1 Care of the Chronic Respiratory Client Keith Rischer RN, MA, CEN.

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Care of the Chronic Respiratory Client

Keith Rischer RN, MA, CEN

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Todays Objectives

Compare & contrast pathophysiology and clinical manifestations of asthma, emphysema, bronchitis & lung cancer.

Identify the diagnostic tests, nursing priorities, and client education with asthma, emphysema, bronchitis, & lung cancer.

Describe the mechanism of action, side effects and nursing responsibilities with pharmacologic management of asthma, emphysema & bronchitis.

Contrast and compare medical vs. surgical management for treatment of lung cancer.

Identify nursing priorities and care of the client with a chest tube.

Identify nursing priorities and care of the client on a mechanical ventilator.

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Obstructive Airway Disorders

COPD

Increase resistance to airflow Bronchi smooth muscle

innervated by autonomic nervous system• Parasympathetic stimulation• Sympathetic stimulation• Inflammatory mediator

response COPD

• Chronic-recurrent obstruction

Emphysemabronchitis

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Obstructive Disorders:AsthmaObstructive Disorders:Asthma PathoPatho

• Intermittent & reversible airway Intermittent & reversible airway obstructionobstruction

INFLAMMATION-ChronicINFLAMMATION-Chronic– Antibody molecules (IgE)Antibody molecules (IgE)– Mast cells>histamine>WBCMast cells>histamine>WBC– Physiological response to Physiological response to

inflammationinflammation» Vessel dilation>capillary Vessel dilation>capillary

leakage>tissue swelling>incr. leakage>tissue swelling>incr. secretionssecretions

Airway hyper-responsivenessAirway hyper-responsiveness Childhood Childhood

– Allergens Allergens – smokingsmoking– Cold/dry airCold/dry air– Bacteria Bacteria

BronchospasmBronchospasm– edema & mucousedema & mucous

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What is a Mast Cell?

Bag of Granules Located in connective

tissue• close to blood vessels

Histamine released• Increase blood flow• Increase vascular

permeability• Binds to H1, H2

receptors

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Etiology of asthmaEtiology of asthma Intrinsic etiologiesIntrinsic etiologies

• uncertain causesuncertain causes• physical or psychological physical or psychological

stressstress• exercise-inducedexercise-induced

Extrinsic etiologiesExtrinsic etiologies• antigen-antibody (allergic) antigen-antibody (allergic)

reaction to specific irritantsreaction to specific irritants air pollutantsair pollutants sinusitissinusitis cold and dry aircold and dry air Meds-ASAMeds-ASA food additivesfood additives hormonal influenceshormonal influences GE refluxGE reflux

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Clinical manifestations of AsthmaClinical manifestations of Asthma

Severe dyspneaSevere dyspnea• wheezing with expiration or inspirationwheezing with expiration or inspiration• Which is worse…Which is worse…

TachypneaTachypnea CoughCough Feelings of chest tightnessFeelings of chest tightness Prolonged expirationProlonged expiration Diminished breath soundsDiminished breath sounds Increased heart rate and blood pressureIncreased heart rate and blood pressure Restlessness, anxiety, agitationRestlessness, anxiety, agitation

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Asthma: Lab & Dx FindingsAsthma: Lab & Dx Findings

Decreased pO2Decreased pO2 Decreased pCO2Decreased pCO2

• EarlyEarly• Late findingsLate findings

Elevated eosinophil countElevated eosinophil count CXRCXR Pulmonary Function TestPulmonary Function Test

• Forced vital capacity (FVC)Forced vital capacity (FVC)• Peak flow meterPeak flow meter

ABG’s• pH 7.28• pO2-55• pCO2-60• HCO3-22• O2 sats-86% RA

ABG’s• pH 7.35• pO2-75• pCO2-30• HCO3-22• O2 sats-90% RA

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Pharmacologic Treatment Options

Relievers = short-acting bronchodilators

• quickly relieves bronchoconstriction and symptoms

Controllers = daily medications taken on a long-term basis

• useful for controlling persistent asthma

• includes anti-inflammatory agents and long-acting bronchodilators

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Beta-2 agonists chart 33-5 p.590-592

Mechanism• bronchodilation through bronchial smooth muscle

relaxation mediated by beta-2 receptors in the lung Short Acting

• albuterol (Proventil, Ventolin)Xopenex

• Pirbuterol (Maxair autoinhaler)• Terbutaline (Brethaire)

Long acting• Salmeterol-Serevent

Onset: 5-15 minutes Duration: 4-6 hours

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Beta-2 agonists

Uses: • Rescue medication to relieve acute symptoms

& prevention of bronchospasms prior to a precipitating event (e.g. exercise)

Adverse effects:• Tachycardia• Restlessness• Tremors• Palpitations • paradoxical bronchoconstriction

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Anticholinergics

Mechanism• block parasympathetic nervous system influence• SNS dominates

Ipratropium (Atrovent) Onset: 3-30 minutes, peak: 1-2 hours Duration: 4-8 hours Adverse effects

• drying of mouth and respiratory secretions• increased wheezing in some individuals

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Inhaled Corticosteroids

Mechanism• Decrease inflammation• block late reaction to allergens and reduce

airway hyperresponsiveness• inhibit microvascular leakage

Common Meds…used qd• budesonide (Pulmocort)• fluticasone (Flovent)• triamcinolone (Azmacort)

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Inhaled Corticosteroids (cont.)

Uses:• long-term prevention of symptoms

(suppression, control, and reversal of inflammation)

• reduce/eliminate oral steroid use Adverse effects:

• oral candidiasis• ??systemic effects at high doses

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Oral Corticosteroids

Common agents• Prednisone

methylprednisolone (Medrol, Solu-Medrol) Uses

• short term (3-10 days) “burst therapy” to gain prompt control of asthma

to prevent progression of exacerbation, speed recovery, and reduce relapse

• long-term prevention of symptoms in severe persistent asthma LT Side Effects

• HTN• Peptic ulcers• Skin fragility• Impaired immunity• Thromboembolism• Cushingoid appearance

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Asthma:Combination Inhalers

Advair Diskus• Fluticasone • Salmeterol (serevent)• Frequency

1 inhalation q12 hours

Combivent MDI• Ipratropium (atrovent)• Albuterol• Frequency

2 puffs 4 times daily

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Asthma: Other Medications

Leukotriene Antagonists • anti-inflammatory• Montelukast (Singulair)• Therapeutic response

Decreased frequency & severity of attacks Decreased exercise induced bronchoconstriction

Mast cell stabilizers• Mechanism• Cromolyn sodium (Intal)• Frequency

1-2 inhalations 4 times daily

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Asthma:Regimen by SeverityAsthma:Regimen by Severity

MildMild• Short-acting beta-agonist inhaler Short-acting beta-agonist inhaler • Anti-inflammatory inhaler used for mild symptoms Anti-inflammatory inhaler used for mild symptoms

occurring dailyoccurring daily ModerateModerate

• Anti-inflammatory inhaler plus medium-dose Anti-inflammatory inhaler plus medium-dose corticosteroid inhalercorticosteroid inhaler

• used for moderate symptoms occurring daily or more used for moderate symptoms occurring daily or more oftenoften

SevereSevere• Anti-inflammatory inhaler plus long-acting Anti-inflammatory inhaler plus long-acting

bronchodilator plus oral corticosteroidbronchodilator plus oral corticosteroid• used for severe symptoms occurring daily or more oftenused for severe symptoms occurring daily or more often

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Priority Nursing Diagnoses for AsthmaPriority Nursing Diagnoses for Asthma

Impaired gas exchange r/t…Impaired gas exchange r/t… Ineffective breathing pattern r/t…Ineffective breathing pattern r/t… Ineffective airway clearance r/t…Ineffective airway clearance r/t… Anxiety r/t…Anxiety r/t… Deficient knowledgeDeficient knowledge

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Asthma:Critical Care Management

Status asthmaticus/severe asthma

Physical assessment• Dyspnea/tachypnea• Wheezing I/E• Diminished aeration to no air

movement• Accessory muscles

Medical management …remember A,B,C,s

• O2• Albuterol neb• Epinephrine subq• Establish IV• IV steroids (solumedrol)• Prepare for possible

intubation

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Planning and implementation for AsthmaPlanning and implementation for Asthma

Assess respiratory and oxygenation statusAssess respiratory and oxygenation status Administer supplemental oxygen as neededAdminister supplemental oxygen as needed Administer broncholdilators as prescribedAdminister broncholdilators as prescribed Observe characteristics of sputumObserve characteristics of sputum Identify/avoid/remove precipitating factorsIdentify/avoid/remove precipitating factors Teach patient relaxation techniquesTeach patient relaxation techniques Prepare for IV accessPrepare for IV access Be prepared for intubationBe prepared for intubation Diagnostic studiesDiagnostic studies Emotional support for patient and familyEmotional support for patient and family

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Expected outcomes/evaluationExpected outcomes/evaluation

Absence of dyspnea, chest tightness, wheezingAbsence of dyspnea, chest tightness, wheezing Respiratory rate 12-20 breaths per minuteRespiratory rate 12-20 breaths per minute Pulse oximetry/arterial blood gas values within Pulse oximetry/arterial blood gas values within

normal range for clientnormal range for client Bilaterally clear and equal breath soundsBilaterally clear and equal breath sounds AfebrileAfebrile Adequate airway clearanceAdequate airway clearance Absence/resolution of anxietyAbsence/resolution of anxiety Clear chest x-ray or return to patient’s baselineClear chest x-ray or return to patient’s baseline Normal or improved peak flowNormal or improved peak flow

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Asthma: Patient EducationAsthma: Patient Education

Identify asthma triggersIdentify asthma triggers Teach patient/family proper used of metered-Teach patient/family proper used of metered-

dose inhalerdose inhaler• Chart 33-6 p.593Chart 33-6 p.593

Rescue inhalers!Rescue inhalers! Instruct client regarding the use of peak flow Instruct client regarding the use of peak flow

meter for self-assessment of asthma statusmeter for self-assessment of asthma status Asthma symptoms requiring emergency Asthma symptoms requiring emergency

interventionintervention

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Emphysema

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Emphysema: PathoEmphysema: Patho

Loss of lung elasticityLoss of lung elasticity• Alveolar destructionAlveolar destruction• Excessive enlargementExcessive enlargement

Loss of “curves” impairs gas Loss of “curves” impairs gas exchangeexchange

Compensation…Compensation…

Hyperinflation of lungHyperinflation of lung• Secondary to air trappingSecondary to air trapping• ““barrel chest” appearancebarrel chest” appearance• ““Pink pufferPink puffer

O2 diffused easier than CO2O2 diffused easier than CO2 CO2 accumulates causing CO2 accumulates causing

chronic resp. acidosischronic resp. acidosis

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Emphysema: Causes & Emphysema: Causes & ComplicationsComplications

Cigarette smoking Cigarette smoking • Pack years requiredPack years required• Smoke>enzyme elastase protease>destroys alveoliSmoke>enzyme elastase protease>destroys alveoli• Destroys ciliaDestroys cilia

Chronic respiratory inflammation Chronic respiratory inflammation • air pollutionair pollution

ComplicationsComplications• Hypoxemia & acidosisHypoxemia & acidosis• Resp. infections/pneumoniaResp. infections/pneumonia• Cur pulmonaleCur pulmonale• Cardiac dysrhythmiasCardiac dysrhythmias

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Emphysema: PhysicalAssessment…Emphysema: PhysicalAssessment…A,B,C’sA,B,C’s

General appearanceGeneral appearance• EmaciatedEmaciated• Barrel chestBarrel chest

Airway/breathingAirway/breathing• DyspneaDyspnea• TachypneaTachypnea• Accessory muscle useAccessory muscle use• Pursed lip breathingPursed lip breathing• Lung soundsLung sounds

overall diminished, and wheezes overall diminished, and wheezes or crackles may be presentor crackles may be present

• Dry cough more so than Dry cough more so than productiveproductive

• O2 sats…O2 sats… CirculationCirculation

• tachycardia (inadequate tachycardia (inadequate oxygenation)oxygenation)

• Arrythmias Arrythmias

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Emphysema: Diagnostic TestsEmphysema: Diagnostic Tests

ABGs ABGs • Chronic resp. acidosisChronic resp. acidosis

Compensation w/HCO3Compensation w/HCO3• Assess pO2, pCO2 and Assess pO2, pCO2 and

HCO3HCO3 CBCCBC

• WBCWBC• HgbHgb• HctHct

polycythemiapolycythemia

Chest x-ray Chest x-ray • hyperinflated lungs with a hyperinflated lungs with a

flattened diaphragmflattened diaphragm

ABG’s• pH 7.35• pO2-55• pCO2-60• HCO3-22• O2 sats-86% RA

ABG’s• pH 7.35• pO2-55• pCO2-60• HCO3-35• O2 sats-86% RA

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ED COPD Case Study

84yr female• PMH: COPD, asthma, HTN, anxiety, mitral stenosis• HPI: productive cough of green phlegm the last 4

days. Primary MD started on po Prednisone and Abx.• Developed incr. SOB through the night with

pronounced fever/chills w/left shoulder pain that increases w/movement. Denies CP

• VS: T-103.2 P-122 (ST) R-36 BP-202/105 sats 88% RA

• Assessment: Neuro-a/o notably anxious Resp-diminished bilat w/exp. Wheezing CV-2/6 murmur

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ED COPD Case Study

Medical Priorities… Nursing priorities Nursing assessments… Nursing interventions…

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ED COPD Case Study

CXR• Large left lower lobe infiltrate

Labs• BMP

Na 138, K+ 3.9, creat. 1.16, gluc 112• CBC

WBC 7.0, Hgb 13.3, Hct 39.9, plat. 217• UA

neg

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Chronic BronchitisChronic Bronchitis A disorder of chronic airway A disorder of chronic airway

inflammationinflammation Major & small bronchiolesMajor & small bronchioles

• Chronic productive cough Chronic productive cough lasting at least 3 months lasting at least 3 months during 2 yearsduring 2 years

• Chronic exposure to irritantsChronic exposure to irritants smokingsmoking

• An inflammatory response in An inflammatory response in the small & large airways the small & large airways resulting in…resulting in…

VasodilationVasodilation CongestionCongestion mucosal edemamucosal edema broncospasmbroncospasm

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Chronic Bronchitis: PathoChronic Bronchitis: Patho EtiologyEtiology

• Smoking Smoking Chronic inflammationChronic inflammation

• Increase in # and size of mucous Increase in # and size of mucous glands glands

More mucousMore mucous• bronchial walls thicken/edemabronchial walls thicken/edema

airflow is impededairflow is impeded• Smaller airways are blockedSmaller airways are blocked

Airflow and gas exchange impactedAirflow and gas exchange impacted pO2…pO2… pCO2…pCO2…

• Cilia disappear, and the airway Cilia disappear, and the airway clearance function is lostclearance function is lost

• Unlike emphysema, cannot increase Unlike emphysema, cannot increase breathing efforts to maintain blood breathing efforts to maintain blood gasesgases

• ““blue bloater”blue bloater”• PolycythemiaPolycythemia

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Chronic Bronchitis: Clinical ManifestationsChronic Bronchitis: Clinical Manifestations

Productive coughProductive cough• Primarily occurring during winter seasonPrimarily occurring during winter season• foul-smelling sputumfoul-smelling sputum

Dyspnea and activity intoleranceDyspnea and activity intolerance Frequent pulmonary infectionsFrequent pulmonary infections ““Blue bloater” Blue bloater”

• bluish-red skin discoloration from cyanosis bluish-red skin discoloration from cyanosis and polycythemiaand polycythemia

Barrel chestBarrel chest

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Emphysema/Bronchitis:Medical Emphysema/Bronchitis:Medical ManagementManagement

GoalsGoals• improve ventilation improve ventilation • promote patent airway by removal of secretionspromote patent airway by removal of secretions

Remove environmental pollutantsRemove environmental pollutants O2 and neb therapyO2 and neb therapy Chest physiotherapyChest physiotherapy Mechanical ventilationMechanical ventilation Surgical procedureSurgical procedure

• bullectomybullectomy• lung volume reduction lung volume reduction • lung transplantationlung transplantation

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Emphysema/Bronchitis: MedicationsEmphysema/Bronchitis: Medications

Beta-adrenergic agonistsBeta-adrenergic agonists• bronchodilators in COPD by nebs or MDIbronchodilators in COPD by nebs or MDI

AnticholinergicsAnticholinergics• Atrovent administered as maintenance by inhalerAtrovent administered as maintenance by inhaler• most effective bronchodilators for COPDmost effective bronchodilators for COPD

TheophyllineTheophylline• may be beneficial to strengthen diaphragm contractility may be beneficial to strengthen diaphragm contractility

and decrease work of breathingand decrease work of breathing CorticosteroidsCorticosteroids

• may be beneficial for pts. w/asthma historymay be beneficial for pts. w/asthma history Immunizations Immunizations

• flu and pneumoniaflu and pneumonia AbxAbx

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Emphysema/Bronchitis: Priority Nursing Dx Emphysema/Bronchitis: Priority Nursing Dx p.600-606p.600-606

Impaired gas exchange r/t…Impaired gas exchange r/t… Ineffective breathing pattern r/t…Ineffective breathing pattern r/t… Ineffective airway clearance r/t…Ineffective airway clearance r/t… Imbalanced nutrition r/t…Imbalanced nutrition r/t… Anxiety r/t…Anxiety r/t… Activity intolerance r/t…Activity intolerance r/t… Fatigue r/t…Fatigue r/t… Deficient knowledgeDeficient knowledge

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Emphysema/Bronchitis: Nursing Care Emphysema/Bronchitis: Nursing Care Priorities remember A,B,C’s…Priorities remember A,B,C’s…

Administer low-flow O2 as neededAdminister low-flow O2 as needed Position patients to maintain effective breathingPosition patients to maintain effective breathing Closely monitor & assess resp. statusClosely monitor & assess resp. status

• AuscultationAuscultation• O2 satsO2 sats• Response to acute interventions/O2Response to acute interventions/O2

Provide education and referrals for pts. w/risk behaviorsProvide education and referrals for pts. w/risk behaviors• Referral to smoking cessation Referral to smoking cessation

Pulmonary conditioning programPulmonary conditioning program Develop appropriate nutritional plansDevelop appropriate nutritional plans Energy conservationEnergy conservation Exercise conditioningExercise conditioning Assess understanding to educationAssess understanding to education

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Emphysema/Bronchitis: Patient Education Emphysema/Bronchitis: Patient Education

Smoking cessationSmoking cessation Teach clients how to avoid occupational or Teach clients how to avoid occupational or

environmental pollutantsenvironmental pollutants Pursed lip breathingPursed lip breathing Maintain adequate nutrition with emphasis on Maintain adequate nutrition with emphasis on

higher calorie intakehigher calorie intake Nutrition may be optimal with frequent small Nutrition may be optimal with frequent small

meals, and 1000-2000cc of fluid dailymeals, and 1000-2000cc of fluid daily Teach energy conservation techniquesTeach energy conservation techniques

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Emphysema/Bronchitis: Expected Emphysema/Bronchitis: Expected Outcomes Outcomes

Activity tolerance is optimizedActivity tolerance is optimized Pulmonary irritants such as smoking, air Pulmonary irritants such as smoking, air

pollution, or occupational exposure are pollution, or occupational exposure are avoidedavoided

Pulmonary infections are reduced in Pulmonary infections are reduced in number and severitynumber and severity

Nutritional intake is adequate but not Nutritional intake is adequate but not excessive for individual energy needsexcessive for individual energy needs

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Pulmonary Tuberculosis

Patho• Mycobacterium

tuberculosis (bacillus)• Most common bacterial

infection globally• Aerosolized

Susceptible host• Nonspecific pneumonitis

alveoli or bronchus• 5-15% ultimately develop• Cell mediated immunity 2-

10 weeks later w/+ mantoux

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Pulmonary Tuberculosis: Infection

Inflammation in lungs surrounded by lymphocytes, collagen

Caseation necrosis• Necrotic tissue turned into

granular mass that become calcified

Seen in low to middle lobes

Can spread systemically to brain, liver , kidneys, bone marrow

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Incidence

HIV Immigrant populations Crowded areas

• LTC, prison, Elderly Homeless Poverty

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Physical Assessment/Diagnosis

Fatigue, lethargy, nausea, weight loss Fever…night sweats Persistent cough…productive streaked

w/blood Decreased aeration, crackles Diagnosis

• Positive smear acid-fast bacillus• + sputum culture…takes 1-3 weeks to confirm• Mantoux 5-10mm induration

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Treatment chart 34-7 p.643

Combination• Isoniazid (INH)• Rifampin

Pt. education• Compliance! 6 months treatment required• Sputum specimens q2-4 weeks during therapy• No longer contagious after 2-3 weeks of treatment• Once negative x3 cured

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Nursing Priorities

Airborne precautions Ventilated room N-95 mask or PAPR

for any staff entering room

TB drugs can cause nausea-anticipate

Nutrition

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Lung Cancer: Patho

Bronchial epithelium• 90% primary• Obstruction

Histologic cell type• Small cell vs. non small cell

Small cell 20% of all lung CA

99% correlation w/smoking

• Adenocarcinoma 35% of all lung CA Spread between smokers

and non smokers Metastasis

• Circulatory & lymphatic

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Lung Cancer: Clinical Manifestations

Non-specific & occur late• Depend on type & location of tumor

Bronchitis/pneumonitis secondary to obstruction• Chills• Fever• Cough

Bloody sputum Dyspnea

• Use of accessory muscles• Wheezing-diminished aeration

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Lung Cancer: Diagnostic

CXR CT Bronchoscopy

• Bronchial washing Needle/surgical biopsy

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Lung Cancer:Medical Management

Non-surgical• Chemotherapy

N&V Mucositis Alopecia Immunosuppression Pan cytopenia

• Radiation Best results when used w/surgery or chemo Daily for 5-6 weeks Esophagitis…esophagus proximal to lungs Side effects

– Skin irritation & peeling– Fatigue– Nausea– Taste changes

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Lung Cancer:Medical Management

Surgical• Thoracotomy

Tumor removal

• Lobectomy Removal lobe of lung

• Pneumonectomy Entire lung

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Lung Cancer: Thoracotomy-Postop p.618-622

Chest tube• Drain placed in pleural

space to restore intrapleural pressure

• Chest tube banded & connected to Pleurovac collection chamber w/several feet tubing

Drainage system• First chamber

Drainage from client• Second chamber

Water seal• Third chamber

suction

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Chest Tube: Nursing Priorities

Assess resp. status closely

Check water seal for bubbling

Milk NOT strip every 2 hours

Assess color-amount drainage• Call MD if >100cc/hr x2

hours first 24 hours Sterile guaze/occlusive

dressing at bedside

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Mechanical Ventilation The use of an ET and

POSITIVE pressure to deliver O2 at preset tidal volume

Modes• Assist Control (AC)

TV & rate preset Additional resp. receive preset

TV• Synchronized Intermittent

Mandatory Ventilation (SIMV) Additional resp. receive own TV Used for weaning

• Continuous Positive Airway Pressure (CPAP)

• Bi-pap Non-mechanical receive both insp. & exp.

Pressures w/facemask

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Mechanical Ventilation

Terminology• Rate • Tidal volume

10-15cc/kg

• Fraction of inspired O2 concentration (FiO2)

Use lowest possible to maintain O2 sats

• Positive End Expiratory Pressure (PEEP)

• Minute volume RR x TV

AC12-TV 600-50%-+5

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Mechanical Ventilation: Adverse Effects

Complications• Aspiration• Infection-VAP• Stress ulcer of GI tract• Tracheal damage• Ventilator dependancy• Decreased cardiac

output Positive pressure decr.

venous return & CO

• Barotrauma pneumothorax

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Mechanical Ventilation:Nursing Priorities

Monitor VS-breath sounds closely

Assess ET securement/length at lip

Clearance of secretions• Closed suction-maintains

sterility• Do not do routinely• Pre-oxygenate

Sedation • Propofol

Oral care Nutritional support

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Mechanical Ventilation:Nursing Priorities

Ventilator Alarm Troubleshooting• High pressure

Secretions-needs sxTubing obstructed or

kinkedBiting ET

• Low pressureDisconnection of tubingFollow tubing from ET to

ventilator

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Oxygen Delivery Atmospheric room air %.......??? Nasal cannula

• Add 3% for each liter of flow to FiO2

• 1-6 liters Oxymizer

• Reservoir to increase FiO2 per liter delivery

• 6-12 liters Face mask

• 40-50% FiO2• 8-15 liters

Face mask w/non-rebreather• 90-100% FiO2• 15 liters

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Respiratory Case Study

Darrell Johnson is a 62-year-old male who comes to the Emergency Room with a 4-day history of increased sputum production, a change in the character of sputum, increased shortness of breath, and a fever of 101° F

He has a smoking history of 2 packs a day for the past 20 years, and he smoked 1 pack a day prior to that beginning at the age of 14.

He reports that he had asthma as a child, and that he has been treated with Albuterol inhalers from time to time as an adult. Mr. Johnson has been hospitalized twice with pneumonia, most recently 2 years ago.

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Respiratory Case Study

Physical exam reveals the following:

Vital signs: T 101° F, P 115, R 30, BP 120/80 O2 sats 90% on room air

Respirations shallow and labored, with use of respiratory accessory muscles.

Increased anteroposterior (AP) diameter of the chest.

Skin dry and warm to touch, with inelastic skin turgor, and fingernail clubbing present.

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Respiratory Case Study

Which assessment is most important for the nurse to complete next?

A) Auscultate breath sounds.B) Determine pupillary response to light.C) Observe for jugular vein distention.D) Palpate pedal pulses.

Which assessment finding supports Mr. Johnson's diagnosis of pneumonia?

A) Pulse rate of 115.B) BP of 120/80.C) Increased AP diameter of the chest.D) Fingernail clubbing.

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Respiratory Case Study

Arterial Blood Gases were obtained with the following results:

• pH 7.28.• pCO2 55.• HCO3 25.• pO2 89.

Based on these ABG results, which acid base imbalance is Mr. Johnson experiencing?

• A) Metabolic acidosis.B) Metabolic alkalosis.C) Respiratory acidosis.D) Respiratory alkalosis.

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Respiratory Case Study

Which nursing diagnosis has the highest priority when planning care for Mr. Johnson?

• A) Altered nutrition, less than body requirements.B) Activity intolerance.C) Anxiety related to increased shortness of breath.D) Ineffective airway clearance.

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Respiratory Case Study

Mr. Johnson is admitted to his room on the Medical Nursing Unit. The healthcare provider prescribes the following:

• Bedrest with bedside commode.• O2 at 2 L/minute via nasal cannula.• Diet as tolerated.• Continuous O2 saturation monitoring via pulse oximeter.• IV fluid of 5% Dextrose and 0.45 Normal Saline at 3 liters per

day.• Obtain a sputum culture.• Medications include:

Ampicillin (Unasyn) 1 gm IVPB every 6 hours. Nebulizer treatments every 4 hours and PRN with saline and

albuterol (Ventolin). Triamcinolone (Azmacort) inhaler, 2 puffs twice a day. Albuterol (Ventolin) inhaler, 2 puffs 4 times a day. Methylprednisolone (Solu-Medrol) 125 mg IVPB every 8 hours.

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Respiratory Case Study

Which nursing action should be implemented before administering the prescribed Unasyn?

• A) Assess the apical heart rate.B) Obtain O2 saturation recording.C) Obtain a sputum culture.D) Record Mr. Johnson's weight.

Which assessment is most important for the nurse to perform while Mr. Johnson is receiving Ventolin?

• A) Monitor temperature.B) Measure intake and output.C) Monitor pulse and BP.D) Measure central venous pressure (CVP).

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Respiratory Case Study

The nurse observes Mr. Johnson as he uses his inhalers. Using a spacer, he takes 2 puffs of the Ventolin, followed a minute later by 2 puffs of the Azmacort.

After observing Mr. Johnson, what client teaching should the nurse initiate?

• A) "Administer the Azmacort first, followed by the Ventolin."B) "Using a spacer reduces medication absorption."C) "Inhale deeply before sealing the mouthpiece."D) "Wait at least one minute between each puff of the same medication."

Which instruction should the nurse provide Mr. Johnson for an acute

episode of asthma?• A) "Administer the Azmacort as soon as possible."

B) "Use the Ventolin inhaler for acute asthma attacks."C) "Call your healthcare provider before administering any medication."D) "You will need IV Solu-Medrol for your next acute attack."

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Respiratory Case Study

Continuous monitoring of Mr. Johnson's oxygen saturation indicates readings ranging between 90%-91%.

After checking the sensor site to make sure the readings are accurate, which intervention should the nurse initiate next?

• A) Increase the oxygen to 6 L/minute per nasal cannula.B) Elevate the head of the bed to a high-Fowler's position.C) Remove the pulse oximeter to reduce anxiety.D) Obtain and administer a prescription for pain relief.

Which action should the nurse implement to ensure accurate oxygen saturation readings via a pulse oximeter?

• A) Elevate the extremity to which the sensor is attached.B) Assess adequacy of circulation prior to applying the sensor.C) Keep the sensor exposed to adequate lighting.D) Remove the sensor when taking the B/P.

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Respiratory Case Study

During the night, Mr. Johnson calls the nurse to report a sudden inability to catch his breath.

Upon assessment, the nurse notes that Mr. Johnson's respiratory rate has increased to 40 with obvious dyspnea, and his O2 saturation reading is 55. His pulse is 110, weak, and thready, and his blood pressure is 70/40.

Which interventions should the nurse initiate immediately?• A) Place resusitation equipment in the room.

B) administer high flow O2C) establish IV access and initiate IV fluid resuscitationD) Initiate CPR.

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Respiratory Case Study

The remainder of Mr. Johnson's hospital stay is uneventful and is transferred back to the floor

Which outcome statement is the best indicator that Mr. Johnson's pneumonia is resolved and he is ready to be discharged?

A) Sputum culture is negative.B) Unasyn peak and trough levels are within normal limits.C) Oxygen saturation level is 92%.D) Temperature is 98° F.

Which additional discharge instruction should the nurse include in the teaching plan to promote optimal health for Mr. Johnson?

A) Avoid physical exertion.B) Avoid crowds and people with infections.C) Limit intake of oral fluids.D) Stay indoors except in the early morning.