2 time/mo

FEV /PEFR≥80% of predicated Asymptomatic and normal PEFR betweenPEFR variability <20% exacerbations

Exacerbation brief (hours to days)Intensity of exacerbations varies

Step2 Mild persistent Symptoms> 2 times/wk but <1 time/day >2 time/mo

FEV1/PEFR ≥80% of predicateExacerbations may affect activity

PEFR variability 20%-30%

Step3Moderate persistent Daily symptom >1times/wk

FEV1/PEFR ≥60% but 80^% of Daily use of inhaled short-acting β2 –agonist predicate

Exacerbations affect activity PEFR variability >30% Exacerbations at least 2 times/wk and may last for days

Step4Sever persist Continual symptoms Frequent

FEV 1/PEFR ≤ 60% Of predicate Limited physical activity PEFR variability > 30% Frequent exacerbation

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COMPLICATIONS Sever Acute asthma can result in complications such

as rib fracture, pneumothorax, pneumomediastinum, atelectasis, pneumonia, and status asthmaticus.

Status asthmaticus : is a severe, life threatening asthma attack that is refractory to usual treatment and place the patient at risk for developing respiratory failure. • Cause of status asthmaticus include viral illness, ingestion

of aspirin or other NSAIDs, emotional stress, increase enviromental pollutans or other allergen expose, abrupt discontinuation drug therapy , and ingestion of β-adrenergic blockers.

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COMPLICATIONS (CON) Status asthmaticus (cont)

Clinical manifestation status asthmaticus result from increase airway resistance as consequence of edema, mucous plugging, and severe with subsequent air trapping , hyperinflation, hypoxemia, and respiratory acidosis.

Complication of status asthmaticus include pneuthorax, pneumomediastinum, acute core pulmonale with right ventricular failure, and sever respiratory muscle fatigue leading to respiratory arrest. Death from status asthmaticus is usually the result of respiratory arrest or cardiac failure.

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DIAGNOSTIC STUDY History and physical examination Pulmonary function studies including response to

bronchodilator therapy Peak expiration flow rate (PEFR) Chest x-ray Measurement of ABGs or oximetry (if sever

exacerbation) Allergy skin testing ( if indicate) Blood level of eosinophils and IgE ( if indicate) Nitric oxide levels Table 29-04

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TABLE29-04

COLLABORATIVE CAREAsthma

DiagnosticHistory and physical examinationPulmonary function studies including response to bronchodilator therapyPeak expiration flow rate (PEFR)Chest x-rayMeasurement of ABGs or oximetry (if sever exacerbation)Allergy skin testing ( if indicate)Blood level of eosinophils and IgE ( if indicate)Nitric oxide levels

Collaborative TherapyMild Intermittent or Persistent AsthmaIdentification and avoidance/elimination of triggersDesensitization (immunotherapy) if indicatePatient and family teachingDrug therapy (see Table 29-5, 29-6, and 29-7)Asthma action plan (see Table 29-13) Status AsthmaticusSaO2 MonitoringABGsInhaled β-adrenergic agonists or anticholinergic agentO2 by mask or nasal prongsIV or oral corticosteroidsIV fluidsIV magnesiumIntubation and assisted ventilation

ABGs, Arterial blood gases, IgE, immunoglobulin E: SaO2, Oxygen saturation

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COLLABORATIVE CARE Desirable therapeutic out come include

1. Control or elimination of chronic symptoms such as cough, Dyspnea, and nocturnal awakenings;

2. Attainment of normal or nearly normal lung function ;3. Restoration or maintenance of normal levels of activity;4. Reduction in the number of, or elimination of,

recurrence exacerbation;5. Reduction in the number of, or elimination of, ED visits

and acute care hospitalizations; and 6. Elimination or reduction of side effects of medication.

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COLLABORATIVE CARE (CON) The patient who has persistent air flow obstruction

and frequent attacks of asthma should be taught to avoid trigger of acute attacks and to predicate before exercising.

Mild Intermittent or Persistent Asthma Identification and avoidance/elimination of triggers Desensitization (immunotherapy) if indicate Patient and family teaching Drug therapy (see Table 29-5, 29-6, and 29-7) Asthma action plan (see Table 29-13)

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COLLABORATIVE CARE (CON) Status Asthmaticus

SaO2 Monitoring ABGs Inhaled β-adrenergic agonists or anticholinergic agent O2 by mask or nasal prongs IV or oral corticosteroids IV fluids IV magnesium Intubation and assisted ventilation

Acute Asthma Episode Measuring FEV1 or PEFR O2 therapy The administration should be monitored by pulse oxmetry to keep the SpO2

>90%(or 95% in pregnant women and patients with coexisting heart disease

Inhaled β2 adrenergic agonists administered by metered dose inhaler (MDI) Aerosolize medications by nebulizer therapy or by MDI with a spacer are

given every 20 minutes for 1 hour.

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DRUG THERAPY Persistent Asthma require daily long-term therapy in

addiction to appropriate to manage acute asthma . Medication are divide into two general classifications: 1) Long-term-control medications to achieve and

maintenance control of persistent asthma.2) Quick-relief medication to threat symptoms and

exacerbations

See Table 29-6

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TABLE 29-6

DRUG THERAPY Long-Term Control versus Quick reliefOf Asthma

Long-term Control MedicationsAntiinflammatory DrugsCorticosteroids (inhaled or oral)Cromolyn (Intal) and nedocromil (Tilade)Leukotriene modifiersOmalizumab(xolair)

BronchodilatorsLong-acting inhaled β2-adrenergic agnosistsAnticholinergics (inhaled)

Antiinflammatory DrugsCorticosteroids (systemic)*

*Considered quick-relief drugs when used in a short burst (3 to 6 days) at the start of therapy or during a period of gradual deterioration. Corticosteroids are not use for immediate relief of an ongoing attack.

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PATIENT TEACHING RELATE TO DRUG THERAPY Information about a bout medication should include

name, dosage, method of administration, and schedule.

Teaching May include : Purpose side effect appropriate action if side effect occur Consequent of improper use The importance of refilling the prescription before

medication run out. and How to use :

Metered-Dose Inhaler (MDI) Dry Powder Inhaler(DPI)

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NURSING MANAGEMENT Asthma

Nursing Assessment if patient can speak and is not in acute distress, a detailed health history, include identify of any precipitating factors and what has helped alleviate attacks in the past, can be taken. Subjective and objective data that should be obtained from the patient with asthma. (See table 29-12 pg624 for More detail)

Nursing Diagnosis Ineffective airway clearance relate to Bronchospam, excessive mucus production,

tenacious secretion and fatigue as evidenced by ineffective cough, inability to raise secretion, adventitious sounds.

Anxiety related to difficulty breathing, perceived or actual loss of control and fear of suffocation as evidenced by restlessness, elevated pulse, respiratory, rate, and blood pressure.

Deficient knowledge relate to lack of information and education about asthma and its treatment as evidence by frequent question regarding all aspects all aspect of long term management.

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NURSING MANAGEMENT (CON) Asthma (con)

Planning The overall goal that are the patient with asthma will1. Maintains >80% of personal best PEFR or FER1 ,2. Have minimal symptom during the day and night,3. Maintain acceptable activity level (including exercise and

other physical activity),4. Have no recurrent exacerbation of asthma or decreased

incidence of asthma attacks,5. Have adequate knowledge to participate in and carry out

management

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NURSING MANAGEMENT (CON)Nursing Implementation Health promotion

The nursing role in preventing asthma attacks or decreasing the severity focuses primary on teaching the patient and family. Patient should be taught to identify and avoid know personal trigger for asthma ( e.g. cold air aspirin, foods, cats, indoor air pollution)(See Table 29-1). The patient to be encourage to maintain fluid intake of 2 to 3 L per day, good nutrition and adequate rest.

A cute intervention

During an acute attacks of asthma it is important to monitor the patient respiratory and cardiovascular system, Include auscultation lung sound taking the pulse rate, respiratory rate, BP; and monitoring ABGs, pulse oximetry and PEFR. Nursing intervention include administrating O2

, bronchodilator s and medications as ordered and going patient monitoring ( especially lung auscultation ), including the effectiveness of this interventions.

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NURSING MANAGEMENT (CON)Nursing Implementation (con)• Ambulatory and Home care :

• the patient with asthma usually take several medications with difference route of administration and time frame for dosage.

• The patient with asthma must learn about the numerous medications and develop self management strategies.

• Good nutrition is important, physical exercise ( e.g swimming , walking, stationary, cycling )

• Write asthma action plan (see table 29-13) should be develop with patient and family

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Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease (COPD) is the preventable and treatable disease state characterized by airflow limitation that is not fully reversible.

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ETIOLOGY Cigarette Smoking : A major risk factor for

developing COPD. Cigarette smoking has also been implicate as a factor in cancer of the mouth, pharynx, larynx , esophagus, pancreas, kidney, stomach ,colon, cervix, uterus and bladder.

Nicotine :is acts by stimulating the sympathetic nerves system, result in increase heart rate, increase peripheral vasoconstriction, increase BP, increase cardiac workload and also decrease the amount of functional hemoglobin and increase platelets aggregation.

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ETIOLOGY (CON)Occupational Chemical and DustsIf a person has intense or prolong exposure to various

dusts, vapors, irritants, or fumes in the workplace, COPD can develop independently of cigarette smoking.

Air Pollution: Many women who have never smoked, are developing COPD because of cooking with this fuels in poorly ventilate area.

Infection: Sever recurring respiratory tract infections in childhoods has been associated with reduced lung function and increased respiratory symptom in adulthood.

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ETIOLOGY (CON)Occupational Chemical and Dusts (cont) heredity α1 antitrypsin(AAT) deficiency is the

genetic risk factors the leads to COPD. AAT is the serum protein produce by the liver and normally found in the lung. Sever AAT deficiency leads to premature bullous emphysema in the lungs found via radiology testing.

Aging : some of emphysema is common in the lungs of older person, even a nonsmoker.

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PATHOPHYSIOLOGYThe pathogenesis of COPD is complex and involve many

mechanism.

1. The inflammatory process : Start with inhalation of noxious particle and gases( ex: cigarette smoke, air pollution)

2. The airway become inflamed : resulting in increase number of enlarged goblet cells. This result in excess mucus production( or chronic bronchitis).

3. Destruction of the lung: Parenchyma in COPD patient result in emphysema with significant loss of attachment, which could be likened to robber bands connecting airways open.

(See fig. 29-7)

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CLINICAL MANIFESTATIONSClinical manifestation is a diagnosis of COPD should be

considered in any patient who has symptoms of cough, sputum production, or dyspnea and or a history of exposure to risk factor for the disease.

Dyspnea usually occurs with exertion. The cough initially may be intermittent. Later it is

present everyday, but the seldom present during the night. In some people the cough may be nonproductive.

Wheezing and chest tightness may be present, but may vary by time of the day or from day to day, especially in patient with more severe disease.

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CLASSIFICATION OF COPD

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COMPLICATIONS Cor pulmonale Exacerbation of COPD Acute respiratory failure Peptic ulcer and gastroesophageal reflux disease Depression/anxiety

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DIAGNOSTIC STUDIES• History and physical examination • Pulmonary function test• Chest X-ray• Serum –antitrypsin level• Sputum specimen for gram stain and culture

• ABGs

• ECG• Exercise testing with oximetry• Echocardiogram or cardiac nuclear scans

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COLLABORATIVE CAREThe primary goals of care for The COPD patient are to

1. Prevent disease progression,2. Relieve symptoms and improve exercise

tolerance,3. Prevent and treat complication, 4. Promote patient participation in care ,5. Prevent and treat exacerbation,6. Improve quality of life.

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COLLABORATIVE CARE (CON) Smoking cessation : cessation of cigarette smoking

in all stage of COPD in the single most effective and cost-effective intervention to reduce the risk of developing COPD and stop the progression of disease.

Drug therapy :medication of COPD can reduce or abolish symptoms, release the capacity to exercise, improve overall health, and reduce the number of severity exacerbation. Bronchodilator medications commonly used areβ2-adrenergic agonists, anticholinergic agents, and methlylxanthines ( see Table 29-7)

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COLLABORATIVE CARE (CON) O2 Therapy : Oxygen therapy is frequently used in

the treatment of COPD and other problems associated with hypoxemia. It is a colorless, odorless, tasteless, gas that constitutes 20.95% of the atmosphere. (see TABLE 29-22, And Fig 29-11 through fig 29-11)

Goals for oxygen therapy to reduce work of breathing, maintain the PaO2 , reduce workload on the heart , keeping the SaO2 during rest, sleep and exertion. The goal of oxygen administration is to supply the patient with adequate oxygen to maximize the oxygen carrying ability of the blood

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COLLABORATIVE CARE (CON) Surgical therapy for COPD: three difference surgical

procedures have been use in sever COPD. One type of surgery is lung volume reduction surgery

(LVRS). The second surgical procedure is bullectomy. The surgical procedure is lung transplantation.

Respiratory and physical therapy : Breath retraining Effective Coughing Chest physiotherapy

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COLLABORATIVE CARE (CON) Respiratory and physical therapy (con) :

Flutter mucus clearance device High-frequency chest compression (ThAIRaphy vest) Acapella Aerosol Nebullization Therapy

Nutrition Therapy : The patient with COPD should try to keep body mass

index (BMI) between 21 to 25 kg /m2 Cold food may give less than hot food. Fluid intake should be at least 3L per day. Fluid should be taken between milk ( rather then with

them)

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NURSING MANAGEMENT COPDo Nursing assessmentSubject data and object data should be obtained from

person with COPD are o Subject data include

Past health history Nutrition metabolic Activity exercise Elimination Sleeping habit Cognitive and coping stress tolerance.

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NURSING MANAGEMENT COPD (CON)o Objective data are including

Intergumentary Respiratory Cardiovascular Gastrointestinal Musculoskeletal Possible finding

o Nursing diagnosis Ineffective airway clearance : related to expiratory

airflow obstruction, ineffective cough, decrease airway humidity and infection in airway as evidence by ineffective or absence cough, present of abnormal breath sounds or absence of breath sounds.

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NURSING MANAGEMENT COPD (CON)o Nursing diagnosis (cont)

Imbalance nutrition: less than body requirement related to poor appetite, lower energy level, shortness of breath, gastric distention, sputum production.

Insomnia: related to anxiety, dyspnea, depression, hypoxemia, orthopnea as evidence by frequent awakening, prolong onset of sleep, fatigue, irritability.

Risk for infection: related to decrease pulmonary function, ineffective airway clearance, and lack of knowledge regarding sings and symptoms of infection.

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NURSING MANAGEMENT COPD (CON)o Planning The overall goals are that the patient with COPD will

have

1. Prevention of disease progressive

2. Ability to perform ADLs and improve exercise tolerance

3. Relief from form symptoms

4. No complication related to COPD

5. Knowledge and ability to implement along term treatment regimen

6. Overall improve quality of life

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NURSING MANAGEMENT COPD (CON)o Nursing implementation

Airway management • Encourage slow, deep breathing , turning and

coughing to mobilize pulmonary secretion • Position patient to maximize ventilation

potential • Perform chest physiotherapy to used effect of

gravity in remove secretions• Administer bronchodilator and aerosol

treatment to facilitate clearance of retained secretion and increase easy of breathing.

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NURSING MANAGEMENT COPD (CON)Oxygen therapy • Administer supplemental O2 as order

• set up O2 equipment and administer through a heat, humidity system

• Observe for signs of oxygen induced hypoventilation

Nutrition therapy Monitor food/fruits ingested and calculate daily caloric intake Select nutrition supplement to provide nutritional between

meal, snakes. Provide food selection to stimulate the appetite Provide appropriate formation about nutritional needs and how

to meet them to ensure nutritional adequacy after discharge

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NURSING MANAGEMENT COPD (CON)Infection control • Instruct patient on appropriated hand washing

technique to prevent spread of infection• Encourage deep breathing and coughing to prevent

stasis of respiratory secrete.

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Cystic FibrosisCF is a hereditary, autosomal recessive,

multisystem disease characterized by altered function of the exocrine glands primarily including lungs, pancreas and sweat glands.

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ETIOLOGY AND PATHOPHYSIOLOGYThe CF gene is located on chromosome 7 and

produces a protein called CF transmembrane regulator (CFTR). The CFTR protein localizes to the lining of the exocrine portion of particular organs and regulates sodium and chloride channels.

But mutation of CFTR gene alter this protein that way sodium and chloride channels are blocked. As a result, cells that line the passage and other organs produced abnormally thick and sticky mucus.

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CLINICAL MANIFESTATIONS The clinical manifestations of CF are caused by the

production of abnormally thick and sticky mucus of the body’s organs and dependent on the severity of the disease.• An initial finding of meconium ileus in the newborn is present• Childhood are failure to grow, clubbing, persistent cough with

mucus production, tachypnea and large, frequent bowel movements.

• Problems with breathing are among the most serious symptoms.

• The first symptom of CF in the adult is frequent cough • DIOS (distal intestinal obstruction syndrome) causes RLQ

pain, loss of appetite, emesis and often palpable mass.• The function of reproductive system are altered.

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COMPLICATIONS• Pneumothorax is common.• The CF patient with lung infection present of small amount of blood

in sputum is common.• Respiratory failure and cor pulmonale are late complications of CF.

DIAGNOSTIC STUDY • The sweat chloride test • Chest X-ray • Pulmonary function test • Fecal analysis for fat

COLLABORATIVE CARE The major objectives of therapy in CF are to • Promote clearance of secretions • Control infection in the lungs • Provide adequate nutrition

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NURSING MANAGEMENT Nursing Assessment

Subjective and objective data that should obtained from the patient with CF are present in Table 29-29

Nursing Diagnoses

nursing diagnoses for the patient with CF may include, but are not limited to, the following:

• Ineffective airway clearance related to abundant, thick bronchial mucus, weakness and fatigue.

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NURSING MANAGEMENT Nursing Diagnoses (cont’d)• Ineffective breathing pattern related to

bronchoconstriction, anxiety and airway obstruction• Impaired gas exchange related t0 recurring lung

infections.• Imbalanced nutrition: less than body requirement

related to dietary intolerance, intestinal gas, and altered pancreatic enzyme production.

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NURSING MANAGEMENT (CON) Planning

The overall goals that the patient with CF will have • Adequate airway clearance • Reduced risk factors associated with respiratory

infections• Adequate nutritional support to maintain appropriate

BMI• Ability to perform ADLs• No complications related to CF• Active participation in planning and implementing a

therapeutic regimen

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NURSING MANAGEMENT (CON) Nursing Implementation

• Acute intervention for the patient with CF includes reliefs of bronchoconstriction, airway obstruction, and airflow limitation.

• Interventions includes aggressive CPT, antibiotics, oxygen therapy and corticosteroids in severe disease.

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Table 29-29

NURSING ASSESSMENTCystic Fibrosis

Subjective dataImportant health informationPast health history: recurrent respiratory and sinus infections, persistent cough with excessive sputum production Medications: use of and compliance with corticosteroids, bronchodilator, antibiotics, herbsFunctional Health Patterns Health perception-Health maintenance: family history of CF, diagnosis of CF in childhoodNutritional-metabolic: dietary intolerance, voracious appetite, weight loss, heartburnElimination: intestinal gas; large, frequent bowel movement, constipationActivity-exercise: fatigue, ↓ exercise tolerance, amount/type of exercise, dyspnea, cough, excessive mucus or sputum production, coughing up bloodCognitive-perceptual: abdominal painSexuality-reproductive: delayed menarche, menstrual irregularities, and secondary amenorrhea, problems conceiving or fathering a childCoping-stress tolerance: anxiety, depression, problems adapting to diagnosis

Objective data GeneralRestlessness, failure to thriveIntegumentary Cyanosis (circumoral, nail bed) distal clubbing, salty skinEyeScleral icterusRespiratory Sinus difficulties, persistent runny nose, diminished breast sounds, sputum (thick, white or green, tenacious), hemoptysis, ↑ work of breathing, use of accessory muscles of respiration, barrel chestCardiovascular Tachycardia Gastrointestinal Protuberant abdomen, abdominal distention, foul, fatty stoolsPossible finding Abnomal ABGs and pulmonary function tests, abnormal sweat, chloride test, chest X-ray, fecal fat analysis

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BronchiectasisEtiology and Pathophysiology• Bronchiectasis is characterized by

permanent, abnormal dilation of one or more large bronchi.

• Pathophysiology change that results in dilation is destruction of the elastic and muscular structures supporting the bronchial wall.

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BRONCHIECTASISClinical manifestations Hallmark of brochiectasis is persist or recurrent

cough with production of large amount of purulent sputum that may exceed 500 ml/day.

Other manifestations of brochiectasis are dyspea, wheezing, pleuritic chest pain, and hemoptysis.

On auscultation of the lungs, crackles are the most common finding.

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BRONCHIECTASISDiagnostic studies • Chest X-ray • High-resolution CT(HRCT) scan of the chest • Sputum • Pulmonary function Collaborative care

Bronchiectasis is difficult to treat.Therapy is aimed at treating acute flare-ups and

preventing decline in lung function.Antibiotics are the mainstay of the treatment

and are often given empirically.

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NURSING MANAGEMENT

An important nursing goal is to promote drainage and removal of bronchial mucus.

Various airway clearance techniques can be effectively used to facilitate secretion removal.

Bed rest may be indicated during the acute phase of illness. Good nutrition is important and may be difficult to

maintain because the patient is often anorexic.

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REVIEW QUESTION 1. Asthma is the best characterized as

a. an inflammatory disease .b. a steady progression of bronchoconstriction.c. an obstructive disease with loss of alveolar walls.d. chronic obstructive disorder characterized by mucus production.

2. In evaluating the asthmatic patient knowledge of self-care. The nurse recognize that additional Instruction is needed when the patient says,a. “I use my corticosteroid inhaler when I feel short of breath.”b. “I get a flu shot of every year and see my health care provider if I

have an upper respiratory infection.”c. “I use of my brochochodialator inhaler before I visit my aunt who

has a catd. “I walk 30 minutes every but some time I have to use my

bronchodilator inhaler before walking to prevent me from getting short of breath.”

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REVIEW QUESTION 3. A plan of care for the patient with COPD could

includea. Exercise such as walking.b. Chronic oral corticosteroid therapy.c. High flow rate of O2 administration.

d. Breathing exercises in involve inhaling longer than exhaling

4. The effect of cigarette smoking on the respiratory system include.

a. Increased proliferation of ciliated cell b. Hypertrophy of the alveolar membrane.c. Destruction of all alveolar macrophage.d. Hyperplasia of goblet cells and increase production of

mucus.

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REVIEW QUESTION 5. The major advantage of venturi mask is that it can

a. Deliver up to 80% O2.

b. Provide continuous 100% humidity.c. Deliver the precise concentration of O2

.

d. Be used while the patient eats and sleep.

6. One of the most important thing that the nurse can teach a patient with COPD is to

a. Move to a hot, dry climate.b. Perform chest physiotherapy.c. Obtain adequate rest in the supine position.d. Know the early sign/symptom Of COPD exerbation.

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REVIEW QUESTION 7. Diagnosis studies that he nurse would expect to be

abnormal in a person with CF area. Insulin tolerance and blood glucose.b. Pancreatic enzyme and hormones.c. Sweat test and vitamin B tolerance test.d. Pulmonary function test and sweat test.

8. A primary goal for the patient with bronchietatis is that the patient will.

a. Have no recurrence of disease.b. Have normal pulmonary function.c. Maintain removal of bronchial secretions.d. Avoid environmental agents that precipitate attacks

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REFERENCE

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