COPD

 Chronic Obstructive Pulmonary Disease (COPD) is a condition of chronic

dyspnea with expiratory airflow limitation that does not significantly fluctuate.
 Chronic Obstructive Pulmonary Disease has been defined by The Global
Initiative for Chronic Obstructive Lung Disease as
“a preventable and treatable disease with some significant extrapulmonary
effects that may contribute to the severity in individual patients.”

Causes
Causes of COPD includes environmental factors and host factors. These includes:
 Smoking depresses the activity of scavenger cells and affects the respiratory
tract’s ciliary cleansing mechanism.
 Occupational exposure. Prolonged and intense exposure to occupational dust
and chemicals, indoor air pollution, and outdoor air pollution all contribute to the
development of COPD.
 Genetic abnormalities. The well-documented genetic risk factor is a deficiency
of alpha1- antitrypsin, an enzyme inhibitor that protects the lung parenchyma
from injury.

Signs & Symptoms

 Chronic cough. Chronic cough is one of the primary symptoms of COPD.
 Sputum production. There is a hyperstimulation of the goblet cells and the
mucus-secreting gland leading to overproduction of sputum.
 Dyspnea on exertion. Dyspnea is usually progressive, persistent, and worsens
with exercise.
 Dyspnea at rest. As COPD progress, dyspnea at rest may occur.
 Weight loss. Dyspnea interferes with eating and the work of breathing is energy
depleting.
 Barrel chest. In patients with emphysema, barrel chest thorax
configuration results from a more fixed position of the ribs in the inspiratory
position and from loss of elasticity.
Diagnostic Procedures

Diagnosis and assessment of COPD must be done carefully since the three main
symptoms are common among chronic pulmonary disorders.
 Health history. The nurse should obtain a thorough health history from patients
with known or potential COPD.
 Pulmonary function studies. Pulmonary function studies are used to help
confirm the diagnosis of COPD, determine disease severity, and monitor disease
progression.
 Spirometry. Spirometry is used to evaluate airway obstruction, which is
determined by the ratio of FEV1 to forced vital capacity.
 ABG. Arterial blood gas measurement is used to assess baseline oxygenation
and gas exchange and is especially important in advanced COPD.
 Chest x-ray. A chest x-ray may be obtained to exclude alternative diagnoses.
 CT scan. Computed tomography chest scan may help in the differential
diagnosis.
 Screening for alpha1-antitrypsin deficiency. Screening can be performed for
patients younger than 45 years old and for those with a strong family history of
COPD.
 Chest x-ray: May reveal hyperinflation of lungs, flattened diaphragm, increased
retrosternal air space, decreased vascular markings/bullae (emphysema),
increased bronchovascular markings (bronchitis), normal findings during periods
of remission (asthma).
 Pulmonary function tests: Done to determine cause of dyspnea, whether
functional abnormality is obstructive or restrictive, to estimate degree of
dysfunction and to evaluate effects of therapy, e.g., bronchodilators. Exercise
pulmonary function studies may also be done to evaluate activity tolerance in
those with known pulmonary impairment/progression of disease.
 The forced expiratory volume over 1 second (FEV1): Reduced FEV1 not only is
the standard way of assessing the clinical course and degree of reversibility in
response to therapy, but also is an important predictor of prognosis.
 Total lung capacity (TLC), functional residual capacity (FRC), and residual
volume (RV): May be increased, indicating air-trapping. In obstructive lung
disease, the RV will make up the greater portion of the TLC.
  Arterial blood gases (ABGs): Determines degree and severity of disease
process, e.g., most often Pao2is decreased, and Paco2 is normal or increased in
chronic bronchitis and emphysema, but is often decreased in asthma; pH normal
or acidotic, mild respiratory alkalosis secondary to hyperventilation
(moderate emphysema or asthma).
 DL CO test: Assesses diffusion in lungs. Carbon monoxide is used to measure
gas diffusion across the alveocapillary membrane. Because carbon monoxide
combines with hemoglobin 200 times more easily than oxygen, it easily affects
the alveoli and small airways where gas exchange occurs. Emphysema is the
only obstructive disease that causes diffusion dysfunction.
 Bronchogram: Can show cylindrical dilation of bronchi on inspiration; bronchial
collapse on forced expiration (emphysema); enlarged mucous ducts (bronchitis).
 Lung scan: Perfusion/ventilation studies may be done to differentiate between
the various pulmonary diseases. COPD is characterized by a mismatch of
perfusion and ventilation (i.e., areas of abnormal ventilation in area of perfusion
defect).
 Complete blood count (CBC) and differential: Increased hemoglobin
(advanced emphysema), increased eosinophils (asthma).
 Blood chemistry: alpha1-antitrypsin is measured to verify deficiency and
diagnosis of primary emphysema.
 Sputum culture: Determines presence of infection, identifies pathogen.
 Cytologic examination: Rules out underlying malignancy or allergic disorder.
 Electrocardiogram (ECG): Right axis deviation, peaked P waves (severe
asthma); atrial dysrhythmias (bronchitis), tall, peaked P waves in leads II, III, AVF
(bronchitis, emphysema); vertical QRS axis (emphysema).
 Exercise ECG, stress test: Helps in assessing degree of pulmonary
dysfunction, evaluating effectiveness of bronchodilator therapy,
planning/evaluating exercise program.

Medical Management
Healthcare providers perform medical management by considering the assessment
data first and matching the appropriate intervention to the existing manifestation.
Pharmacologic Therapy
  Bronchodilators. Bronchodilators relieve bronchospasm by altering the
smooth muscle tone and reduce airway obstruction by allowing increased oxygen
distribution throughout the lungs and improving alveolar ventilation.
 Corticosteroids. A short trial course of oral corticosteroids may be prescribed
for patients to determine whether pulmonary function improves and symptoms
decrease.
 Other medications. Other pharmacologic treatments that may be used in COPD
include alpha1-antitrypsin augmentation therapy, antibiotic
agents, mucolytic agents, antitussive agents, vasodilators, and narcotics.
Management of Exacerbations
 Optimization of bronchodilator medications is first-line therapy and involves
identifying the best medications or combinations of medications taken on a
regular schedule for a specific patient.
 Hospitalization. Indications for hospitalization for acute exacerbation of COPD
include severe dyspnea that does not respond to initial therapy, confusion or
lethargy, respiratory muscle fatigue, paradoxical chest wall movement, and
peripheral edema.
 Oxygen therapy. Upon arrival of the patient in the emergency room,
supplemental oxygen therapy is administered and rapid assessment is performed
to determine if the exacerbation is life-threatening.
 Antibiotics. Antibiotics have been shown to be of some benefit to patients with
increased dyspnea, increased sputum production, and increased sputum
purulence.

Surgical Management
Patients with COPD also have options for surgery to improve their condition.
 Bullectomy. Bullectomy is a surgical option for select patients with bullous
emphysema and can help reduce dyspnea and improve lung function.
 Lung Volume Reduction Surgery. Lung volume reduction surgery is
a palliative surgery in patients with homogenous disease or disease that is
focused in one area and not widespread throughout the lungs.
 Lung Transplantation. Lung transplantation is a viable option for definitive
surgical treatment of end-stage emphysema.
Nursing Management

Management of patients with COPD should be incorporated with teaching and

improving the respiratory status of the patient.
Nursing Assessment
Assessment of the respiratory system should be done rapidly yet accurately.
 Assess patient’s exposure to risk factors.
 Assess the patient’s past and present medical history.
 Assess the signs and symptoms of COPD and their severity.
 Assess the patient’s knowledge of the disease.
 Assess the patient’s vital signs.
 Assess breath sounds and pattern.
Diagnosis
Diagnosis of COPD would mainly depend on the assessment data gathered by the
healthcare team members.
 Impaired gas exchange due to chronic inhalation of toxins.
 Ineffective airway clearance related to bronchoconstriction, increased mucus
production, ineffective cough, and other complications.
 Ineffective breathing pattern related to shortness of breath, mucus,
bronchoconstriction, and airway irritants.
 Self-care deficit related to fatigue.
 Activity intolerance related to hypoxemia and ineffective breathing patterns.
Planning & Goals
Main article: 5 Chronic Obstructive Pulmonary Disease (COPD) Nursing Care Plans
Goals to achieve in patients with COPD include:
 Improvement in gas exchange.
 Achievement of airway clearance.
 Improvement in breathing pattern.
 Independence in self-care activities.
  Improvement in activity intolerance.
 Ventilation/oxygenation adequate to meet self-care needs.
 Nutritional intake meeting caloric needs.
 Infection treated/prevented.
 Disease process/prognosis and therapeutic regimen understood.
 Plan in place to meet needs after discharge.
Nursing Priorities
1. Maintain airway patency.
2. Assist with measures to facilitate gas exchange.
3. Enhance nutritional intake.
4. Prevent complications, slow progression of condition.
5. Provide information about disease process/prognosis and treatment regimen.
Nursing Interventions
Patient and family teaching is an important nursing intervention to enhance self-
management in patients with any chronic pulmonary disorder.
To achieve airway clearance:
 The nurse must appropriately administer bronchodilators and corticosteroids and
become alert for potential side effects.
 Direct or controlled coughing. The nurse instructs the patient in direct or
controlled coughing, which is more effective and reduces fatigue associated with
undirected forceful coughing.
To improve breathing pattern:
 Inspiratory muscle training. This may help improve the breathing pattern.
 Diaphragmatic breathing. Diaphragmatic breathing reduces respiratory rate,
increases alveolar ventilation, and sometimes helps expel as much air as
possible during expiration.
 Pursed lip breathing. Pursed lip breathing helps slow expiration, prevents
collapse of small airways, and control the rate and depth of respiration.
To improve activity intolerance:
 Manage daily activities. Daily activities must be paced throughout the day and
support devices can be also used to decrease energy expenditure.
  Exercise training. Exercise training can help strengthen muscles of the upper
and lower extremities and improve exercise tolerance and endurance.
 Walking aids. Use of walking aids may be recommended to improve activity
levels and ambulation.
To monitor and manage potential complications:
 Monitor cognitive changes. The nurse should monitor for cognitive changes
such as personality and behavior changes and memory impairment.
 Monitor pulse oximetry values. Pulse oximetry values are used to assess the
patient’s need for oxygen and administer supplemental oxygen as prescribed.
 Prevent infection. The nurse should encourage the patient to be immunized
against influenza and S. pneumonia because the patient is prone to respiratory
infection.
Evaluation
During evaluation, the effectiveness of the care plan would be measured if goals were
achieved in the end and the patient:
 Identifies the hazards of cigarette smoking.
 Identifies resources for smoking cessation.
 Enrolls in smoking cessation program.
 Minimizes or eliminates exposures.
 Verbalizes the need for fluids.
 Is free of infection.
 Practices breathing techniques.
 Performs activities with less shortness of breath.

Chronic Bronchitis
Chronic bronchitis is a type of COPD (chronic obstructive pulmonary disease). COPD is
a group of lung diseases that make it hard to breathe and get worse over time. The
other main type of COPD is emphysema. Most people with COPD have both
emphysema and chronic bronchitis, but how severe each type is can be different from
person to person.
Chronic bronchitis is inflammation (swelling) and irritation of the bronchial tubes. These
tubes are the airways that carry air to and from the air sacs in your lungs. The irritation
of the tubes causes mucus to build up. This mucus and the swelling of the tubes make it
harder for your lungs to move oxygen in and carbon dioxide out of your body.

Signs & Symptoms

At first, you may have no symptoms or only mild symptoms. As the disease gets worse,
your symptoms usually become more severe. They can include
 Frequent coughing or a cough that produces a lot mucus
 Wheezing
 A whistling or squeaky sound when you breathe
 Shortness of breath, especially with physical activity
 Tightness in your chest
Some people with chronic bronchitis get frequent respiratory infections such
as colds and the flu. In severe cases, chronic bronchitis can cause weight loss,
weakness in your lower muscles, and swelling in your ankles, feet, or legs.

Causes
The cause of chronic bronchitis is usually long-term exposure to irritants that damage
your lungs and airways. In the United States, cigarette smoke is the main cause. Pipe,
cigar, and other types of tobacco smoke can also cause chronic bronchitis, especially if
you inhale them.

Exposure to other inhaled irritants can contribute to chronic bronchitis. These include
secondhand smoke, air pollution, and chemical fumes or dusts from the environment or
workplace.

Rarely, a genetic condition called alpha-1 antitrypsin deficiency can play a role in
causing chronic bronchitis.

Medical Management
There is no cure for chronic bronchitis. However, treatments can help with symptoms,
slow the progress of the disease, and improve your ability to stay active. There are also
treatments to prevent or treat complications of the disease. Treatments include
 Lifestyle changes, such as
 Quitting smoking if you are a smoker. This is the most important step you
can take to treat chronic bronchitis.
 Avoiding secondhand smoke and places where you might breathe in other
lung irritants
 Ask your health care provider for an eating plan that will meet your
nutritional needs. Also ask about how much physical activity you can do.
Physical activity can strengthen the muscles that help you breathe and
improve your overall wellness.
 Medicines, such as
 Bronchodilators, which relax the muscles around your airways. This helps
open your airways and makes breathing easier. Most bronchodilators are
taken through an inhaler. In more severe cases, the inhaler may also
contain steroids to reduce inflammation.
 Vaccines for the flu and pneumococcal pneumonia, since people with
chronic bronchitis are at higher risk for serious problems from these
diseases.
 Antibiotics if you get a bacterial or viral lung infection
 Oxygen therapy, if you have severe chronic bronchitis and low levels of oxygen
in your blood. Oxygen therapy can help you breathe better. You may need extra
oxygen all the time or only at certain times.
 Pulmonary rehabilitation, which is a program that helps improve the well-being
of people who have chronic breathing problems. It may include
 An exercise program
 Disease management training
 Nutritional counseling
 Psychological counseling
 A lung transplant, as a last resort for people who have severe symptoms that
have not gotten better with medicines
If you have chronic bronchitis, it's important to know when and where to get help for
your symptoms. You should get emergency care if you have severe symptoms, such as
trouble catching your breath or talking. Call your health care provider if your symptoms
are getting worse or if you have signs of an infection, such as a fever.

Medical Management

Healthcare providers perform medical management by considering the assessment

data first and matching the appropriate intervention to the existing manifestation.
Pharmacologic Therapy
 Bronchodilators. Bronchodilators relieve bronchospasm by altering the
smooth muscle tone and reduce airway obstruction by allowing increased oxygen
distribution throughout the lungs and improving alveolar ventilation.
 Corticosteroids. A short trial course of oral corticosteroids may be prescribed
for patients to determine whether pulmonary function improves and symptoms
decrease.
 Other medications. Other pharmacologic treatments that may be used in COPD
include alpha1-antitrypsin augmentation therapy, antibiotic
agents, mucolytic agents, antitussive agents, vasodilators, and narcotics.
Management of Exacerbations
 Optimization of bronchodilator medications is first-line therapy and involves
identifying the best medications or combinations of medications taken on a
regular schedule for a specific patient.
 Hospitalization. Indications for hospitalization for acute exacerbation of COPD
include severe dyspnea that does not respond to initial therapy, confusion or
lethargy, respiratory muscle fatigue, paradoxical chest wall movement, and
peripheral edema.
 Oxygen therapy. Upon arrival of the patient in the emergency room,
supplemental oxygen therapy is administered and rapid assessment is performed
to determine if the exacerbation is life-threatening.
 Antibiotics. Antibiotics have been shown to be of some benefit to patients with
increased dyspnea, increased sputum production, and increased sputum
purulence.
Surgical Management

Patients with COPD also have options for surgery to improve their condition.
  Bullectomy. Bullectomy is a surgical option for select patients with bullous
emphysema and can help reduce dyspnea and improve lung function.
 Lung Volume Reduction Surgery. Lung volume reduction surgery is
a palliative surgery in patients with homogenous disease or disease that is
focused in one area and not widespread throughout the lungs.
 Lung Transplantation. Lung transplantation is a viable option for definitive
surgical treatment of end-stage emphysema.

Nursing Management

Management of patients with COPD should be incorporated with teaching and

improving the respiratory status of the patient.
Nursing Assessment
Assessment of the respiratory system should be done rapidly yet accurately.
 Assess patient’s exposure to risk factors.
 Assess the patient’s past and present medical history.
 Assess the signs and symptoms of COPD and their severity.
 Assess the patient’s knowledge of the disease.
 Assess the patient’s vital signs.
 Assess breath sounds and pattern.

Nursing Interventions
Patient and family teaching is an important nursing intervention to enhance self-
management in patients with any chronic pulmonary disorder.
To achieve airway clearance:
 The nurse must appropriately administer bronchodilators and corticosteroids and
become alert for potential side effects.
 Direct or controlled coughing. The nurse instructs the patient in direct or
controlled coughing, which is more effective and reduces fatigue associated with
undirected forceful coughing.
To improve breathing pattern:
  Inspiratory muscle training. This may help improve the breathing pattern.
 Diaphragmatic breathing. Diaphragmatic breathing reduces respiratory rate,
increases alveolar ventilation, and sometimes helps expel as much air as
possible during expiration.
 Pursed lip breathing. Pursed lip breathing helps slow expiration, prevents
collapse of small airways, and control the rate and depth of respiration.
To improve activity intolerance:
 Manage daily activities. Daily activities must be paced throughout the day and
support devices can be also used to decrease energy expenditure.
 Exercise training. Exercise training can help strengthen muscles of the upper
and lower extremities and improve exercise tolerance and endurance.
 Walking aids. Use of walking aids may be recommended to improve activity
levels and ambulation.
To monitor and manage potential complications:
 Monitor cognitive changes. The nurse should monitor for cognitive changes
such as personality and behavior changes and memory impairment.
 Monitor pulse oximetry values. Pulse oximetry values are used to assess the
patient’s need for oxygen and administer supplemental oxygen as prescribed.
 Prevent infection. The nurse should encourage the patient to be iunized
against influenza and S. pneumonia because the patient is prone to respiratory
infection.

Emphysema
 Emphysema is the enlargement and destruction of the alveolar, bronchial, and
bronchiolar tissue with resultant loss of recoil, air trapping, thoracic
overdistention, sputum accumulation, and loss of diaphragmatic muscle tone.
 These changes cause a state of carbon dioxide retention,hypoxia, and
respiratory acidosis.

Causes
The actual cause of emphysema is unknown. Risk factors for the development of
emphysema include cigarette smoking, living or working in a highly polluted area, and a
family history of pulmonary disease. Frequent childhood pulmonary infections have
been identified as a cause of bronchiectasis
Signs & Symptoms
You can have emphysema for many years without noticing any signs or symptoms. The main
symptom of emphysema is shortness of breath, which usually begins gradually.

You may start avoiding activities that cause you to be short of breath, so the symptom
doesn't become a problem until it starts interfering with daily tasks. Emphysema
eventually causes shortness of breath even while you're at rest.

Causes
The main cause of emphysema is long-term exposure to airborne irritants, including:
 Tobacco smoke
 Marijuana smoke
 Air pollution
 Chemical fumes and dust
Rarely, emphysema is caused by an inherited deficiency of a protein that protects the
elastic structures in the lungs. It's called alpha-1-antitrypsin deficiency emphysema.

Diagnostic Procedures
Imaging tests
A chest X-ray can help support a diagnosis of advanced emphysema and rule out other
causes of shortness of breath. But the chest X-ray can also show normal findings if you
have emphysema.
Computerized tomography (CT) scans combine X-ray images taken from many different
directions to create cross-sectional views of internal organs. CT scans can be useful for
detecting and diagnosing emphysema. You may also have a CT scan if you're a
candidate for lung surgery.
Lab tests
Blood taken from an artery in your wrist can be tested to determine how well your lungs
transfer oxygen into, and remove carbon dioxide from, your bloodstream.
Lung function tests
These noninvasive tests measure how much air your lungs can hold and how well the
air flows in and out of your lungs. They can also measure how well your lungs deliver
oxygen to your bloodstream. One of the most common tests uses a simple instrument
called a spirometer, which you blow into.
Medical Management
Emphysema and COPD can't be cured, but treatments can help relieve symptoms and
slow the progression of the disease.
Medications
Depending upon the severity of your symptoms, your doctor might suggest:
 Bronchodilators. These drugs can help relieve coughing, shortness of breath
and breathing problems by relaxing constricted airways.
 Inhaled steroids. Corticosteroid drugs inhaled as aerosol sprays reduce
inflammation and may help relieve shortness of breath.
 Antibiotics. If you have a bacterial infection, like acute bronchitis or pneumonia,
antibiotics are appropriate.
Therapy
 Pulmonary rehabilitation. A pulmonary rehabilitation program can teach you
breathing exercises and techniques that may help reduce your breathlessness
and improve your ability to exercise.
 Nutrition therapy. You'll also receive advice about proper nutrition. In the early
stages of emphysema, many people need to lose weight, while people with late-
stage emphysema often need to gain weight.
 Supplemental oxygen. If you have severe emphysema with low blood oxygen
levels, using oxygen regularly at home and when you exercise may provide some
relief. Many people use oxygen 24 hours a day. It's usually administered via
narrow tubing that fits into your nostrils.
Surgery
Depending on the severity of your emphysema, your doctor may suggest one or more
different types of surgery, including:
 Lung volume reduction surgery. In this procedure, surgeons remove small
wedges of damaged lung tissue. Removing the diseased tissue helps the
remaining lung tissue expand and work more efficiently and helps improve
breathing.
 Lung transplant. Lung transplantation is an option if you have severe lung
damage and other options have failed.
Nursing Management

 Maintaining a patent airway is a priority. Use a humidifier at night to help the

patient mobilize secretions in the morning.
 Encourage the patient to use controlled coughing to clear secretions that might
have collected in the lungs during sleep.
 Instruct the patient to sit at the bedside or in a comfortable chair, hug a pillow,
bend the head downward a little, take several deep breaths, and cough strongly.
 Place patients who are experiencing dyspnea in a high Fowler position to
improve lung expansion. Placing pillows on the overhead table and having the
patient lean over in the orthopneic position may also be helpful. Teach the patient
pursed-lip and diaphragmatic breathing.
 To avoid infection, screen visitors for contagious diseases and instruct the patient
to avoid crowds.
 Conserve the patient’s energy in every possible way. Plan activities to allow for
rest periods, eliminating nonessential procedures until the patient is stronger. It
may be necessary to assist with the activities of daily living and to anticipate the
patient’s needs by having supplies within easy reach.
 Refer the patient to a pulmonary rehabilitation program if one is available in the
community.
 Patient education is vital to long-term management. Teach the patient about the
disease and its implications for lifestyle changes, such as avoidance of cigarette
smoke and other irritants, activity alterations, and any necessary occupational
changes. Provide information to the patient and family about medications and
equipment.

Asthma
Asthma is a condition in which your airways narrow and swell and may produce extra mucus.
This can make breathing difficult and trigger coughing, a whistling sound (wheezing) when you
breathe out and shortness of breath.
For some people, asthma is a minor nuisance. For others, it can be a major problem that
interferes with daily activities and may lead to a life-threatening asthma attack.
Asthma can't be cured, but its symptoms can be controlled. Because asthma often changes
over time, it's important that you work with your doctor to track your signs and symptoms and
adjust your treatment as needed.

Signs & Symptoms of Asthma

 Most common symptoms of asthma are cough (with or without mucus production),
dyspnea, and wheezing (first on expiration, then possibly during inspiration as well).
 Cough. There are instances that cough is the only symptom.
 Dyspnea. General tightness may occur which leads to dyspnea.
 Wheezing. There may be wheezing, first on expiration, and then possibly during
inspiration as well.
 Asthma attacks frequently occur at night or in the early morning.
 An asthma exacerbation is frequently preceded by increasing symptoms over days, but it
may begin abruptly.
 Expiration requires effort and becomes prolonged.
 As exacerbation progresses, central cyanosis secondary to severe hypoxia may occur.
 Additional symptoms, such as diaphoresis, tachycardia, and a widened pulse pressure,
may occur.
 Exercise-induced asthma: maximal symptoms during exercise, absence of nocturnal
symptoms, and sometimes only a description of a “choking” sensation during exercise.
 A severe, continuous reaction, status asthmaticus, may occur. It is life-threatening.
 Eczema, rashes, and temporary edema are allergic reactions that may be noted with
asthma.
 Prevention
 Patients with recurrent asthma should undergo tests to identify the substances that
precipitate the symptoms.

 Allergens. Allergens, either seasonal or perennial, can be prevented through avoiding

contact with them whenever possible.
 Knowledge. Knowledge is the key to quality asthma care.
 Evaluation. Evaluation of impairment and risk are key in the control.
Causes of asthma

The fundamental causes of asthma are not completely understood. The strongest risk
factors for developing asthma are a combination of genetic predisposition with
environmental exposure to inhaled substances and particles that may provoke allergic
reactions or irritate the airways, such as:

 indoor allergens (for example house dust mites in bedding, carpets and stuffed furniture,
pollution and pet dander)
 outdoor allergens (such as pollens and moulds)
 tobacco smoke
 chemical irritants in the workplace
 air pollution
 Other triggers can include cold air, extreme emotional arousal such as anger or fear, and
physical exercise. Even certain medications can trigger asthma: aspirin and other non-
steroid anti-inflammatory drugs, and beta-blockers (which are used to treat high blood
pressure, heart conditions and migraine).

Urbanization has been associated with an increase in asthma. But the exact nature of
this relationship is unclear.
Medical Management
Immediate intervention may be necessary, because continuing and progressive dyspnea leads
to increased anxiety, aggravating the situation.

Pharmacologic Therapy
 Short-acting beta2 –adrenergic agonists. These are the medications of choice
for relief of acute symptoms and prevention of exercise-induced asthma.
 Anticholinergics. Anticholinergics inhibit muscarinic cholinergic receptors and
reduce intrinsic vagal tone of the airway.
 Corticosteroids. Corticosteroids are most effective in alleviating symptoms,
improving airway function, and decreasing peak flow variability.
 Leukotriene modifiers. Anti Leukotrienes are potent bronchoconstrictors that
also dilate blood vessels and alter permeability.
 Immunomodulators. Prevent binding of IgE to the high affinity receptors of
basophils and mast cells.

Peak Flow Monitoring

Peak Flow Meter
 Peak flow meters. Peak flow meters measure the highest airflow during a forced
expiration.
 Daily peak flow monitoring. This is recommended for patients who meet one or
more of the following criteria: have moderate or severe persistent asthma, have
poor perception of changes in airflow or worsening symptoms, have unexplained
response to environmental or occupational exposures, or at the discretion of the
clinician or patient.
 Function. If peak flow monitoring is used, it helps measure asthma severity and,
when added to symptom monitoring, indicates the current degree of asthma
control.

Nursing Management
The immediate care of patients with asthma depend on the severity of the symptoms.

Nursing Assessment
Assessment of a patient with asthma includes the following:
 Assess the patient’s respiratory status by monitoring the severity of the symptoms.
 Assess for breath sounds.
 Assess the patient’s peak flow.
 Assess the level of oxygen saturation through the pulse oximeter.
 Monitor the patient’s vital signs.
Nursing Diagnosis
Based on the data gathered, the nursing diagnoses appropriate for the patient with asthma
include:
 Ineffective airway clearance related to increased production of mucus and
bronchospasm.
 Impaired gas exchange related to altered delivery of inspired O2.
 Anxiety related to perceived threat of death.

Nursing Care Planning & Goals

To achieve success in the treatment of a patient with asthma, the following goals should be
applied:
 Maintenance of airway patency.
 Expectoration of secretions.
 Demonstration of absence/reduction of congestion with breath sounds clear, respirations
noiseless, improved oxygen exchange.
 Verbalization of understanding of causes and therapeutic management regimen.
 Demonstration of behaviors to improve or maintain clear airway.
 Identification of potential complications and how to initiate appropriate preventive or
corrective actions.

Nursing Interventions
The nurse generally performs the following interventions:

 Assess history. Obtain a history of allergic reactions to medications before administering

medications.
 Assess respiratory status. Assess the patient’s respiratory status by monitoring the
severity of symptoms, breath sounds, peak flow, pulse oximetry, and vital signs.
 Assess medications. Identify medications that the patient is currently taking. Administer
medications as prescribed and monitor the patient’s responses to those medications;
medications may include an antibiotic if the patient has an underlying respiratory
infection.
 Pharmacologic therapy. Administer medications as prescribed and monitor patient’s
responses to medications.
 Fluid therapy. Administer fluids if the patient is dehydrated.

Evaluation
To determine the effectiveness of the plan of care, evaluation must be performed. The following
must be evaluated:

 Maintenance of airway patency.

 Expectoration or clearance of secretions.
  Absence /reduction of congestion with breath sound clear, noiseless respirations, and
improved oxygen exchange.
 Verbalized understanding of causes and therapeutic management regimen.
 Demonstrated behaviors to improve or maintain clear airway.
 Identified potential complications and how to initiate appropriate preventive or corrective
actions.

Status Asthmaticus
 Status asthmaticus is severe and persistent asthma that does not respond to
conventional therapy; attacks can occur with little or no warning and can
progress rapidly to asphyxiation.
 Infection, anxiety, nebulizer abuse, dehydration, increased adrenergic blockage,
and nonspecific irritants may contribute to these episodes.
 An acute episode may be precipitated by hypersensitivity to aspirin.
 Two predominant pathologic problems occur: a decrease in bronchial diameter
and a ventilation–perfusion abnormality.

Manifestations
 Wheezing
 Labored breathing
 Prolonged exhalation
 Neck engorgement

Diagnostic Procedures
 Primarily pulmonary function studies and ABG analysis
 Respiratory alkalosis most common finding

Medical Management
 Initial treatment: beta-2-adrenergic agonists, corticosteroids, supplemental
oxygen and IV fluids to hydrate patient. Sedatives are contraindicated.
 Highflow supplemental oxygen is best delivered using a partial or complete
nonrebreather mask (PaO2 at a minimum of 92 mm Hg or O2 saturation greater
than 95%).
  Magnesium sulfate, a calcium antagonist, may be administered to induce smooth
muscle relaxation.
 Hospitalization if no response to repeated treatments or if blood gas levels
deteriorate or pulmonary function scores are low.
 Mechanical ventilation if patient is tiring or in respiratory failure or if condition
does not respond to treatment.

Nursing Management
The main focus of nursing management is to actively assess the airway and the
patient’s response to treatment. The nurse should be prepared for the next intervention
if the patient does not respond to treatment.
 Constantly monitor the patient for the first 12 to 24 hours, or until status
asthmaticus is under control. Blood pressure and cardiac rhythm should be
monitored continuously during the acute phase and until the patient stabilizes
and responds to therapy.
 Assess the patient’s skin turgor for signs of dehydration; fluid intake is essential
to combat dehydration, to loosen secretions, and to facilitate expectoration.
 Administer IV fluids as prescribed, up to 3 to 4 L/day, unless contraindicated.
 Encourage the patient to conserve energy.
 Ensure patient’s room is quiet and free of respiratory irritants (eg, flowers,
tobacco smoke, perfumes, or odors of cleaning agents); nonallergenic pillows
should be used.

Cystic Fibrosis
 Cystic fibrosis (CF) is a disease of exocrine gland function that involves multiple
organ systems but chiefly results in chronic respiratory infections, pancreatic
enzyme insufficiency, and associated complications in untreated patients.
 Cystic fibrosis is an autosomal recessive disorder, and most carriers of the gene
are asymptomatic.
 Pulmonary involvement occurs in 90% of patients surviving the neonatal period.
 End-stage lung disease is the principal cause of death.
Clinical Manifestations

The age at diagnosis varies widely, however, as do the clinical presentation, severity of
symptoms, and rate of disease progression in the organs involved. Clinical
manifestations vary with the patient’s age at presentation.
 Meconium ileus. Meconium ileus is the presenting symptom of CF in 5% to 10%
of the newborns who later develop additional manifestations.
 Absence of pancreatic enzymes. Depletion or absence of pancreatic enzymes
before birth results in impaired digestive activity, and the meconium becomes
viscid (thick) and mucilaginous (sticky).
 Intestinal obstruction. Bile-stained emesis may result from obstruction of the
intestines, as well as a distended abdomen, and an absence of stool.
 Chronic cough. A hard, nonproductive chronic cough may be the first sign, and
it may later become frequent bronchial infections.
 Lack of oxygen. Development of a barrel chest and clubbing of fingers indicate
chronic lack of oxygen.
 Pancreatic insufficiency. Patients with pancreatic insufficiency have fat-soluble
vitamin deficiency and malabsorption of fats, proteins, and carbohydrates
(however, malabsorption of carbohydrates is not as severe as that of fats and
proteins); patients present with failure to thrive (despite an adequate appetite),
flatulence or foul-smelling flatus, recurrent abdominal pain, and abdominal
distention.
 Steatorrhea. Malabsorption results in steatorrhea, characterized by frequent,
poorly formed, large, bulky, foul-smelling, greasy stools that float in water.
 High electrolyte concentrations. The tears, saliva, and sweat of children with
CF contain abnormally high concentrations of electrolytes, and most such
children have enlarged submaxillary salivary glands.
 Sterility. Males with CF who reach adulthood will most likely be sterile because
of the blockage or absence of the vas deferens or other ducts; females often
have thick cervical secretions that prohibit the passage of sperm.

Causes
Cystic fibrosis is an autosomal recessive disease caused by defects in the CFTR gene,
which encodes for a protein that functions as a chloride channel, and also regulates the
flow of other ions across the apical surface of epithelial cells.
  CFTR mutations. CFTR mutations result in abnormalities of cAMP-regulated
chloride transport across epithelial cells on mucosal surfaces; the failure of
chloride conductance by epithelial cells and associated water transport
abnormalities result in viscid secretions in the respiratory tract, pancreas, GI
tract, sweat glands, and other exocrine tissues.
 Environmental factors. The incomplete correlation of genotype with phenotype
suggests either an environmental component of organ dysfunction or modifying
genes that are only recently being characterized; the role of modifier genes is
supported by the fact that neonates with cystic fibrosis who have intestinal
obstruction most commonly have abnormalities in 2 or more CFTR modifier
genes; in contrast, older children develop obstruction mostly as a result of
environmental factors, such as introduction of pancreatic enzymes causing a
stricture.

Assessment and Diagnostic Findings

The diagnosis of cystic fibrosis (CF) is based on typical pulmonary manifestations, GI
tract manifestations, a family history, and positive sweat test results.
 Noninvasive CFTR analysis. Noninvasive CFTR analysis involves a technique
for recovering DNA from cells obtained by buccal brushing; this technique can be
used to determine the carrier status of the parents of a fetus with suspected CF
based on sonographic findings of meconium ileus.
 Restriction fragment length polymorphism (RFLP) analysis. When only one
or neither parent has an identified CF mutation but the couple has a previous
child with CF, the status of the fetus can be predicted by restriction fragment
length polymorphism (RFLP) analysis; genetic material from both parents, the
affected sibling, and the fetus must be available for RFLP testing.
 Newborn screening. Newborn screening for CF is universally required in the
United States.
 Sweat chloride test. The principal diagnostic test to confirm CF is a sweat
chloride test using the pilocarpine iontophoresis method to collect sweat and
perform a chemical analysis of its chloride content is currently considered to be
the only adequately sensitive and specific type of sweat test.
 Radiography. On chest radiography, initial changes are hyperinflation and
peribronchial thickening. Progressive air trapping with bronchiectasis may be
apparent in the upper lobes.
 Genotyping. Genotype testing is recommended for individuals with a positive
family history and for couples planning a pregnancy.
Medical Management
As a result of the complex and multisystemic involvement of cystic fibrosis (CF) and the
need for care by specialists, treatment and follow-up care at specialty centers with
multidisciplinary care teams (ie, cystic fibrosis centers) is recommended.
 Diet. In general, a normal diet with additional energy and unrestricted fat intake is
recommended; a high-energy and high-fat diet, in addition to supplemental
vitamins (especially fat soluble) and minerals, is recommended to compensate
for malabsorption and the increased energy demand of chronic inflammation.
 Exercise. Regular exercise increases physical fitness in patients with cystic
fibrosis; upper body exercises, such as canoe paddling, may increase
respiratory muscle endurance.
 Monitoring. Patients are monitored in the CF clinic every 2-3 months to achieve
maintenance of growth and development, maintenance of as nearly normal lung
function as possible, intervention and retardation of the progression of lung
disease, clinical assessment to monitor gastrointestinal tract involvement, and
monitoring for complications and their treatment .
 Vaccines. Routine vaccinations are indicated in patients with cystic fibrosis,
including seasonal influenza vaccination.

Pharmacologic Management
Medications used to treat patients with cystic fibrosis may include pancreatic enzyme
supplements, multivitamins (particularly fat-soluble
vitamins), mucolytics, antibiotics (including inhaled, oral, or parenteral), bronchodilators,
anti-inflammatory agents, and CFTR potentiators.
 Pancreatic enzymes. These agents aid digestion when the pancreas is
malfunctioning; current pancreatic enzyme preparations are derived from porcine
extracts and contain various proportions of lipase, amylase, and protease.
 Vitamins. Vitamins are organic substances required by the body in small
amounts for various metabolic processes; they may be synthesized in small or
insufficient amounts in the body or not synthesized at all, thus requiring
supplementation; vitamins A, D, E, and K are fat soluble while biotin, folic acid,
niacin, pantothenic acid, B vitamins (ie, B-1, B-2, B-6, B-12), and vitamin C are
generally water soluble.
 Bronchodilators. In children with CF, the use of bronchodilators must be
evaluated; children with bronchiectasis may have a paradoxic bronchodilatation
 in response to beta-adrenergic agents; pulmonary function testing before and
after bronchodilators is suggested to avoid these counterproductive effects.
 Mucolytics. Mucolytics, such as dornase alfa, an enzyme that hydrolyses the
DNA, are used in patients with CF to improve airway clearance.
 Cystic fibrosis transmembrane conductance regulator (CFTR). Cystic
fibrosis transmembrane conductance regulator (CFTR) potentiators are the first
available treatment that targets the defective CFTR protein, which is the
underlying cause of cystic fibrosis.
 Antibiotics. Antibiotic therapy has been found to be related to the greater
likelihood of recovery after acute decline in FEV1.

Nursing Management
Management of a child with cystic fibrosis should be holistic and meticulous.
Nursing Assessment
The collection of data on the child with CF varies depending on the child’s age and the
circumstances of the admission.
 Interview the caregivers. Conduct a complete parent interview that includes the
standard information, as well as data concerning respiratory infections, the child’s
appetite and eating habits, stools, noticeable salty perspiration, history of bowel
obstruction as an infant, and family history for CF, if known.
 Assess caregiver’s knowledge. Also determine the caregiver’s knowledge of
the condition.
 Assess vital signs. When collecting data about vital signs, include observation
of respirations, such as cough, breath sounds, and barrel chest, and signs of
pancreatic involvement.
 Assess skin condition. Examine skin around the rectum for irritation and
breakdown from frequent foul stools.
Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses are:
 Ineffective airway clearance related to thick, tenacious mucus production.
 Ineffective breathing pattern related to tracheobronchial obstruction.
 Risk for infection related to bacterial growth medium provided by pulmonary
mucus and impaired body defenses.
  Imbalanced nutrition:less than body requirements related to impaired
absorption of nutrients.
 Anxiety related to hospitalization.
 Compromised family coping related to child’s chronic illness and its demands
on caregivers.
 Deficient knowledge of the caregiver related to illness, treatment, and home
care.
Nursing Care Planning and Goals
Main Article: 5 Cystic Fibrosis Nursing Care Plans
The major goals for the child include:
 Relieving immediate respiratory distress.
 Maintaining adequate oxygenation.
 Remaining free from infection.
 Improving nutritional status.
 Relieving anxiety.
Nursing Interventions
Implementation of the following goals include these interventions:
 Improve airway clearance. Monitor the child for signs of respiratory distress;
teach the child to cough effectively; examine and document the mucus produced;
increase fluid intake; and encourage the child to drink extra fluids.
 Improve breathing. Maintain the child in a semi-Fowler’s position; use pulse
oximetry; maintain oxygen saturation higher than 90%; administer oxygen as
ordered; administer mouth care every 2 to 4 hours; perform chest physiotherapy
every 2 to 4 hours as ordered; plan nursing and therapeutic activities and
diversional activities; and teach them to exercise to help loosen the thick mucus.
 Prevent infection. Good handwashing techniques should be practiced by all;
practice and teach other good hygiene habits; monitor vital signs every 4 hours;
restrict people with an infection from contact with the child; and administer
antibiotics as prescribed.
 Maintain adequate nutrition. Greatly increase the child’s caloric intake; provide
the child with high-calorie, high protein snacks, such as peanut butter and
cheese; administer pancreatic enzymes with all meals and snacks; encourage
 the child to eat salty snacks; report any changes in bowel movements; and weigh
and measure the child.
 Reducing the child’s anxiety. Provide age-appropriate activities to help
alleviate anxiety and boredom; encourage the family caregiver to stay with the
child; allow the child to have familiar toys or mementos from home.
 Provide family support. Give the family and the child opportunities to voice
fears and anxiety; respond with active listening techniques; and provide
emotional support throughout the entire hospital stay.
Evaluation
Goals are met as evidenced by:
 Relief of immediate respiratory distress.
 Maintainance of adequate oxygenation.
 Freedom from infection.
 Improvement of nutritional status.
 Relief of anxiety.