PN 132

COPD NEOPLASMS

RESPIRATORY MEDS

LEARNING OBJECTIVES

• Define pathophysiology of common chronic respiratory disorders

• Discuss nursing interventions for patients with chronic respiratory disorders

• Define pathophysiology of malignant neoplasms (Lung Cancer) in the respiratory tract

• Discuss nursing interventions for patients with respiratory neoplasms

• Identify common respiratory medications

Chronic Bronchitis

Asthma

Bronchiectasis

COPD

WHAT IS COPD?• Progressive and irreversible

condition

• Diminished inspiratory and expiratory capacity of lungs

• Obstructs flow of air to or from the bronchioles – chronic airflow limitations

• Includes

• Emphysema

• Chronic bronchitis

• Asthma

• Bronchiectasis

CHRONIC BRONCHITIS

ETIOLOGY AND PATHOPHYSIOLOGY• Recurrent productive cough for minimum of 3 month / year for at least 2 years

• Caused by physical or chemical irritants and recurrent lung infections

• Cigarette smoking most common cause

• Other causes

• Workers inhaling dust (coal / grain)

• Underlying process

• Impairment of cilia (can’t move secretions)

• Mucous gland hypertrophy

• Causes hyper secretion alters cilia function

• Bronchial tubes become inflamed and scarred

• Patient cannot clear mucus becomes medium for bacteria

• Leads to bronchospasms

• Poor O2 / CO2 exchange increased CO2 in the blood

CLINICAL MANIFESTATIONS• Productive cough

• Most pronounced in the morning

• Increased dyspnea

• Uses accessory muscles

• Cor Pulmonale

• Right side heart hypertrophy pulmonary hypertension

• Cyanosis

• Often accompanied by right ventricular failure

• Characteristic reddish-blue skin

ASSESSMENT• Subjective

• Hx of smoking or exposure to irritants

• Family history of respiratory disorders

• Current medications and treatment regimen

• Objective• Assess productive cough

• Characteristics and amount of sputum

• Assess severity of dyspnea

• Note wheezing

• Patient’s level of restlessness and anxiety

• Monitor vital signs

• Tachycardia

• Tachypnea

• Elevated temp

NURSING INTERVENTIONS• Hydration to liquefy secretions

• Suction prn

• Provide “low-flow” oxygen (1 – 2 L via nasal cannula)

• Maintain SpO2 > 90%

• Frequent oral hygiene

• Frequent rest periods

• Counsel about smoking cessation

• Assess

• Degree of dyspnea

• Use of sternal muscles for breathing

• Degree of fatigue

• Administer medications

Teach• Effective breathing

techniques• Avoid infection exposure• Notify MD at first sign of

respiratory infection• Changes in sputum

• Provide medication teaching

• Stress adequate fluid intake

• Encourage smoking cessation program

ASTHMA

• Wide spread narrowing of the airways

• Extrinsic

• Caused by external factors

• Pollen

• Dust

• Feathers

• Animal dander

• Foods

• Intrinsic

• Often triggered by respiratory infection

• Recurrence of attacks affected by

• Mental / physical fatigue

• Emotional factors

ETIOLOGY AND PATHOPHYSIOLOGY

• Mild Asthma• Dyspnea with exertion

• Wheezing

• Symptoms usually controlled with medication

• Status Asthmaticus• Severe, life-threatening attack

• Does not respond to usual treatment

• Trapped air leads to exhaustion and respiratory failure

• Acute Asthma Attack• Usually happens at night

• Tachypnea

• Tachycardia

• Diaphoresis

• Chest tightness

• Cough

• Expiratory wheezing (caused by forcing air out)

• Use of accessory muscles

• Nasal flaring

• Increased anxiety

• Thick copious mucus

CLINICAL MANIFESTATIONS

• Subjective• c/o anxiety

• Fear of suffocation

• Breathlessness

• Chest tightness

• Cough

• At night and early morning

• Objective• Assess s/s hypoxia

• Restlessness

• Inappropriate behavior

• Elevated pulse and B/P

• “hunched forward”

• Inspiratory and expiratory wheezes

• Thick stringy mucus

ASSESSMENT

• Administer medications

• Ensure adequate fluid intake and optimal ventilation

• Rest with activity

• Elevate HOB

• O2

• Monitor vital signs

• Monitor electrolytes

• Empathetic emotional support!

• Teach • Effective breathing

• Lip-pursed breathing

• Correct use of peak flow meter

NURSING INTERVENTIONS

BRONCHIECTASIS

ETIOLOGY AND PATHOPHYSIOLOGY

• Abnormal / permanent dilation of one or more large bronchi

• Eventually destroys musculature and elastic support of bronchial wall

• Gradual loss of pulmonary muscle tone after repeated infections

• More difficult to clear mucus from the lungs

• Decreased expiratory air flow

• Occurs as complication of recurrent inflammation and infection

• Usually secondary to failure of normal lung tissue defenses

• Cystic fibrosis

• Foreign body

• tumor

CLINICAL MANIFESTATIONS• S/S occur after respiratory infection

• Late S/S

• Dyspnea

• Cyanosis

• Clubbing fingers

• Coughing on arising in the morning and when laying down

• Copious amounts of foul-smelling sputum

• Fatigue

• Weakness

• Loss of appetite

Subjective• Report of

• Difficulty breathing

• Weight loss

• Fever

Objective• Lung auscultation• Fine crackles and

wheezes in lower lobes

• Prolonged expiratory phase

• Increased dyspnea

• Hemoptysis (50%) of patients

ASSESSMENT

• Cool mist vaporizer

• Increase fluid intake

• Assess vital signs and lung sounds q 2 – 4 h

• Suction prn

• Assist with coughing, deep breathing q2h

• Teach• Avoidance of

• Smoke

• Fumes

• Irritating inhalants

• Discourage smoking

• Rest with activity

• Medication teaching

• s/s of secondary infection

NURSING INTERVENTIONS

NEOPLASMS

LUNG CANCER

ETIOLOGY / PATHOPHYSIOLOGY

• Leading cause of death from cancer in both men and women• Tumors -result from anywhere in the body -primary tumor -metastases from the colon and the kidney are common.

ETIOLOGY / PATHOPHYSIOLOGY• 80-90% of lung tumors

• linked to cigarette smoking • passive smoking• breathing in side stream smoke

• Secondhand smoke• risk for the development of lung cancer in non-smokers

• History of smoking for 20 years or more

-prime risk factor for lung cancer

• Occupational hazard risk factors• Asbestos• Radon• uranium

• Air pollution may also increase one’s risk.

• Mortality• specific type of cancer• size of the tumor when it is detected.

ETIOLOGY / PATHOPHYSIOLOGY

TYPES OF LUNG CANCER

• Classified by microscopic study of the tumor• Treatment is specific to

• the type

• extent of the disease (staging)

• Tumor type and staging

• Small cell Ca (oat cell)

• Non small cell Ca

• Squamous cell Ca

• Large cell Ca

• Most people who develop the disease are older than 50

• Pneumonectomy

• Removal of the entire lung

• Lobeectomy

• Removal of affected lung lobe

• Segmental resection

• Only a portion of the lung lobe is removed

• Radiation and Chemotherapy

• 1/3 are inoperable when first seen

• Surgical mortality

• 10% pneumonectomy

• 2 – 3% lobectomy

• Lobectomy and segmental resection requires chest tube insertion

MEDICAL MANAGEMENT

CLINICAL MANIFESTATIONS

• Asymptomatic in the early stages• Lesion perforates the pleural space• Pleural effusion• Severe pain

• Central lesions • Obstruction• Erosion of the bronchus

CLINICAL MANIFESTATIONS

• Cough

• Hemoptysis

• Fever

• Dyspnea

• Chills

SUPERIOR VENA CAVA SYNDROME

• Invasion of the tumor into the superior vena cava

• edema of neck and face

SUBJECTIVE • Chronic cough• Hoarseness• Weight loss • Extreme fatigue• Family history of

cancer• History of cigarette

smoking• Exposure to

occupational irritants.

OBJECTIVE • Cough

• Dry• hacking • Moist• factors that relieve the cough

• Sputum• Consistency• Amount • Frequency • Duration• Precipitating factors

• Auscultate the lungs• Unilateral wheezing• Crackles

ASSESSMENT

NURSING INTERVENTIONS

• Whether treatment offers comfort or cure

• Patient needs comprehensive nursing interventions

• Consider:

• Patient’s quality of life

• Education

• Needed emotional support

• Symptom management.

NURSING INTERVENTIONS – POST-OP

• Prevention of complications

• Effective airway clearance

• Frequent repositioning

• Cough/deep breathing

• Use of incentive spirometer

• Prevention of circulatory problems

• encourage exercise of legs and feet

NURSING INTERVENTIONS• Oxygen• Vital signs• I&O• Pulse oximetry• Monitor labs• Repositioning• IV administration• Check patency of chest tubes if in use• Medication Administration• Analgesics• Antineoplastics• antiemetics

PATIENT/FAMILY TEACHING

• Effective coughing techniques• Physical mobility• Nutrition -diet high in protein and calories -2000 mL of fluids per day (unless contraindicated)

• Discourage smoking

PN 132

RESPIRATORY MEDICATIONS

NASAL DECONGESTANTS

Adrenergics

• Ephedrine (Vicks)

• Oxymetazoline (Afrin)

• Phenylephrine (Neosynephrine)

Intranasal Steroids

• Beclomethasone dipropionate

• Beconase

• Vancenanse

• Flunisolide (Nasalide)

ORAL DECONGESTANTS

• Prolonged effects

• Less potent

• No rebound congestion

• Exclusively adrenergics

• Example: Pseudoephedrine (Sudafed)

TOPICAL DECONGESTANTS

• Adrenergics-Prompt onset

-Sustained use Rebound Congestion

• Both adrenergics and steroids

-Potent - work well

NASAL STEROIDS

• Anti-inflammatory-Decrease inflammation-Relieve nasal congestion

NASAL DECONGESTANTS: SIDE EFFECTS

Adrenergics• Nervousness

• Insomnia

• Palpitations

• Tremors

Steroids• Local mucosal dryness and irritation

• Candida infections

DISORDERS TREATED WITHNASAL DECONGESTANTS

• Acute or chronic rhinitis• Common cold• Sinusitis• Hay fever• Other allergies

NASAL DECONGESTANTS NURSING IMPLICATIONS

• Avoid decongestants in the following clients:• Heart disease

• Hypertensive disease• Respiratory Disease

• Assess for drug allergies

BRONCHODILATORS

• Can be aerosolized to relax and open the bronchial airways.

• Can treat several disease syndromes

• COPD

• Asthma

BRONCHODILATORS

• Classes of Bronchodilators:

• Sympathomimetic Agents

• Xanthine Bronchodilators

• Anticholinergics

• Leukotriene Receptor Antagonists

• 5-lipoxygenase inhibitors

• Mast Cell stabilizers

• Corticosteroids

BRONCHODILATOR ADMINISTRATION

• Use of an Inhaler• MDI (Multi-dose inhaler) is also called a rescue inhaler,

it delivers a puff of medication that is inhaled.

• Nebulizer dispenses a larger dose of the bronchodilator over a longer duration in the form of a mist that is breathed in.

SYMPATHOMIMETIC AGENTS

• Examples:• Epinephrine

• Isoproterenol (Isuprel)

• Albuterol

• General Side Effects:• Nausea, increased anxiety, palpitations, tremors, and

increased heart rate

SYMPATHOMIMETIC AGENTS

• Uses:

• Treat acute asthmatic attacks as well as prevent attacks

• Quickly reduces airway constriction and restore normal airflow

• Relief of bronchospasm, bronchial asthma, bronchitis, etc.

• Treat hypotension and shock

XANTHINES• Chemical class of agents that contain caffeine

• Oldest class of bronchodilators – used in ancient times

• Mechanism of Action• Increase levels of energy producing cAMP

• Inhibits phosphodiesterase

an enzyme that breaks down cAMP

• Results: smooth muscle relaxation; Broncho dilation; increased airflow

XANTHINES – SIDE EFFECTS

• Adverse reaction: cardiac life-threatening side effect

• Xanthine Derivatives

• Side Effects:• Nausea, vomiting, anorexia

• GERD during sleep

• Sinus tachycardia, extra systole, palpitations, ventricular derivatives

• Transient increase urination

ANTICHOLINERGICS• Actions: • Local effects

• Slow and prolonged

• Used to prevent bronchospasm

• Not used for acute asthma exacerbations

• Examples:

• Ipratropium bromide (Atrovent)

• Tiotropium Bromide (Spiriva Handihaler)

ANTICHOLINERGICS: SIDE EFFECTS• Usually not absorbed systemically

• If absorbed, have the potential to produce:• Dry mouth

• GI distress

• Headache

• Coughing

• Anxiety

LEUKOTRIENE RECEPTOR ANTAGONISTS

• Directly prevent bronchospasm

• Developed to treat asthma

• Leukotrienes:• Are inflammatory molecules

• Released by mast cells

• Causes bronchioles to contract

• Can cause development of edema in the lungs

LEUKOTRIENE RECEPTOR ANTAGONISTS

• Currently available agents:• Montelukast (Singular)

• Zafirlukast (Accolate)

• Side Effects:• Headache

• Nausea

• Diarrhea

• Liver dysfunction

LEUKOTRIENE RECEPTOR ANTAGONISTS

• Client Education:

• Use for chronic management of asthma – not acute episodes

• Improvement should be seen in about 1 week

5-LIPOXYGENASE INHIBITORS• New class

• Inhibit the formation of leukotrienes

• Used to inhibit some cancer growth

• Use: prevent lung infection

• Example: Zileuton

MAST CELL STABILIZERS

• Used prophylactically

• No direct Broncho dilation activity

• Indirect action

• Stabilizes the cell membranes of the inflammatory cells – mast cells, monocytes, macrophages• Prevents the release of harmful

cellular contents

MAST CELL STABILIZERS

• Acts as an adjunct to overall management of clients with lung disease

• Prevents bronchospasm when exposed to:• Cold air

• Exercise

• Allergens

• Dry air

MAST CELL STABILIZERS

• Examples:

• Cromolyn (Nasalcrom, Intal)

• Nedocromil (Tilade)

CORTICOSTEROIDS

• Inhaled Corticosteroids:• Anti-inflammatory

• Inhaled forms reduce systemic effects

• Treatment of chronic Asthma - does not relieve acute asthma

• Stabilize membranes of cells that release harmful broncho-constricting substances

• Increases responsiveness of bronchial smooth muscle to beta-adrenergic stimulation

CORTICOSTEROIDS• Examples:

• Beclomethasone dipropionate (Beclovent, Vanceril)

• Tramcinalone acteonide (Azmacort)

• Flunisolide (AeroBid)

• Combination Products:• Advair – fluticasone + salmeterol; dry

powder in circular diskus

• Salmeterol – long acting bronchodilator

• Corticosteroid – anti-inflammatory agent; used daily

EXPECTORANTS

• Drugs that aid in the expectoration (removal) of mucous

• Reduce the viscosity of secretions

• Stimulates the flow of respiratory secretions

• Note: Secretions – by loosening and thinning sputum and bronchial secretions, the tendency to cough is indirectly diminished.

EXPECTORANTS: SIDE EFFECTS

• Common side effects:• Guaifenesin

• Nausea, vomiting

• Gastric irritation

• Terpin hydrate• Gastric upset (elixir has high alcohol

content)

EXPECTORANTS: NURSING IMPLICATIONS

• Use with caution in the elderly

• Encourage client to drink fluids• Monitor for therapeutic effects.• Report a fever lasting longer than a week.

ANTITUSSIVES

• Cough Relief

• Used to relieve nonproductive coughs associated with:• Pertussis Common colds

• Bronchitis Laryngitis

• Sinusitis Influenza

• Pharyngitis

ANTITUSSIVES

• Drugs used to control coughing• Opioids and non-opioids• Narcotics•Used for nonproductive coughs

OPIOID ANTITUSSIVES

• Suppress the cough reflex by direct action on the cough center in the medulla• Example: codeine + guiafenesin =

Robitussin AC

NON-NARCOTIC ANTITUSSIVES

• Dextromethorphan• Suppresses the cough reflex in the cough center in the

medulla; a chemical derivative of the opiate narcotics

• Result: diminished cough

• Produces no respiratory depression, analgesia, or dependence

• Example: Robitussin-DM

ANTITUSSIVE AGENTS: SIDE EFFECTS

• Benzonatate (Tessalon Pearls)

• Dizziness, headache, sedation

• Dextromethorphan

• Dizziness, drowsiness, nausea

• Opioids

• Sedation, nausea, vomiting, lightheadedness, constipation

ANTITUSSIVE AGENTS: NURSING INTERVENTIONS

• Perform respiratory assessment• Instruct clients to:• Avoid driving or operating heavy equipment

• Do not drink liquids for 30 to 35 minutes after taking a cough syrup or using a cough lozenge

ANTITUSSIVE AGENTS: CLIENT TEACHING

• Report any of the following symptoms to the health care professional:• Cough that lasts more than 2 weeks

• A persistent headache

• Fever

• Rash

SUMMARY• Defined pathophysiology of common chronic respiratory

disorders

• Discussed nursing interventions for patients with chronic respiratory disorders

• Defined pathophysiology of malignant neoplasms (Lung Cancer) in the respiratory tract

• Discussed nursing interventions for patients with respiratory neoplasms

• Identified common respiratory medications

ASSIGNMENT• Read and Review

• AHN - Chapter 9

• Pp. 420 – 430 (Chronic Respiratory Disorders)

• Pp. 413 – 415 (Lung Cancer)

• Pp. 401 – 403 (Respiratory Medications)

• *** Finalize Mid-Term Paper (Due Day 6)

• Be sure to keep a copy!

• Review for Quiz 2 (chronic respiratory disorders / neoplasms / respiratory meds)

NEXT CLASS• **Quiz 2 – Proctored Open-Book Exam (5% of

course grade) verses ATI: Pharmacology 3.0

• Covers Day 5 material

• Begin Group Projects

• Investigating and identifying project resources

• Establish project responsibilities

QUESTIONS?