Chapter 6 – Respiratory Nursing Process

Goals of treating the elderly patient with lung disease

• Prevent symptoms that interfere with quality of life
• Prevent exacerbations of lung disease
• Minimize need for emergency department visits
• Maintain normal activity levels
• Maintain (nearly) normal pulmonary function
• Minimize use of “rescue” medication
• Minimize adverse effects of medication

Abnormal breath sounds

• Crackles—intermittent, nonmusical, caused by fluid filled alveoli popping open
• Wheezes—high pitched, occur when air flow is blocked
• Rhonchi—low pitched, snoring, rattling, occur when fluid partially blocks large airways

Overlapping symptoms

• Pulmonary embolism?
• GERD?
• Obstruction?
• ACEi cough?
• Vocal cord dysfunction?

Stepwise approach to
managing asthma

• Intermittent asthma
  • Step 1
    
    • Preferred:  short acting β-agonist (SABA) prn
    • Example:  Albuterol
• Persistent asthma with daily medication
  • Step 2
    • Preferred:  low dose inhaled corticosteroids (ICS)
    • Example:  Beclomethasone
  • Step 3
    • Preferred:  Low dose ICS + LABA or medium dose ICS
    • Example LABA:  Advair
  • Step 4
    • Preferred:  Medium dose ICS + LABA
  • Step 5
    • Preferred:  High dose ICS + LABA
    • And consider Omalizumab for patients who have allergies
  • Step 6
    
    • Preferred:  High dose ICS + LABA + oral corticosteroid
    • And consider Omalizumab for patients who have allergies

Stepwise approach to
managing asthma

• At each step…
  • Patient educations
  • Environmental control
  • Step up if needed
  • Step down if possible and if asthma is well controlled for at least 3 months

Use of inhalers

• Refer to video link in syllabus
• Spacers are useful for the elderly who have difficulty with coordination and timing
• Encourage to rinse with warm water and expectorate (“swish and spit ”) to minimize candidiasis, gum disease, tooth decay

Use of nebulizers

• Provides misted form of medication
• Easy to use at home
• Machine requires regular cleaning
• Breathe slowly, deeply
• Hold each breath 1-2 seconds before breathing out
• Important to continue until dose is complete

Use of peak flow meter

• Measures movement of air out of lungs
• Helps patient anticipate asthmatic episode
• Patient finds best peak flow number
  • Every day for 2 weeks
  • On waking and between 1200-1400
  • Before inhaled β-agonist

Potentially harmful medications for the patient with asthma

• Β-blockers—can induce bronchospasm
• NSAIDs—bronchospasm
• Diuretics—hypokalemia
• Antihistamines—prolonged QT interval
• ACEi—cough
• Antidepressants—symptoms of depression can be worsened by corticosteroids

Management of COPD

• Assessment, monitoring treatment of disease
• Reduce risk factors
• Prevent disease progression
• Assess, manage anxiety and depression
• Mucolytic therapy (e.g., Mucomyst)
• Rehabilitation
• Manage exacerbations

Tobacco smoking is the single most important risk factor for lung disease

• Causes bronchoconstriction, impaired air flow, inflammation
• Impaired ciliary action → diminished protection
• Increased risk of cancer
• Significant risk in all forms
• “there is no safe way to use tobacco”—American cancer society