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NR202 Test 4 COPD study guide, Obstructive restrictive disorders


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What is the definition of COPD
A disease of airflow limitation which, unlike asthma, is not completely reversible and generally progresses over time.
Characteristics of COPD/Assessment findings
Chronic cough and expectoration
various degrees of dyspnea at rest or at exertion
decreased or absent fremitus (palpitation)
hyperresonance (percussed)
Early inspiratory crackles (auscultated)
Pathophysiology of COPD
Increased inflammatory response (usually because of noxious types of particles)
Airway smooth muscle tone is controlled by a balance between sympathetic (adrenergic) and parasympathetic (cholinergic) nervous systems
What drugs are prescribed for those with COPD
Beta 2 agonists relax bronchial smooth muscle
Anticholinergics prevent bronchospasm
For a patient with COPD, what is abnormal about the cilia, capillaries, goblet cells, and mucus glands
The mucus glands and goblet cells hypertrophy which leads to an increased mucus production.
cilia are destroyed, contributing to an inability to clear thick, tenacious mucus that blocks airways
Capillaries thicken which inhibits gas exchange
What is the sympathetic and parasympathetic nervous systems
Sympathetic nervous system: The part of the autonomic nervous system that contains chiefly adrenergic fibers and tends to depress secretion, decrease the tone and contractility of smooth muscle, and increase heart rate
Parasympathetic nervous system-the part of the autonomic nervous system that contains chiefly cholinergic fibers, that tends to induce secretion, to increase the tone and contractility of smooth muscle, and to slow heart rate, and that consists of a cranial and a sacral part
What happens to the airflow in someone with COPD
1. There is recurrent obstruction of airflow
2. Air trapping
-caused by mucus plugs and narrowed airways
-Airways enlarge during inspiration
-Airways narrow during expiration
-ball valving
what is ball valving
(provides somewhat of an explanation)
the thick mucous and hypertrophied bronchial smooth muscle obstructs the airways making breathing more difficult, especially expiratory. This trapping of gases in the distal part of the lungs, leads an uneven ventilation-perfusion relationship, hypoventilation, increased PaCO2 and hypoxemia. These mechanisms of ball valving are shared both by asthma and by chronic bronchitis but not emphysema.
How is COPD diagnosed
By measuring the following:
FEV1: forced expiratory volume in 1 sec.--Decreased w/COPD
Residual Volume (RV)-Volume of air remaining in lungs after maximum expiration--increased
Total lung capacity TLC-The volume of air contained in the lungs at the end of a maximal inspiration --increased
Functional residual capacity FRC--volume of air remaining in lungs after normal expiration--increased
most do not reverse with meds
Risk factors (COPD)
1. Cigarette smoking 90% of cases
2. Most serious and disabling in middle age and elderly
3. 25% have total body pain
4. 2/3 have serious chronic dyspnea
5. Functional limitations-need help with ADLs
6. Anxieties r/t air hunger
7. frequent infections
From question nine--what is increased, and what is decreased in COPD pts:
FEV1 decreased
Definition of chronic Bronchitis
Chronic cough with sputum daily for minimum of 3 months/year at least 2 successive years
May have chronic hypoxemia with resultant cor pulmonale
May have reduced responsiveness to hypoxemia and hypercarbia (excess CO2)
Definition of Emphasema
Abnormal enlargement of air spaces distal to the terminal nonrespiratory bronchioles
Nonreversible pathophysiology of emphasema
1. Destruction of elastin structure of distal airways and alveoli.
2. Septal walls are lost
Reduction of gas exchange surface
3. Increased air trapping-Loss of elastic recoil and support structures-increased A-P diameter
2 types of Emphysema
1. Centrilobular: dilation of bronchioles caused by smoking
2. Panlobular-Dilation and destruction of alveolar walls-all over the place
What do you assess for 1st in A dyspneic patient with COPD
Activity tolerance
Nursing assessments
What are some subjective/Objective assessments (COPD pt)
1. Subjective
a. Chronic bronchitis-chronic cough & sputum production, wheezing & peripheral edema -1st signs
b. Emphysema-dyspnea on exertion, at rest eventually, weight loss, inability to perform ADLs
2. Objective
a. Chronic Bronchitis-Signs of right heart failure, peripheral edema, distended neck veins; skin color dusky or cyanotic (caused by hypoxemia or hypercarbia)
b. Emphysema-Barrel chest, posture & work of breathing, use of accessory muscles, pursed lip breathing, skin color pinkish
Diagnostic findings Acute Bronchitis
1. Reduced FEV1-some reversibility following bronchodilator therapy on some patients.
2. Increased FET > 6 sec
3. ABGs-hypoxemia, often hypercapnia with compensated respiratory acidosis
4. Polycythemia on some patients-elevated RBC or HCT
Diagnostic findings Emphysema
1. Pulmonary function tests -Increased residual volume and TLC
-reduced FEV1
-nonreversibility following bronchodilators
increased compliance/decreased recoil
-decreased diffusion capacity-septal walls are lost
2. ABGs-hypoxemia may be ild with PaCO2-greatest during sleep
3. Radiologic findings-CXR shows low flattened diaphrams
Nursing diagnosis (COPD patients)
1. Ineffective airway clearance r/t copious secretions e/b excess sputum production, coarse crackles and gurgles
2. Ineffective breathing pattern r/t decreased lung recoil and air trapping e/b decreased chest excursion, barrel chest, reduced FEV1
3. Impaired gas exchange r/t destruction of alveolar walls or CO2 retention e/b decreased chest excursion, barrel chest, reduced FEV1
9 nursing interventions
1. Improve ventilation and gas exchange
2. Decrease anxiety
3. Provide adequate nutrition
4. Teach proper use of medications
5. Consider influenza and pneumococcal vaccine
6. Prevent infections
7. Suitable antibiotics-ampicillin-clavulanate 2, 3rd gen. cephalosporin, quinolone, tetracycline, and clarithromycin
8. Activity (walking)
9. Hydration
Methods to improve ventillation and gas exchange
1. Use lowest Fio2 that produces adequate oxygenation; observe for CO2 retention
2. Observe for signs of fluid overload, monitor daily wt, & I&O
3. Monitor ABGs-pH important, notify doc if PO2 falls below pt known baseline
4. Pulmonary hygiene-TCDB
5. Pursed lip breathing
6. abdominal breathing
7. 3 pt position
How to prevent infections
teach pt to avoid crowds, allergens, cold air
quit smoking
report change in color, consistency, and amount of sputum--need antibiotic, take pneumoccal vaccination and influenza vaccination
Do not take cough suppressants
Definition of Sleep Apnea
Absence of airflow for 10 seconds or more with desaturation, 30 or more times during a 7 hr sleep period
Etiology of Sleep apnea
1. Male
2. obesity
3. enlarged tonsils
4. use of alcohol or sedatives
5. over 70 years old
6. hypothyroidism
Manifestations of sleep apnea
1. Snoring (chronic & loud)
2. Choking sensation during sleep
3. cessation of breathing during sleep
4. restlessness
5. Thrashing extremities during sleep
6. daytime fatigue/sleepiness
8. large neck girth
9. Systemic or pulmonary hypertension
Diagnostics and Pathophysiology of Sleep apnea:
diagnostics: Polysomnogram
-10 sec apnea present

PaO2 drops, PaCO2 rises and pH drops causing respiratory acidosis
Change in pO2 &/or pCO2 to stimulate breathing
Wake in hte morning with headaches and still feeling tired
May doze off at inappropriate times & suffer an increased incidence of accidents
Treatment of sleep apnea
Avoid alcohol, tobacco & sleeping pills
Lose weight (if obese)
Sleep on side
Continuous positive airway clearance pressure CPAP
Side effects of CPAP and what happens in surgery
S.E. -- nasal irritation and drying, facial skin irritation, sore eyes, headaches, abdominal bloating and mask leaks

Removal of tonsils, adenoids (esp. in children), nasasl polyps, Uvulopalatoplasty removes excess tissue in back of throat
Restrictive disorders Definition
Limited expansion of lungs-inspiration primarily effected i.e. all of these can lead to dyspnea and respiratory failure:
-Parenchymal inflammation
-Diffuse pulmonary disease
-pleural disease
-Lung collapse
-Resectional surgery
-Neuromuscular disorders
What are the 2 groups of restrictive lung disease
1. Intrinsic lung diseases
2. Extrinsic lung diseases
What do intrinsic lung diseases cause
1. Inflammation and/or scarring of lung tissue (interstitial lung disease)
2. Fill the air spaces with exudate adn debris (pneumonitis). I.e. asbestosis, coal workers, pneumoconiosis, Silicosis (crystalline silicon dust)--ceramics, building materials, cement, paints, porcelain, scouring soaps, wood fillers
What do extrinsic disorders cause
Causes lung restriction and impair of ventilatory function
What are the extrinsic disorders grouped as
non-muscular diseases of the chest wall-deformity of thoracic cage such as kyphoscoliosis and ankylosing spondylitis.
--Scoliosis-lateral curvature of the spine, kyphosis-posterior curvature.
2. Neuromuscular diseases
--diseases affecting muscles of respiration or their nerve supply.
Spinal cord injury
--Poliomyelitis, Guillain-Barre syndrome, ALS, myasthenia gravis, muscular dystrophies.
Nursing diagnoses for restrictive disorders
1. Activity intolerance--1st and most important
2. Impaired gas exchange
3. Ineffective breathing patterns
Treatment for restrictive disorders
1. Pace activities (frequent rest periods)
2. Steroids
3. Oxygen
4. Antibiotics
5. Preventitive measures
Bronchoscopy-what is it's purpose
To visualize the bronchiole tree.
To clear any secretions
To obtain a biopsy
Nursing interventions for a Bronchoscopy
1. Keep the patient NPO before the procedure
2. Monitor SaO2 and VS during procedure
3. Check the gag reflex after procedure before allowing patient to eat or drink
Benifits of an inhaler
1. Increased effectiveness (decreases with improper use)
2. Faster action
3. Less chance of toxicity and side effects-then take something p.o.
Technique of an inhaler
1. Shake the inhaler well
2. Hold canister with index finger on top and thumb on bottom of mouthpiece
2. Take 1-2 slow deep breaths
3. On third breath press canister as pt inhales
4. Hold breath for 10 sec
5. Exhale slowly through pursed lips
6. Repeat as ordered
7. Spacers increase penetration into lungs
8. Repeat as ordered
9. Spacers increase penetration into lungs
10. Rinse mouthpiece daily
11. If steroid inhaler, rinse mouth to prevent thrush
12. If taking both bronchodilator and steroid inhalers, take dilator 1st.
Cromolyn sodium and anticholinergic inhalers are not effective for prn relief of symptoms of asthma. They must be taken regularly to prevent symptoms.
Bronchodilators-name some Methylxanthines and explain the actions, interactions, and symptoms of toxicity
Methylxanthines (aminophylline, theophylline, choledy) (oral or IV)
Actions: relax smooth muscle and bronchial airways, stimulates skeletal and cardiac muscles, increases CO, urine output, sodium secretion, vasodilates.
Symptoms of toxicity
1. Serum levels above 20 (10-20 therapeutic)
2. Nausea, vomiting, flushing, tachycardia, irritability, anxiety.
Interactions/Avoid: Nicotine, adrenergic agents, dilantin, barbituates, caffeine.
Adrenergic Bronchodilators (oral & inhalers): name the 2 types and their drug names. Actions for these drugs:
1. B1 agonists: receptors (lungs and myocardium)
-Isuprel, epinephrine
2. B2 agonists: receptors (primarily in the lungs)
-Brethine, alupent, bronkosol, albuterol, proventil
Actions: Relaxes smooth muscles through stimulation of receptor site causing bronchial dilation, increased heart rate and contractility
Nursing considerations for Adrenergic bronchodilators
Give B1 cautiously in cardiac pt.
Beta blockers may interact
Eliminate cough in acute bronchitis
When albuterol and atrovent is combined there is a 24% improvement in FEV1
Steroids (oral, IV & inhalers) -give names, actions, and nursing considerations
Solumedrol, prednisone, beclamethasone
Nursing considerations: if used (orally/IV) longer than 7 days, it must be tapered
May cause wt gain, fluid retention, mood changes, impotence, elevated BS, ask of sx of infection, slow wound healing
Anticholinergics (Bronchial dilators)-Give name, actions, and nursing considerations
Ipratropium bromide -Atrovent (inhaler)
Most effective bronchodilator for COPD
Action: inhibits vagus stimulation that would cause bronchoconstriction and mast cell mediator release.
Nursing considerations:
-Helps more with COPD than asthma
-Has a delayed action, thus is less effective for immediate relief of asthma sx
-must be taken consistently to be effective
Cromolyn Sodium (inhaled)
Give actions and nursing considerations
Actions: stabilizes or prevents mediator release from mast cells thus inhibiting allergy induced sx.
Nursing considerations:
1. Must be given prior to exposure to be effective
2. Do not use to relieve acute asthma sx
3. Take 10-15 min and less than 60 min prior to exposure

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