1. Why does aspiration occur in the right lung more often than the left lung (page 476)Because the right main bronchi is shorter, wider and straighter then the left one, favoring aspirations to gravitate to the right

2. What is a normal Tidal Volume (Vt) in adults? What does this number represent? (page 477)Tidal volume is the volume of air exchanged at each breathNormal tidal volume (Vt) in adults is about 500 mL (in a 150lb man)Of each 500 mL inhaled, about 150 mL remains in the anatomic dead space (Vd)

3. When patients are on ventilators, there is a SIGH programmed into the breathing rate every 5 or six breaths. What is the purpose of the SIGH? (Could not find in the textbook, used reference of several websites)

Ventilator breath with greater volume than preset tidal volume, used to prevent atelectasis, however, not always used (Tidal volume may be enough to prevent atelectasis)

Temporarily increase sighs from 3 to 6 BPM to improve oxygenation via alveolar recruitment. Once oxygenation has improved, wean the rate of the sigh breaths back to 3.

Beneficial in maintaining arterial oxygenation (PaO2)4. Why is the postoperative patient at increased risk for atelectasis? (pages 351 and

477)Because of the effects of anesthesia, which changes the regular pattern of breathing and the absorption of gases and pressures. This change may combine to cause some degree of collapse of the alveoli in lungs. Other factors are immobility and inability/ unwillingness to take deep breaths due to pain after surgery; witch contributes to secretion retention in lungs, and respiratory excursion.

5. Describe PLEURAL EFFUSION (page 478, 549 and video)Pleural effusion is a build up of fluid in the pleural space (between visceral and parietal pleura). The pleural space is normally filled with a small amount of pleural fluid (5 to 15 mL) that acts as a lubricant. Pathologic conditions can alter the balance between hydrostatic pressures, oncotic pressure and membrane permeability and can cause pleural fluid to build up abnormally. Conditions such as pneumonia, CHF, and liver failure alter the lymphatic flow and can lead to:

Transudative pleural effusion: accumulation of protein-poor and cell-poor fluid and mostly non-inflammatory, altered hydrostatic pressure or decreased oncotic pressure (Ex: CHF, liver failure)

Exudative pleural effusion: increased membrane permeability, inflammatory (Ex: infections, tumors)

As the fluid build up, it presses against the lungs decreasing lung diameter and decreasing air exchange efficiency.

6. What symptoms would we expect to see in patients with a pleural effusion? (550)Dyspnea, occasional sharp and non-radiating chest pain (worse in inhalation), and coughPhysical findings: Decreased movement of chest on affected side, dullness to percussion, diminished breath sounds over affected area

7. Why does the patient with emphysema have a dry cough and not a wet/productive cough? (Could not find page)In emphysema, the air sacs of the alveoli and their walls are destroyed causing the air space within to become abnormally enlarged. The alveoli also loose its recoiling abilities; they are able to forcibly expand receiving air during inspiration but are not able to expire the air during exhalation, causing air trapping. The patient coughs in the attempt to force air out of lungs and not mucous or secretion. Patients with emphysema often develop chronic bronchitis and COPD, which in that case a productive cough can be present

8. What preexisting diseases increase a patient’s risk for getting a pleural effusion? Why? (page 478)CHF, due to impaired ability to maintain fluid balance between intravascular and oncotic fluid pressures, causing a general build up of fluids in all parts of the body, including the pleural space (the lymphatic system maintains fluid balance within the pleural space)Liver failure, due to electrolyte imbalance. With liver failure, protein cannot remain in blood as it normally would and blood becomes hypotonic causing fluid to move out to the vessels and into body tissues such as the lungs and pleural spacePneumonia: Fluid buildup from inflammation diffuses into pleural space TB: caused by bacteria in the pleural space, this triggers an inflammatory reaction and pleural exudate of protein rich fluidMalignancy: causing lymphatic blockagePurulent pleural fluid: empyema

9. Which conditions limit the diaphragm or chest wall movement in patients and cause dyspnea? What happens as a result? (page 478)Chest wall restrictive conditions such as phrenic nerve paralysis, rib fracture, neuromuscular disease. Causes the patient to breathe with smaller tidal volume, as a result the lungs do not fully inflate and gas exchange is impaired

10. Name 2 diseases that involve problems with expiration and elastic recoil of the lungsAsthma, COPD (emphysema and chronic bronchitis)Use of accessory muscle to expire air

11. Name 3 diseases that affect the compliance of the lungs. What happens when compliance is decreased? (page 478 and 479)Conditions that increase fluid in the lung: pulmonary edema and pneumoniaConditions that impair elasticity of the lungs: emphysema and COPDConditions that restrict lung movement: pleural effusion

When compliance of the lungs is decreased the lungs do not inflate properly, causing a restriction of lung space, therefore, decreasing inspiratory capacity.

12. Look on table 26-1. What are the normal values for arterial blood gases at sea level? (page 479)pH: 7.35 to 7.45 PaO2: 80 to 100 mm/Hg Sa O2: more than 95% PaCO2: 35 to 45 mm/Hg HCO3-: 22 to 26 mEq/L

NotePaO2 (partial pressure of O2 in arterial blood) and SaO2 (arterial O2 saturation) are used to determine lung ability to oxygenate arterial bloodPaO2: represents the amount of O2 dissolved in plasma, expressed in mm/HgSaO2: represents saturation (%) of the hemoglobin in comparison to its capacityHCO3-: bicarbonate in arterial blood

13. What is meant by “mixed venous blood gas”? (page 479 and 1608)Mixed venous blood gas is used to assess and monitor blood gases in patients who have impaired cardiac output or hemodynamic instability. Such patients have inadequate tissue O2 delivery and abnormal O2 consumption. These blood samples are called “mixed venous blood gas” because it contains venous blood that has returned to the heart and got mixed in the right ventricle. In order to access the mixed venous blood in the right ventricle, a catheter is inserted through the pulmonary artery until it reaches the right ventricle. The catheter is named PA: pulmonary artery catheter.When tissue oxygenation delivery is impaired or when the hemoglobin saturation is impaired PvO2 and SvO2 will fallPvO2: partial pressure of O2 in venous bloodSvO2: venous O2 saturation

14. What are the Central Nervous symptoms we see during EARLY Inadequate oxygenation states? What are the CNS symptoms we will see later as the problem worsens? (page 479)Early symptoms CNS

Unexplained restlessness and irritability Unexplained apprehension Unexplained confusion and lethargy

Late symptoms CNS Unexplained confusion and lethargy Combativeness

15. Describe the early and late Respiratory, Cardiovascular, and other symptoms we will see in Early and Late inadequate oxygenation scenarios (table 26-2) (page 479)Early Respiratory

Tachypnea Dyspnea on exertion

Late Respiratory Dyspnea at rest Use of accessory muscles Refraction of interspaces on inspirations Pause for breath between sentences, words

Early Cardiovascular Tachycardia Hypertension Dysrhythmias

Late Cardiovascular Dysrhythmias Hypotension Cyanosis Cool, clammy skin

Early and late others symptoms Diaphoresis Decreased urine output Unexplained fatigue What are the critical values for PaO2 and SpO2? When do these numbers

represent serious issues? (table 26-3) Found on page 480.

16. Critical Values of Pa02 and Sp02 and their significance (table 26-3):

PaO2 (%) SpO2 (%) Significance

≥70 ≥94 Adequate unless patient is hemodynamically unstable or Hgb has difficulty releasing O2 to the tissues

60 90 Adequate in almost all patients. Provides adequate oxygenation but with less margin for error than above.

55 88 Adequate for patients with chronic hypoxemia if no cardiac problems occur. These values are also used as criteria for prescription of continuous oxygen therapy.

40 75 Inadequate but may be acceptable on a short-term basis if the patient also has CO2 retention. In this situation, respirations may be stimulated by a low PaO2. Thus the PaO2 cannot be raised rapidly.

<40 <75 Inadequate. Tissue hypoxia and cardiac dysrhythmias can be expected.

17.How does the hydrogen ion concentration affect the respiratory rate and tidal volume? Pg. 480

Basically, the respiratory center in the medulla responds to both chemical and mechanical signals. Central chemoreceptors are located in the medulla and respond to changes in the H+ concentration. -An increase in the [H+] (acidosis) causes the medulla to increase the respiratory rate and tidal volume. A decrease in [H+] (alkalosis) has the opposite effect.

18.Describe the defense mechanisms of the respiratory system. Pg. 480-481

-Filtration of air: nasal hairs filter inspired air. Mucociliary Clearance System: movement of mucus accomplished below the larynx. -Cough Reflex: protective reflex action that clears the airway by a high-pressure, high-velocity flow of air. Only effective in moving secretions above the sub-segmental (large or main-airways) level. -Reflex Bronchoconstriction: defense mechanism. In response to the inhalation of large amounts of irritating substances (dust) the bronchi constrict in an effort to prevent entry of the irritants. -Alveolar Macrophages: primary defense mechanism at the alveolar level. Alveolar macrophages rapidly phagocytize inhaled foreign particles such as bacteria.

19.What are the structural, defense mechanism, and respiratory control differences common to the elderly population? What diseases or preexisting factors increase the older person’s risk of respiratory problems? Table 26-4 on page 481

-Structural: calcification of the costal cartilages, chest wall stiffening, decreased elastic recoil, decreased chest wall compliance, increased AP diameter, decreased functioning alveoli, decreased respiratory strength.Defense Mechanism: decreased: cell-mediated immunity, specific antibodies, cilia function, cough force, alveolar macrophage function, and sensation in pharynx.Respiratory Control: decreased response to hypoxemia and hypercapnia. Risk factors: significant smoking history, obesity, and chronic illness.

20. When interviewing a patient with Respiratory problems, which medication would particularly alert you to ask about history of cough? Pg. 482

Angiotensin-converting enzyme (ACE) inhibitor because cough is a relatively common side effect of this drug.

21.When assessing the respiratory system, what would a loose sounding cough indicate? What would a dry, hacking cough indicate? What would a harsh, barky cough suggest? Pg. 482

Loose sounding cough would indicate secretions; dry, hacking cough suggests upper airway irritation or obstruction; a harsh, barky cough suggests upper airway obstruction from inhibited vocal cord movement related to subglottic edema.

22.Look at the Table 26-5. If you had to do a focused respiratory assessment and you were FORCED to only ask one question out of each category, which question would you ask and why? Pg. 483 (I think everyone should look at the table since this question is primarily to make sure you looked at the table and read it)

Health Perception- Health Management: Have you ever smoked? Do you smoke now? If yes, how many and for how long? I would choose this questions because smoking is the number one risk factor for COPD and lung cancer. Nutritional- Metabolic: Have you recently lost weight because of difficulty eating secondary to a respiratory problem? I would choose this question because a significant weight loss can drastically change the focus of the nursing plan and the interventions.Elimination: Does your respiratory problem make it difficult for you to get to the toilet? This question not only examines the patient’s QOL due to this problem but also assesses the patient’s activity tolerance. Activity- Exercise: Are you able to maintain your typical activity pattern. If not, explain. This question is broad while the other questions were more concise. I will receive more information about my patient with this question.

Sleep-rest: Do you need to sleep upright in a chair? The patient with cardiovascular disease may need to sleep upright. Cognitive- Perceptual Pattern: Do you ever feel restless, irritable, or confused without a reason? This could indicate hypoxia. Self-perception, role- relationship, sexuality, coping-stress, and value-belief: each section only has 1-2 questions each that are very similar to each other.

23. Why do you ask patients about a family history of respiratory problems? Pg. 483

Respiratory problems that have a strong genetic link include cystic fibrosis, COPD resulting from alpha 1- antitrypsin deficiency, and asthma. If people have a family history of these respiratory problems, they have a much greater risk of developing them.

24. Patients don’t really know the difference between HEMOPTYSIS (bloody sputum) and HEMATEMESIS (vomiting blood). As the nurse, what will you do to determine which is occurring in your patient? What conditions commonly lead to hemoptysis? Pg. 483

To differentiate between hemoptysis and hematemesis I should carefully question and then test the mucus for an acidic pH (which is present with hematemesis). Hemoptysis can be found with a variety of conditions including pneumonia, TB, lung cancer, and severe bronchiectasis.

25. Mrs. Jones smoked 2.5 packs of cigarettes a day for 25 years before finally quitting. How would the RN document this pack year history? Pg. 483-484

The pack year is determined by multiplying the number of packs smoked per day by the number of years smoked. So 2.5 (25) = 62.5 pack years.

26. Why is it important to assess for weight loss in respiratory patients? How can the different patient responses to these questions cue you in to what the specific respiratory problem may be? Pg.484

Well, weight loss is symptom of many respiratory diseases. It is very important to ask if the weight loss was intentional. The food intake may be altered by anorexia (from medications), fatigue (from hypoxemia, increased work of breathing) or feeling full quickly (from lung hyperinflation) Anorexia, weight loss, and chronic malnutrition are common in patients with COPD, lung cancer, TB and chronic severe infection (bronchiectasis). Ask about the fluid intake as well. Dehydration can cause mucus to thicken and obstruct the airway.

27. Review the respiratory assessment in your Lewis Text. What is the normal ratio of Inspiration to Expiration? What are early vs late signs of hypoxemia? Pg. 486

The normal rate is 12-20 breaths/ minute. In the older adult, it is 16-25 breaths/ minute. Inspiration (I) should take half as long as expiration (E). (I:E ratio = 1:2) Early signs of hypoxemia: coughing, fast heart rate, confusionLate signs of hypoxemia: Cyanosis which is observed in the conjunctivae, lips, palms, and under the tongue. Clubbing.

28. Describe Vesicular, Bronchovesicular, and bronchial breath sounds. What is the inspiratory/expiratory ratio for each sound type? Pg. 488

Vesicular: relatively soft, low pitched, gentle rushing sounds. They are heard all over lung areas except the major bronchi. Vesicular sounds have a 3:1 ratio. Bronchovesicular: medium pitch and intensity and are heard anteriorly over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae. 1:1 ratio. Bronchial: louder and higher pitched and resemble air blowing through a hollow pipe. Heard alongside trachea in the neck. 2:3 ratio with a gap between inspiration and expiration. This reflects the short pause between respiratory cycles.

29. Describe ADVENTITIOUS SOUNDS. Pg. 488-489 Table 26-8 goes into detail for every sound. Adventitious sounds are extra breath sounds that are abnormal. This includes crackles, rhonchi, wheezes, and pleural friction rub.

Fine crackles: series of short-duration, discontinuous, high pitched sounds heard just before the end of inspiration. Similar sound to that made by rolling hair between fingers just behind ear.Coarse crackles: series of long-duration, discontinuous, low-pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa. Evident on inspiration, and at times, expiration. Similar sound to blowing through straw under water. Increase in bubbling quality with more fluid. Rhonchi: continuous rumbling, snoring, or rattling sounds from obstruction of large airways with secretions. Most prominent on expiration. Change often evident after coughing or suctioning. Wheezes: continuous high-pitched squeaking or musical sound caused by rapid vibration of bronchial walls.Stridor: continuous musical or crowing sound of constant pitch. Result of partial obstruction of larynx or trachea. Pleural friction rub: creaking or grating sound from roughened, inflamed pleural surfaces rubbing together.

30.What are the NORMAL assessment findings of the respiratory system (table 26-7) pg. 488

Nose: symmetric with no deformities; nasal mucosa pink, moist with no edema, exudate, blood, or polyps; nasal septum straight; nares patent bilaterallyOral mucosa: light pink, moist, with no exudate or ulcerationsPharynx: smooth, moist, pinkNeck: trachea midlineChest: AP diameter = 1:2; Respirations non-labored at 14 breaths/min; Breath sounds vesicular without crackles, rhonchi, or wheezes; excursion equal bilaterally with no increase in tactile fremitus

31. In what diseases will you see pursed-lip breathing and use of the tripod position? What do these findings indicate? Page 489TPursed-lip breathing can be seen in COPD, asthma, which indicates increased breathlessness. This strategy is taught to slow expiration and decrease dyspnea.Tripod positioning (inability to lie flat) can be seen in COPD, asthma exacerbation, and pulmonary edema, which indicates moderate to severe respiratory distress.

32. Describe ABDOMINAL PARADOX, its possible cause and significance. Page 489TAbdominal Paradox is the inwards opposed to the normal outward movement of the abdomen during inspiration. Is generally caused by inefficient or ineffective breathing pattern and is a nonspecific indicator of severe respiratory distress.Youtube link: https://www.youtube.com/watch?v=fdaB6VWNi6A

33. Describe Wheezes. What is the difference in disease process between Inspiratory wheezing and Expiratory wheezing? In what diseases is wheezing a common finding? Page 489TWheezes are continuous high-pitched squeaking or musical sound caused by rapid vibration of bronchial walls. A wheeze is possibly heard in expiration (most common) and inspiration (heard in inspiration only as the airway obstruction increases). Wheezes can be heard in Asthma (bronchospasm), airway obstruction, and COPD.Youtube link: https://www.youtube.com/watch?v=9S_WwaXY1eE

34. Describe Endoscopic Bronchoscopy. When is this procedure used (for what purposes?) Page 492TA procedure where the bronchi are visualized through a fiberoptic tube. I fiberoptic scope is used for diagnosis, biopsy, and specimen collection or assessment of changes. It may also be done to suction mucous plugs, lavage the lungs, or remove foreign objects.

35. Describe End-tidal CO2 (PETCO2) (capnography). Page 491TCapnography is used to assess the level of CO2 in exhaled air. Showing a graphic dsiplays partial pressure of CO2. Expired gases are sampled from the patient’s airway and are analyzed by a CO2 sensor that uses infrared light to measure exhaled CO2. The sensor may be attached to an adaptor on the endotracheal or tracheostomy tube. A nasal cannula with a sidestream capnometer can be used in

patients without an artificial airway. This can be used to diagnose lung disease and monitor patients.

36. Percutaneous needle aspiration (TTNA) involves inserting a needle through the chest wall under CT guidance. Why is it important to have a Chest xray after TTNA? Page 493Due to the risk of pneumothorax.

37. Differentiate between CT and MRI. What would you teach a patient undergoing either of these procedures to help prepare them? What are some of the risks associated with these procedures? Page 492TCT is performed for diagnosis of lesions difficult to assess by conventional X-ray studies (spiral CT is used to diagnose pulmonary embolism). Nurse should assess if patient is allergic to shellfish (iodine), ensure the patient is well hydrated both before and after the procedure, and warn patient that the contrast dye may cause the feeling of being warm and flushed. Instruct patient that they will need to lie flat on a hard table and the scanner will rotate around them while making clicking noises. Instruct patient to undress to the waist, put on gown, and remove any metal between neck and waist.

MRI is used to diagnose lesions difficult to assess by CT scan and for distinguishing vascular from none vascular structures. Nurse should provide claustrophobic patients with relaxation or other modes to cope. Patient must remove all metal before test. Patients with pacemakers and implantable cardioverter-defibrillators may not be able to have MRIs. Instruct patient to undress to the waist, put on gown, and remove any metal between neck and waist.

38. Look at table 26-11. In which patients would a >5mm induration indicate a positive reaction? > 10 mm? > 15 mm? Page 494T

> 5mm induration indicates a positive in HIV infected patients, people who recently came in to contact with person with TB, people with fibrotic lesions on chest X-ray consistent with prior TB, patients with organ transplant, immunosuppressed patients.

> 10mm induration indicates a positive in recent immigrants from high prevalence countries, injecting drug users, residents and employees of high risk congregate settings, Mycobateriology laboratory personnel, and people with clinical conditions

>1 5mm induration indicates a positive in all other people who are at low risk39. Incentive Spirometry may be ordered before and after administration of a

bronchodilator. Why would this be done? What is a positive response to a bronchodilator? Page 495IS is ordered before and after to determine the patients response to the bronchodilator. A positive response to the bronchodilator is greater than 200mL increase or greater that 12% increase between Pre and Post administration.

For the following questions watch the Khan Academy video on Types of Pulmonary disease:

The following answers were found in the Khan academy video

40. Differentiate between Restrictive and obstructive lung diseaseRestrictive (oxygen not coming in, not expanding properly)-in restrictive diseases we lack oxygen. Can be due to stiffness and becomes hard to blow up (fibrosis, muscular disease that affect chest wall, amyloidosis)Obstructive (CO2 is hard to get out)-air is essentially stick inside the lungs (COPD, emphysema, chronic bronchitis, and asthma)

41. What is the difference between the pathophysiology of these categories of lung disease?Restrictive (oxygen not coming in, not expanding properly)Obstructive (CO2 is hard to get out)

42. What are the main obstructive respiratory diseases?

COPD, emphysema, chronic bronchitis, and asthma43. Describe the pathophysiology for Emphysema, Chronic Bronchitis, and Asthma

Inhibits the lungs for collapsing back to its “normal” because the walls have lost their normal elastic qualities.

44. List the main types of restrictive Pulmonary diseaseFibrosis, muscular disease that affect chest wall, amyloidosis

45. List 2 causes of Ventilation problemsPneumonia and Edema (fluid being where it shouldn’t be)

46.Define Perfusion Problems of the lungs. List the main cause of perfusion Problems in the lungs.

Perfusion: The movement of blood through though the pulmonary capillaries…… Therefore the problem would be lack of or no movement of blood through the pulmonary capillaries. When blood supply is available but decreased, the term ischemia is used

Main Causes: Right to left shunt, Pneumonia, atelectasis, tumors, mucous plugs

Read pages 522-533 and answer the following questions:

47.What is Pneumonia? When is Pneumonia more likely to occur?

Page 522: Pneumonia is an acute infection of the lung parenchyma (The key elements of an organ essential to its functioning, as distinct from the capsule that encompasses it and other supporting structures.)

Last paragraph pg 522: More likely to occur when the defense mechanism become incompetent are overwhelmed by the virulence or quantity of infectious agents.

48.What are the risk factors for Pneumonia (T 28-1)?

Pg 523 (table)

Abdominal or thoracic surgery Older than 65 Air pollution Altered consciousness/ alcohol, head injury, stroke, drug overdose Prolonged bed rest Chronic disease /liver, kidney, heart, dm, cancer Debilitating illness Inhalation/aspiration of toxic substance Intestinal and gastric tubal feedings Iv drug use Malnutrition Smoking Long term care facility Recent antibiotic therapy Trach intubation UPPER RESP TRACT INFE.

49.What are the 3 paths used by organisms that cause pneumonia?

Pg 523 Below table 28-1

Aspiration: of normal flora from nasophatynx or oropharynx.

Inhalation: of microbes present in the air: mycoplasma pneumonia on fungal

Hematogenous spread: primary infection elsewhere/ staph aureus

Now, watch the Khan Academy video WHAT IS PNEUMONIA & STREMPTOCOCCUS PNEUMONIAE FLU VACCINE, and continue reading pages 522-533. Answer the following questions.

50.Differentiate between Community Acquired Pneumonia, Medical care Associated Pneumonia (ventilator associated, Hospital acquired, and health care associated), Aspiration Pneumonia, and Opportunistic pneumonia. Who is at increased risk for each of these problems?

Starts on page 523 and goes to pg 524

Community-acquired pneumonia (CAP) is infectious pneumonia in a person who has not

recently been hospitalized. CAP is the most common type of pneumonia. The most common

causes of CAP vary depending on a person's age, but they include Streptococcus pneumoniae,

viruses, the atypical bacteria, and Haemophilus influenzae. Overall, Streptococcus pneumoniae is

the most common cause of community-acquired pneumonia worldwide. Gram-negative

bacteria cause CAP in certain at-risk populations.. The term "walking pneumonia" has been

used to describe a type of community-acquired pneumonia of less severity (because the sufferer

can continue to "walk" rather than require hospitalization). Walking pneumonia is usually

caused by the atypical bacterium, Mycoplasma pneumoniae.

Medical Care- Associated Pneumonia: encompasses three forms:

Hospital-acquired

1. Hospital-acquired pneumonia, also called nosocomial pneumonia, is pneumonia

acquired during or after hospitalization for another illness or procedure that occurs

48 hours or longer after admission. The causes, microbiology, treatment and prognosis

are different from those of community-acquired pneumonia. Hospitalized patients may

have many risk factors for pneumonia, including mechanical ventilation,

prolonged malnutrition, underlying heart and lung diseases, decreased amounts of

stomach acid, and immune disturbances. Additionally, the microorganisms a person is

exposed to in a hospital are often different from those at home. Hospital-acquired

microorganisms may include resistant bacteria such

as MRSA, Pseudomonas, Enterobacter, and Serratia. Because individuals with hospital-

acquired pneumonia usually have underlying illnesses and are exposed to more

dangerous bacteria, it tends to be more deadly than community-acquired pneumonia. 

2. Ventilator-associated pneumonia (VAP) is a subset of hospital-acquired pneumonia.

VAP is pneumonia which occurs after at least 48 hours of intubation and mechanical

ventilation.

3. Health –Care associated: is a new onset pneumonia in a patient who  includes

patients who have recently been hospitalized within 90 days of the infection, resided in a

nursing home or long-term care facility, or received parenteral antimicrobial therapy,

chemotherapy, or wound care within 30 days of pneumonia

Aspiration pneumonia:  is an inflammation of your lungs and bronchial tubes. It happens after you inhale foreign matter. It is also known as anaerobic pneumonia. This condition is caused by inhaling materials such as vomit, food, or liquid.

Opportunistic pneumonia: occurs in people with weakened immune system (e.g., people with AIDS, cancer, organ transplant). Organisms that are not usually harmful to people with healthy immune systems cause these types of infections

51.What is the CURB-65 scale? How does it help the practitioner identify the severity of pneumonia?

Page 523 in box 28-3May be used as a supplement to clinical judgment to determine the severity of pneumonia and if a patient needs to be hospitalized.1 point for each of the following:C: ConfusionU: BUN >20 mg/dlR: respiratoryB: Systolic BP <90 or diastolic <60Older than 65

Scoring: 0: treat at home1-2 consider hospitalization3 or more hospitalization4-5 consider ICU52.P. Jiroveci pneumonia (PCP) is rare in healthy individuals. What disease process increases the risk of this type of pneumonia? What are the symptoms? What will the RN be likely to observe on x-ray with this type of pneumonia?

Page 524 last paragraph 1st column

HIV

Onset slow and subtle:FeverTachypneaTachycardiaDyspneaNonproductive coughHypoxemia

Diffuse bilateral infiltrates

53.What is the MOST common life threatening infectious complication after Hematopoietic stem cell transplantation? (hint, check out page 524 under Opportunistic Pneumonia)

Last sentence under opportunistic pg 524

CMV Cytomegalovirus (a herpes virus)

54.Why is it important to not wait until the sputum specimen comes back before treating a patient with Pneumonia with antibiotics?

Page 525 second column towards top of page

Delays in antibiotic therapy can increase morbidity and mortality risks.

55.Who should be vaccinated for Pneumonia? How frequently do they need this vaccination?

Page 525 under collaborative care

Vaccination is recommended for individual 65 years or older and younger patients who are at high risk.

56.How long does a patient need to be fever free before treatment for Pneumonia should be stopped?

Page 526 bottom paragraph

Total treatment time for patients with CAP should be a minimum of 5 days and the patient should be fever free for 48-72 hours before stopping treatment.

57.A patient tells you, “I got the flu shot in 2011 and I still got sick! No I don’t bother getting one!” What is your BEST response to this (hint: explain how the flu shot really works—khan academy video)

Flu shot can vaccinate various strains but are still limited to the number of strains that it can “protect” you from. Strains are mutating all the time and therefore a vaccination is needed every year.

58.Describe the Pathophysiology of Emphysema, Chronic Bronchitis, and Asthma

Page 580: Emphysema is a disease of the lung tissue, abnormal permanent enlargement of the air spaces distal to the terminal bronchioles accompanied by the destruction of the walls. This process is not reversible and responds less well to medical treatment. Emphysema is slowly progressive; you will get short of breath and become more disabled as time goes on. Eventually you may require continuous concentrated oxygen to be comfortable.

Chronic bronchitis is a serious long-term disorder that often requires regular medical treatment. a respiratory disease in which the mucus membrane in the lungs' bronchial passages becomes inflamed. As the irritated membrane swells and grows thicker, it narrows or shuts off the tiny airways in the lungs, resulting in coughing spells that may be accompanied by phlegm and breathlessness.The disease comes in two forms: acute (lasting from one to three weeks) and chronic (lasting at least 3 months of the year for two years in a row). Chronic bronchitis is one of two main types of a COPD. The other main form of COPD is emphysema. Both forms of COPD make it difficult to breathe.

Bottom on 562 Asthma is a spastic and inflammatory disease of the airways that causes reversible obstruction of the bronchial tubes. It usually responds to treatment (bronchoconstriction airway hyperresponsiveness/hyperactivity)

59.Differentiate between restrictive and obstructive lung disease? What is the difference between the pathophysiology of these categories?

Obstructive lung diseases include conditions that make it hard to exhale all the air in the lungs. People with restrictive lung disease (lower respiratory) have difficulty fully expanding their lungs with air. Impairs the ability of the chest wall and diaphragm to move with respiration.

Obstructive and restrictive lung disease share the same main symptom: shortness of breath with exertion.

Patient can have both:Chronic Bronchitis (obstructive problem)Pulmonary Fibrosis (restrictive problem)

60. What are the main obstructive pulmonary diseases? Page 580.Chronic bronchitis and emphysema.

61.List the main types of RESTRICTIVE PULMONARY DISEASE (page 549)

RPD caused by EXTRAPULMONARY CONDITIONS RPD caused by INTRAPULMONARY CONDITIONS

62.List 2 causes of ventilation problems.

PNUEMONIA: more likely to occur when the defense mechanisms become incompetent or are overwhelmed by the virulence or quantity of infectious agents (523)

PULMONARY EDEMA: s an abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs; most common caused is left sided heart failure (551)

63.Define perfusion problems of the lungs

Inability of blood to move through the pulmonary capillaries due to clotting (pulmonary embolus)

64.List the main cause of perfusion problems in the lung.

PULMONARY EMBOLISM: is the blockage of pulmonary arteries by a thrombus, fat or air embolus, or tumor tissue; A pulmonary embolus consists of material that gains access to the venous system and then to the pulmonary circulation. The embolus travels with the blood flow through ever-smaller blood vessels until it lodges and obstructs perfusion of the alveoli (Fig. 28-11). Because of higher blood flow, the lower lobes of the lung are commonly affected. (552)

65.List 3 nursing diagnoses related to Pneumonia (527)

Impaired gas exchange related to fluid and exudate accumulation at the capillary-alveolar membrane

Ineffective breathing pattern related to inflammation and pain Acute pain related to inflammation and ineffective pain management and/or

comfort measures

66.What measures can we take to prevent pneumonia in patients who are at risk? (list at least one preventative measure for each type of pneumonia) (523-525)

Community-Acquired Pneumonia (CAP) = VACCINATION, NO SMOKING, HAND WASHING

Medical Care Associated: Hospital-associated, Ventilator-Associated, & Health Care-Associated Pneumonia (MCAP) = Prevented by using STRICT ASEPTIC TECHNIQUE WITH TRACH SUCTIONING, WASH HANDS

Aspiration pneumonia = Proper oral hygiene, Sit up while eating, Opportunistic pneumonia = FLU AND PNEUMOCOCCAL VACCINE

67.What are the factors that influence the likelihood of TB transmission? (528-529)

(1) number of organisms expelled into the air (2) concentration of organisms (small spaces with limited ventilation would mean

higher concentration), (3) length of time of exposure, and (4) immune system of the exposed person.

68.What is the difference between PRIMARY TB INFECTION, LTENT TB INECTION (LTBI), ACTIVE TB DISEASE, and REACTIVATION TB? What individuals are at the greatest risk for developing ACTIVE TB? (529)

LATENT TB: occurs in a person who does not have active TB disease (Table 28-9). These individuals are asymptomatic and cannot transmit the TB bacteria to others.

ACTIVE TB: If the initial immune response is not adequate, the body cannot contain the organisms, the bacteria replicate, and active TB disease results; HIV PATIENTS AT GREATER RISK

PRIMARY TB: When active disease develops within the first 2 years of infection, it is termed primary TB.

REACTIVATION TB: TB disease occurring 2 or more years after the initial infection.

69.When do symptoms of pulmonary TB develop? What are the main pulmonary manifestations of TB? What are late vs. early signs of TB? (529)

Symptoms of pulmonary TB usually do not develop until 2 to 3 weeks after infection or reactivation.

PULMONARY MANIFESTATIONS: Bad cough that lasts => 3 weeks; cough that becomes frequent and is productive.

EARLY SIGNS: fatigue, malaise, anorexia, unexplained weight loss, low-grade fevers, and night sweat

LATE SIGNS: Dyspnea and Hemoptysis

70.What is the difference between MILIARY TB and PLEURAL TB?(530)

MILIARY TB: widespread dissemination of the mycobacterium via bloodstream; characterized by large amount of TB BACILLI

PLEURAL TB: Pleural effusion caused by bacteria in the PLEURAL SPACE, which trigger an inflammatory reaction and a pleural exudate of protein rich fluid

71.What are the medications used to treat TB? What particular precaution should be taken for the patient on Isoniazid (INH)? (531)

Isoniazid, Rifampin(RIFADIN), Pyrazinamide (PZA), Ethambutol (Myambutol), = RIPE

ifabutin (Mycobutin), streptomycin, rifapentine (Priftin), fluoroquinolones, aminoglycosides, bedaquiline (Sirturo)

INH PRECAUTION: Alcohol may increase hepatotoxicity of the drug. Instruct patient to avoid drinking alcohol during treatment. Monitor for signs of liver damage before and while taking drug.

72.What is DIRECTLY OBSERVED THERAPY (DOT) and why is it important in the treatment of TB? (531)

Directly observed therapy (DOT) involves providing the antituberculous drugs directly to patients and watching as they swallow the medications. It is the preferred strategy for all patients with TB to ensure adherence and is recommended for all patients at risk for nonadherence.

73.If a patient is admitted to the ED or nursing unit with respiratory symtoms they should be triaged for the possibility of TB. What does this involve? (p 533)

Placed on airborne isolation Receive a medical workup (chest x ray, sputum smear, and culture) Receive appropriate drug therapy

74.What are the expected outcomes after treatment for patients with TB?

Complete resolution of the disease Normal pulmonary function Absence of any complications No transmission of TB

NOW MOVE ON TO PAGES 535-541)

75. What are the common causes of lung cancer?

Tobacco smoke exposure: responsible for 80-90% of lung cancers

High levels of pollution, industrial radiation, and asbestos, genetic factors

76.What type of cells are usually responsible for lung tumors? Where do lung cancers typically occur

Most primary lung tumors are believed to arise from mutated epithelial cells. Lung cancers occur primarily in the segmental bronchi or beyond and have a preference for the upper lobes of the lungs. (first paragraph under pathophysiology on page 536)

77.What are the 2 categories of primary lung cancers? What are the common sites of metastases for lung cancer? 2 categories of primary lung cancers: NSCLC or non-small cell lung cancer and SCLC or Small cell lung cancer. Common sites for metastasis are the liver, brain, bones, lymph nodes, and adrenal glands. (paragraph 2 under pathophys page 536)

78. Define PARANEOPLASTIC SYNDROME = caused by humoral factors (hormones, cytokines) excreted by tumor cells or by an immune response against the tumor. Examples: hypercalcemia, SIADH, adrenal hypersecretion, hematologic disorders, and neurologic syndromes. When these conditions are caused by humoral factors r/t lung cancer. (under paraneoplastic syndrome page 536)

79.Among the non-small cell lung cancers, which one has the fastest growth? The slowest growth? Among all categories of lung cancer, which one grows the fastest and has the overall poorest prognosis? (See T 28-16) Large cell (undifferentiated) carcinoma = fastest growth. Squamous cell carcinoma = slowest growth. Small cell carcinoma = grows fastest and poorest prognosis of all lung cancer categories. (T 28-15 page 537)

80.List the tumor characteristics and lymph involvement for each stage of non-small cell lung cancer (T 28-17)

Stage I: tumor is small and localized to lung, no lymph node involvement. Tumor <3 cm or 3-5 cm.Stage II: increased tumor size, some lymph node involvement. Tumor 3-5 cm with invasion to local lymph node, or 5-7 cm without local lymph involvement, or 5-7 cm with local lymph involvement, or >7 cm.Stage III: increased spread of tumor, has spread to nearby structures.Stage IV: Distant metastasis. Tumor has distal metastasis. (Page 538 T 28-17)

81.What is the best treatment for NSCLC stage 1-IIIA without mediastinal involvement? What is the survival rate? What does this procedure involve? Surgical resection is best treatment since provides best chance for a cure. 5 year survival rate 30-50%. Surgical procedures that may be performed: pneumonectomy, lobectomy, segmental or wedge resection procedures. (Page 538-539 paragraphs under surgical therapy heading.)

82.Describe STEREOTACTIC BODY RADIOTHERAPY (SBRT) A new type of lung cancer treatment also called stereotactic surgery or radiosurgery. A type of radiation therapy that uses high doses of radiation delivered accurately to the tumor. Utilizes special positioning procedures and radiology techniques so that a higher dose of radiation can be delivered to the tumor and only a small part of the healthy lung is exposed. Therapy is given over 1 to 3 days. (page 539 paragraph under heading: stereotactic body radiotherapy)

83.List 5 nursing diagnoses related to lung cancer

-ineffective airway clearance related to increased tracheobronchial secretions and presence of tumor.-anxiety related to lack of knowledge of diagnosis or unknown prognosis and treatments.-Ineffective self-health management related to lack of knowledge about the disease process and therapeutic regimen.-ineffective breathing pattern related to decreased lung capacity.-impaired gas exchange related to tumor obstructing airflow.(Page 539-540, last paragraph under nursing diagnosis)

84.Describe the general, integumentary, respiratory, cardiovascular, neurologic, and musculoskeletal objective data that is likely to be found in a patient with lung cancer (T 28-

General: fever, neck and axillary lymphadenopathy, paraneoplastic syndrome.Integumentary: jaundice, edema of neck and face, digital clubbing.Respiratory: wheezing, hoarseness, stridor, unilateral diaphragm paralysis, pleural effusions.Cardiovascular: pericardial effusions, cardiac tamponade, dysrhythmiasNeurologic: unsteady gaitMusculoskeletal: pathologic fractures, muscle wasting.(Page 540, T 28-18)

85.Define HAMARTOMA, MUCOUS GLAND ADENOMA, MESOTHELIOMA, and SECONDARY METASTASES.

-Hamartoma: most common benign tumor, is slow growing congenital tumor composed of fibrous tissue, fat, and blood vessels.-Mucous gland adenoma: is a benign tumor arising in the bronchi that consists of columnar cystic spaces.-Mesothelioma: either malignant or benign and originate from the visceral pleura. Malignant are associated with exposure to asbestos, benign are localized lesions.-Secondary metastases: malignant cells from another part of the body reach the lungs via the pulmonary capillaries or the lymphatic network. The primary malignancies that spread to the lungs often originate in the GI or genitourinary tract and in the breast. General symptoms often: chest pain and nonproductive cough.(page 541, paragraph under “other types of lung tumors”

NOW, MOVE ON TO CHAPTER 29: PAGES 560-601. BEFORE YOU START READING WATCH THE KHAN ACADEMY VIDEOS ON RESPIRATORY DISTRESS, ASTHMA SHORT TERM THERAPY, and ASTHMA LONG TERM THERAPY. Answer the following questions: 86-90 are from khan academy video on respiratory distress posted in videos under module 7 introduction page.

86. What are the manifestations of respiratory distress? What will you SEE the patient doing? See: patient sitting up/tripod position, rate of respirations goes up, pupils may dilate, increased work of breathing, nasal flaring, cyanosis (especially in lips, extremities), chronic respiratory distress includes nail clubbing.

87.Why is respiratory distress worse when a patient lies flat? Laying down gravitational forces are working against the diaphragm and respiratory muscles as well as keeping fluid in place and pooling.

88.What is the normal respiratory rate in an adult? 8-16 respirations per minute (STATED IN KHAN ACADEMY VIDEO)

89.Why does a patient with respiratory distress have dilated pupils? What causes this to occur? Sympathetic nervous system stimulation, flight or fight response kicks in. Dilates pupils in response to stress/anxiety/fear associated with difficulty breathing.

90.What are the signs you see when a patient has an increased work of breathing (WOB)? Short of breath, accessory muscles of respiration become involved in breathing (muscles of neck, ribs, etc) and retractions of accessory muscles working and decreased pressure in thorax. Nasal flaring,

91. What are the signs of Chronic Respiratory distress? Describe stridor.- Respiratory: tachypnea(fast breathing), hyperventilation, or shortness of breath,

hypoxia

- Whole body: fever or low oxygen in the body, tripod position/accessory muscle use/ inability to lie flat, Abdominal paradox: Inward (rather than normal outward) movement of abdomen during inspiration, fatigue, agitation, anxiety, confusion or sleepiness

- Also common: blue skin from poor circulation, coughing, high carbon dioxide levels in blood, muscle weakness, or organ dysfunction

- Stridor: Continuous musical or crowing sound of constant pitch/ high pitch. Result of partial obstruction of larynx or trachea.

92. Describe the categories of Asthma and how frequently they occur-page 565- Asthma can be classified as intermittent, mild persistent, moderate persistent, or

severe persistent. -

93. How do beta 2 agonists help people with an asthma attack? Pg572- They stimulate beta adrenergic receptors in the bronchioles, thus producing

bronchodilation. They also increase mucociliary clearance, prevent bronchospasm precipitated by exercise and other stimuli because they prevent the release of inflammatory mediators from mast cells.

94. What is the basic way Bipap and CPAP work for patients with asthma?- BiPAP, biphasic positive airway pressure; CPAP, continuous positive airway

pressure- method of delivering oxygen by positive pressure mask/ positive pressure

ventilation- improves lung mechanics by improving laminar airway flow by stenting closed

airways or semi-obstructed airways this decreasing atelectatic alveoli, improving pulmonary compliance, and reducing work of breathing.

95. What are some of the main triggers that can cause asthma attacks to occur? pg 561-562 Table 29-1- Allergen inhalation, air pollutants, inflammation and infection, drugs,

occupational exposure, food additives, stress, exercise, cold dry air, hormones, menses, GERD

96. What is the goal of long term asthma treatment?- The goal of asthma treatment is to achieve and maintain control of the disease.

97. How does a nebulizer work? Pg 574-575-small machine used to convert drug solutions into mists. Mist is inhaled through a face mask or mouthpiece held between the teeth. The patient is placed in an upright position that allows for most efficient breathing to ensure adequate penetration and deposition of the aerosolized medication. The patient must breathe slowly and deeply through the mouth and hold inspirations for 2-3 seconds. Deep diaphragmatic breathing helps ensure deposition of the medication.

98. What are the classes of medications that treat inflammation that occurs in asthma? Pg569-572Corticosteroids(Corticosteroids are antiinflammatory medications that reduce bronchial hyperresponsiveness, block the late-phase response, and inhibit migration of inflammatory cells. Corticosteroids are more effective in improving asthma control than any other long-term drug.), phosphodiesterase inhibitor type 4 (PDE-4) , leukotrienes( in long term use)How do bronchodilators work in the treatment of asthma? Beta adrenergic receptors are stimulated within the bronchioles thus producing bronchodilation. They also increase mucociliary clearance. Anticholinergic drugs block the bronchoconstricting effect of the parasympathetic nervous system. What are the different categories of bronchodilators? Beta adrenergic agonist, methylxanthines, anticholinergic drugs How are they the same? How are they different?- methylxanthines: Sustained-release methylxanthine (theophylline) preparations are not a first-line controller medication. They are used only as an alternative therapy for step 2 care in mild persistent asthma. Methylxanthine is a bronchodilator with mild antiinflammatory effects, but the exact mechanism of action is unknown.- Anticholinergic agents (e.g., ipratropium) block the bronchoconstricting effect of the parasympathetic nervous system. These drugs are less effective than β2-adrenergic agonists. Anticholinergic drugs are used for quick relief in those patients unable to tolerate SABAs. In addition, they are used for the patient in severe asthma exacerbation in emergency situations, often nebulized with an SABA. Other than these indications, they have no role in the treatment of asthma.

99. What is the hygiene hypothesis in relation to the risk for asthma? Pg562- The hygiene hypothesis suggests that a newborn baby's immune system must be

educated so it will function properly during infancy and the rest of life. People who are exposed to certain infections early in life, use few antibiotics, are exposed to other children (e.g., siblings, day care), or live in the country or with

pets have a lower incidence of asthma. People for whom these factors are not present in childhood have a higher incidence of asthma.

100. How does the inflammation of asthma lead to limited airflow? Pg564 - The airflow is limited because the inflammation results in bronchoconstriction,

airway hyperresponsiveness (hyperreactivity), and edema of the airways/ The resulting inflammatory process causes vascular congestion, edema, production of thick and tenacious mucus, bronchial muscle spasm, thickening of airway walls, and increased bronchial hyperresponsiveness.

101. What are the characteristic signs of an asthma attack? Pg564- The characteristic clinical manifestations of asthma are wheezing, cough, dyspnea, and

chest tightness after exposure to a precipitating factor or trigger. Expiration may be prolonged. Instead of a normal inspiratory-expiratory ratio of 1:2, it may be prolonged to 1:3 or 1:4. Normally the bronchioles constrict during expiration. However, as a result of bronchospasm, edema, and mucus in the bronchioles, the airways become narrower than usual. Thus it takes longer for the air to move out of the bronchioles. This produces the characteristic wheezing, air trapping, and hyperinflation.

102. What is COUGH VARIANT ASTHMA? Pg 565- In some patients with asthma, cough is the only symptom, and this is termed cough

variant asthma. The bronchospasm may not be severe enough to cause airflow obstruction, but it can increase bronchial tone and cause irritation with stimulation of the cough receptors. The cough may be nonproductive. Secretions may be thick, tenacious, white, gelatinous mucus, which makes their removal difficult.

103. Describe what a person with severe and life threatening asthma exacerbations looks like. Pg 565- Severe asthma exacerbations occur when the patient is dyspneic at rest and the

patient speaks in words, not sentences, because of the difficulty of breathing. The patient is usually sitting forward to maximize the diaphragmatic movement with prominent wheezing, a respiratory rate higher than 30 breaths/minute, and pulse greater than 120 beats/minute. Accessory muscles in the neck are straining to lift the chest wall, and the patient is often agitated. The peak flow (peak expiratory flow rate [PEFR]) is 40% of the personal best or less than 150 L/minute. Arterial blood gas (ABG) changes are listed in Table 29-3. Neck vein distention may result.

- Patients with life-threatening asthma are typically too dyspneic to speak and perspire profusely. They may even be drowsy or confused as the ABGs further deteriorate. The breath sounds may be difficult to hear, and no wheezing is apparent because the airflow is exceptionally limited. Peak flow is less than 25% of the personal best. They become bradycardic and are close to respiratory arrest

- *** If the patient has been wheezing and then there is an absence of a wheeze (i.e., silent chest) and the patient is obviously struggling, this is a life-threatening situation that may require mechanical ventilation.***

104. Describe the term SILENT CHEST. Pg 565

- Diminished or absent breath sounds may indicate a significant decrease in air movement resulting from exhaustion and an inability to generate enough muscle force to ventilate. Severely diminished breath sounds, often referred to as the “silent chest,” are an ominous sign, indicating severe obstruction and impending respiratory failure.

105. Which medication should be stopped 6-12 hours before a PFT (pulmonary function test)?- ****When PFTs are scheduled, ask the patient to stop taking any

bronchodilator medications for 6 to 12 hours before the tests** FROM THE BOOK pg 566 .avoid any aspirin, ibuprofen, or other blood-thinning drugs before the procedure. If you are currently taking Aspirin, Coumadin, Clopidogrel (Plavix), Dabigatran (Pradaxa) or any other blood thinning medication

121.Describe how to teach a patient pursed lip breathing (t 29-13) PAGE 579

Patient should do before, during and after activity that causes SOB. LIKE YOU’RE ABOUT TO WHISTLE

Inhale slowly and deeply through nose

Exhale through pursed lips three times longer than your inhale

Relax cheeks

8-10 repetitions 3-4 times daily

Activities to get used to PLB: blow through straw in water to make bubbles

122.Why is a peak flow meter helpful in the management of Asthma? Page 579

PFM is to asthma what a BP cuff is to your BP. A PFM shows how well your lungs are moving air out of your lungs.

With asthma, your lungs will narrow slowly so a PFM will indicate narrowing hours or days before narrowing occurs allowing to take your medicine before an attack can occur

123.Describe how to teach a patient the method for using a peak flow meter (T 29-14) Page 579

Using PFM: Move indicator to bottom of the scale

Stand up, take your largest deepest breath, put mouthpiece and close lips around. DO NOT PUT TONGUE OVER HOLE. Blow out as hard and fast as you can with a SINGLE blow. Record number, if cough or made mistake DON’T WRITE DOWN AND DO IT AGAIN. Repeat 2 more times and write best of the 3 attempts

124.What actions should a patient take when Peak Flow Numbers change? (T 29-14) Page 579

Once you have found your peak expiratory flow PEF number over a 2 week period, the actions you take are crucial should they change:

If PEF is 50% to 80% of number TAKE INHALED QUICK RELIEF MEDICINE

If PEF is increases more than 20% of number after taking quick relief medicine, CALL YOUR PHSYICIAN TO ADDING MORE MEDICINE TO BETTER CONTROL ASTHMA

125.What is alpha 1 antitrypsin (AAT) deficiency and what disease is it associated with? Page 582 MIDDLE RIGHT

AAT is a protein produced in the liver that protects organs, especially the lungs, from cigarette smoke and infections.

AAT deficiency (not enough) is an autosomal recessive disorder that may lead to COPD

126.What is typically the first symptom seen in a patient with COPD? Page 585 THIRD PARAGRAPH

Chronic, intermittent cough usually seen everyday.

127.What symptoms do patients tend to complain of when they are developing COPD? Why do they tend to ignore these symptoms? 585 WHOLE PAGE

Cough, not able to take deep breaths, heaviness in the chest, gasping, increased hunger for air and increased effort to breath. Patients will often dismiss as they think it is related to them aging and out of shape.

Other symptoms dyspnea at rest, slow walking, chest breathing, wheezing and tightness depending on time of day, fatigue, weight loss.

128.In what stage of COPD would you see dyspnea at rest? Page 585 MIDDLE

LATE STAGE OR ADVANCED

129.What symptoms do we often see in people who have advanced COPD? Page 585 BOTTOM

Fatigue, weight loss, anorexia (even with adequate nutrition) TRIPOD POSITION. Edema in ankles.

130.What are the physical examination findings common with COPD? Page 585 BOTTOM

Prolonged expiration, wheeze, decreased breath sounds in all lung fields. PT may breathe louder so it can be heard. ANTERIOR-POSTERIOR diameter is increased BARREL CHEST. Tripod position. Naturally pursed lips using accessory muscles to breathe.

131.In a patient with COPD, what would edema in the ankles indicate?

RIGHT SIDE HEART INVOLVMENT COR PULMONALE

132.What is the main cause of COR PULMONALE? Page 585 BOTTOM

PULMONARY HYPERTENSION WHICH CAUSES PULMONARY VESSELS TO CONSTRICT FROM ACIDOSIS

133.Dyspnea is the most common symptom of chronic cor pulmonale. What are some other manifestations of right-sided heart failure that can develop? Page 586 MIDDLE

Normal lung sounds with SOME CRACKLES. JVD. Liver enlargement (HEPATOMEGALY) with URQ tenderness, peripheral edema, weight gain. ECG changes in SEVERE cases. BNP may be increased.

134.What is the treatment for Cor-Pulmonale aimed at? Page 586 BOTTOM

MANAGEMENT OF COPD by continuous low-flow long term oxygen therapy.

135.When a patient has an exacerbation of COPD, the RN should monitor the ABGs. What problems might occur that can be identified by ABG abnormalities?

REPIRATORY ACIDOSIS AND HYPOEXEMIA. HIGH PACO2 HIGH HCO3

136.Describe the following oxygen administration devices and nursing interventions needed with each type (table 29-20): NASAL CANNULA, SIMPLE FACE MASK, PARTIAL AND NON-REBREATHER MASKS, OXYGEN CONSERVING CANNULA, TRACHEOSTOMY COLLAR, TRACHEOSTOMY T BAR, VENTURI MASK

NASAL CANNULA - Most common. Low O2 concentrations of 1L to 6 L/ min ( 24-44%). COPD patients usually tolerate 2L/ min. Asses for skin breakdown may need padding cannula around ears. 5L/Min asses for dry mucous membranes, can cause frontal sinus pain.

SIMPLE FACE MASK- For short periods of time. O2 concentrations of 35-50% can be reached by 6-12 L/min. Wash and dry under mash Q2H. Asses for skin necrosis around mask, may be relieved with gauze or other padding.

PARTIAL AND NON REBREATHER MASK- Short term (24 hours) for high O2 concentrations 10-15L (60-90% O2). O2 flows into bag and mask during inhalation. Allows patient to rebreathe first third of exhaled air (its rich in oxygen) along with flowing 02. Vents stay open for partial mask only. Oxygen rate should be sufficient to keep bag from collapsing during inspiration to prevent CO2 build up (Respiratory acidosis), so increase flow if bag collapses. With non rebreather make sure valves are open during expiration and close during inspiration to prevent decrease in FIO2. Monitor patient because more advance

interventions like CPAP, BIPAP or intubation may be necessary if partial/non rebreather not effective enough.

OXYGEN CONSERVING CANNULA- Long term, at home (like in pulmonary fibrosis, pulmonary hypertension). Comes in two types: Oxymizer (“moustache”) or pendant type. Built in reservoir that increases o2 concentrations allowing patient to use lower airflow (30-50%). Increases comfort and lower cost. Up to 8L/min. Asses for necrosis and skin break down around the ears. CANNULA CAN NOT BE CLEANED. Manufacturer recommends changing cannula ever week. More expensive cannulas. Evaluation of ABG’s and oximetery used to determine proper airflow.

TRACHEOSTOMY COLLAR- Tied around neck, delivers high humidity via tracheostomy. Venturi device can be attached to flow meter to deliver exact amounts of O2. Clean collar Q4H to get rid of built up secretions, prevent aspirations of fluids, and aspiration. Drain periodically.

TRACHEOSTOMY T BAR- Identical to tracheostomy collar but with vent and T connecter that allows catheter (i.e. ballard catheter) to allow suctioning. Monitor to see if it is pulling on trach tube, irritation and potential tissue damage. See trach collar nursing interventions.

VENTURI MASK- Can deliver precise, high airflow. O2 delivery in 24%, 28%, 31%, 35%, 40%, 50%.Especially helpful for delivering constant low 02 in patients with COPD. Entrainment devices on make must be changed to deliver higher concentrations of O2. Air entrainment ports must not be included. See simple mask nursing interventions.

137.For what oxygen concentrations is humidification or nebulization required? High liter flow of 02 delivering more than 35-50% of O2.

138.Describe the complications of oxygen administration including: COMBUSTION, CARBON DIOXIDE NARCOSIS, OXYGEN TOXICITY, ABSORPTION ATELECTASIS, and INFECTION.

COMBUSTION: O2 is flammable/combustable. Prohibit smoking around the area/place no smoking sign on patients door.

CARBON DIOXIDE NACROSIS: Accumulation of CO2 is the respiratory center’s drive to breathe. Patients with COPD because tolerant of high levels of C02, Their drive to breath becomes hypoxemia. By Providing oxygen, theoretically you take away their drive to breathe. Regardless this is not completely solid because other factors such as ventilation and perfusion come into play, and not all patients with COPD retain CO2. Most important is providing enough oxygen because this not providing enough is much more damaging, causing hypoxia. Make sure to have an ongoing assessment when providing O2, monitoring both physical and cognitive effects.

OXYGEN TOXICITY- Rare. Prolonged exposure to high O2 levels. Causes severe inflammatory response due to O2 radicals and damage to alveolar-capillary membranes resulting in: Pulmonary edema, shunting of blood, and hypoxemia.

ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS). Monitor ABG’s frequently, O2 over 50% for more than 24 hours should be considered potentially toxic.

ABSORPTION ATELECTASIS- Atelectasis is the collapse of a lung. Nitrogen makes up 79%(why couldn’t they just make that 80%) of the air we breathe. It stays in the alveoli and is not absorbed into the blood stream which prevents which prevents collapse of alveoli. When high 02 is given it replaces the nitrogen, causing collapse. This is absorption atelectasis.

INFECTION- Can be major hazard. Heated nebulizers present highest risk because the constant humidity and warmth promotes bacteria growth. The most common organism being PSEUDOMONAS AERUGINOSA. Disposable closed system equipment such as the ballard suctioning system.

139.Look at the box on page 592 regarding DELEGATION DECISIONS with oxygen administration. Be sure that you KNOW what you can and cannot delegate!

RN roles- (EVALUATION AND ASSESMENTS CAN NEVER BE DELEGATED) ASSESS for need of 02 adjustment, EVALUATE response to 02 therapy, monitor for signs of adverse affects, choose optimal 02 device, teach patient and family.

LPN- In stable patients , adjust 02

Unlicensed Assistive Personnel (UAP, CNA, PCA, PCT, Nurse Tech)-Use Pulse ox to measure O2. Report 02 SAT to RN. Adjust nasal cannula or mask. Report to RN any changes in consciousness or complaints of SOB.

140.When patients use oxygen at home, what are some ways they can decrease their risk for infection? (T 29-22) Found on page 593.

Oral care (brush teeth and mouth wash frequently throughout the day). Wash nasal cannula with soap and water once or twice a week. Replace cannula Q2-4 weeks. Replace cannula after cold. Remove coughed out secretions. Changed filter according to company manufacturer recommendation. If 02 concentrator being used, unplug and wipe down unit daily with damp cloth and dry it.

141.What are the safety issues that must be addressed when home oxygen is in use? (T 29-22). Found on page 593.

“No smoking” signs outside the house. O2 will not “blow up” but will increase the rate at which fire burns. Do not allow smoking inside of house. Nasal cannulas and masks can catch on fire causing facial burns. Do not use flammable liquids such as paint thinners, cleaning fluids, gasoline, kerosene, oil based paints, and aerosols sprays while using 02. Do not use blankets or fabrics that carry static charge such as wool or synthetics. Inform

electric company that you are using an o2 concentrator so it knows the importance of restoring your power during power failure.

142.Teach a patient how to perform the Huff Cough (T 29-23). Found on page 594

Place patient in sitting position, preferably feet on floor and forearms resting on a pillow. Inhale slowly through mouth while breathing deeply from diagphram. Hold breath for 2-3 seconds. Forcefully exhale quickly as if you are trying to fog up a mirror (Creating the “huff”). Repeat two or three times, refraining from a regular cough. Cough when mucous is felt in breathing tubes. Rest for five or ten regular breaths. Repeat the huffs (3-5 cycles) until you feel that you have cleared mucus or you become tired.

143.Describe POSTURAL DRAINAGE. What is the purpose of this technique? How is it accomplished? What medications are usually given before postural drainage? How long does a patient maintain this position during percussion and vibration? How should Postural Drainage be scheduled? How are PERCUSSION and VIBRATION used with postural drainage to help remove secretions? Found on page 594-595.

Postural drainage is the use of position techniques to drain secretions from specific segments of lungs and bronchi into the trachea. The purpose of various positions is to drain each segment into larger airways. Patient is usually place in a head down or side lying position. Medications administered before include aerosolized bronchodilators and hydration therapy. A patient maintains the position for five minutes during percussion and vibration; a common order/ schedule is three two to four times a day, in acute settings up to Q4H. It should be scheduled an hour before meals and three hours after meals. Percussion- hand is placed in a cup like position, and should create an air pocket between the patient’s chest and the hand. Flexion of the wrist should be used, and a hallow sound should be heard. This allows the movement of thick mucus. Make sure to do this on top of a hospital gown, shirt, or thin towel. Vibration- tense the hands and arm muscles and press mildly with flat hand on affected area while patient exhales slowly. This moves secretions into larger airways, is a milder technique, and can be used when percussion is contradicted

144.Describe the Flutter airway clearance device and the HIGH-FREQUENCY CHEST WALL OSCILLATION vest. Found on page 595.

The flutter is shaped like a small fat pipe. There’s a stainless steel ball within it and a mouthpiece is attached. The patient exhales into the flutter, causing the ball to move and send vibrations (oscillations) through the airway loosening up secretions and mucous. The high frequency chest wall oscillation vest is inflated with hoses that are connected to a high frequency pulse generator, causing vibrations on the chest moving secretions into larger airways. Vest way 23-30 pounds, are portable, are quiet, and come in suitcases

145.List methods the nurse can use to increase the nutritional intake of a patient with COPD (these are specific methods…p 595& 596, T 29-24). Found on page 596.

Patients should rest thirty minutes before meals and use a bronchodilator to prevent dyspnea. They should avoid exercise an hour before the planned meal. Make sure patient has good dentation. Walking and getting out of bed during the day stimulates appetite, promoting weight gain. 3L/ day fluids unless contradicted, and drinks should be had in between meals not during (prevent abdomen distention/feeling full). High caloric foods should be eaten first. Try small frequent meals and snacks vs large spaced out meals. Increase calories by adding condiments like mayonnaise butter, peanut butter, etc. Keep favorite foods around. Cold foods help people fill less full versus hot foods. Keep ready prepared meals at hand to use when patient has increased SOB (no energy to waste making food). Patient should eat larger meals when they are less tired. Skim milk can be added to milk for protein and calories (2tbs to 8oz). Use milk or half and half instead of water when making soaps, cocoa, etc. Add cheese to food. Choose deserts with eggs like angel food cake, bread pudding, etc. (protein)

Extra information about weight loss in COPD patients.

Patients with COPD are frequently underweight, have low muscle mass, and often have cachexia. It is a predictor of a bad prognosis (not going to get better). Weight gain can combat mortality. Suspected causes of lost weight include older age, faster metabolism caused by the consistent inflammatory response. Patients who are on high dose corticosteroids can experience protein catabolism, decreasing muscle mass.

146.Define the fluid intake minimum for patients with COPD. When should fluids be consumed? Found on page 595.

3L/ day and in between meals to prevent stomach distention and pressure and diaphragm.

147.Patients with advanced COPD often become malnourished. How much protein will the patient with excessive malnutrition need in order to restore muscle mass? Found on page 595.

Patients who are EXCESSIVELY underweight need 2.5 g of protein/kg to restore muscle mass.

Extra info: Moderately underweight COPD patient 1.5 g of protein/ kg and 25-25 kcal/kg to maintain weight.

148.What are the surgical therapies used for COPD? Found on page 596

What is the goal of Lung Volume Reduction Surgery (LVRS) and how is this accomplished? There are three surgeries for COPD: Lung Volume Reduction Surgery( LVRS), bullectomy, and lung transplant.

LVRS- removing most diseased lung tissue to allow the healthy lung tissue to work better, reduces size of lung. Rationale behind surgical procedure: decrease airway obstruction and increased room for healthy alveoli to expand. Reduces lung volume

increases lung and chest wall mechanism. It is being explored to see if it can be done via bronchoscope.

Bullectomy- For carefully selected patients with emphysematous COPD who have large bullae (over 1cm) and is usually done via thoracoscope.

Lung Transplant- Patients with advanced COPD. Usually done single lung because of shortage of donors but can be done bilaterally.

149.What is the goal of Lung Volume Reduction Surgery(LVRS) and how is this accomplished?

AGAIN (AKA REPEATED INFORMATION), The goal of LVRS to reduce the long volume by removing diseased lung tissue, allowing remaining lung tissue to preform better.

150.What is Pulmonary Rehabilitation? What is a mandatory component of any Pulmonary rehabilitation program? Found on page 597.

A EBP multidisciplinary approach to customize individual treatments for COPD patients. It reduces symptoms and increases quality of life. Can be done in and out patient setting, along as in the home. Includes exercising, nutrition, smoking cessation and education. Decreases hospitalization as well as anxiety and depression. The mandatory component is exercise that focuses on muscles used in ambulation.

151.What are some of the energy saving tips taught through Pulmonary Rehab? Found on page 599.

Alternative forms of shaving, showering, and reaching may need to be explored. Bring a mirror to a table and shave and blow dry your hair there sitting down in tripod position (arms resting on table chest in fixed position). Use an electric shaver. If patient has 02 therapy use It while doing hygienic practices. Sit as much as possible and have rest periods when participating in activities. Cluster activities. Exhale when pushing/ pulling/ or any other form of effort and inhale while resting.

152.You are teaching a patient about the exercise component of Pulmonary rehab but the patient is worried about getting short of breath during exercise. What can you tell the patient and instruct him to do to minimize this problem? (p 600)

Tell patient that SOB will probably happen during exercise. Instruct patient to wait five minutes after finishing their exercise before using B-adrenergic agonist to allow a chance to recover. If it takes longer than five minutes to come back to the base long the exercise was overdone and patient should reduce intensity. Suggest the patient use a diary of the exercise program to track progress and increase confidence.