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PHYSIOLOGICAL BASIS OF THE CARE OF THE ELDERLY

CLIENTRespiratory System

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Patient Scenario D.A. is a 78 year old male who states he

cannot get rid of his “cold” He has a productive cough Sputum is white to grey He has a 31 pack year smoking history He uses Albuterol inhaler up to 6 times

per day

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Informal evaluationWhat additional information do you

need?

Subjective information Objective information Psychosocial information

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Anatomy of the lungs

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Performance of respiration Controlled by respiratory muscles of the

thorax Diaphragm Intercostal muscles

Coordinated by respiratory centers of the brain and carotid arteries

Respiratory centers respond to changes in: Blood levels of oxygen Carbon dioxide Blood pH

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Age related changes of the respiratory system

Stiffening of connective tissue of lungs Alteration in alveolar shape → increased

alveolar diameter Decreased alveolar

surface area Increased chest

wall stiffness Stiffening of the

diaphragm

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Consequences of age-related changes

Increased residual volume Decreased vital capacity Premature airway closure → air trapping

in lower airways

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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

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Measurement of oxygenation

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Lung volumes and capacities

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PFT results are based on predicted values

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Arterial blood gases

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Overlapping symptoms Pulmonary embolism? GERD? Obstruction? ACEi cough? Vocal cord dysfunction?

Asthma

Chronic bronchitisCOPD

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Commonalities within lung diseases

Symptom Asthma Chronic bronchitis

COPD Heart Failure

Wheezing Chest tightness Chronic productive cough

Maybe

Nocturnal dyspnea Smoking history Maybe

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Asthma Airway inflammation Increased mucous secretion production Increased airway

responsiveness/sensitivity Reversible airflow obstruction (usually) Eventually causes irreversible

damage and scarring Often overlooked in the

older client

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The asthmatic lung

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Symptoms of asthma Coughing Wheezing Shortness of breath Chest tightness Nocturnal dyspnea between 0400-0600

CHF nocturnal dyspnea occurs 1-2 hours after retiring

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Classifications of asthmaMild Intermittent

Mild Persistent

Moderate Persistent

Severe Persistent

□ Sx ≤ 2 days per week

□ Sx ≤ 2 nights per week

□ Sx > 1 times per week but < once per day

□ Nighttime sx > twice per month

□ Symptoms daily

□ Nighttime sx > one night per week

□ Continuous daily symptoms

□ Frequent nighttime symptoms

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Goals of asthma therapy Prevent symptoms that interfere with

quality of life Prevent exacerbations of asthma 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

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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

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Stepwise approach to managing asthma

Step 3 Preferred: Low dose ICS + LABA or medium

dose ICS Example LABA: Advair

Step 4 Preferred: Medium dose ICS + LABA

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Stepwise approach to managing asthma

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

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Stepwise approach to managing asthma

At each step…

Patient education Environmental control Step up if needed Step down if possible and

if asthma is well controlled for at least 3 months

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Use of inhalers Refer to video link in syllabus Spacers are useful for

the elderly who have difficulty with coordination and timing (refer to link)

Encourage to rinse with warm water and expectorate (“swish and spit ”) to minimize candidiasis, gum disease, tooth decay

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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

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Use of peak flow meter Measures movement of air out of lungs Helps patient antici- pate asthmatic episode Patient finds best peak flow number

Every day for 2 weeks On waking and between 1200-1400 Before inhaled β-agonist

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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

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Chronic obstructive pulmonary disease

COPD

Chronic bronchitis

Emphysema

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Criteria for chronic bronchitis

Cough and sputum production on most days

Minimum of 3 months for at least 2 successive years, or,

For 6 months during 1 year

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A note on acute bronchitis…

Acute inflammation of the bronchi Usually self-limiting Viral Similar to pneumonia: productive cough,

chills, lethargy, low grade fever Negative chest xray Treatment: rest, humidification, cough

suppressants, acetaminophen

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Criteria for emphysema Permanent destruction of the alveoli Collapse/narrowing of

bronchioles Usually in older adults with long smoking history

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Chronic bronchitis Emphysema

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Blue bloater COPD with chronic bronchitis Increased mucous production Normal to decreased lung capacity Increased residual lung volume with air

trapping Cyanosis and right heart failure Body responds by decreasing ventilation

and increasing cardiac output

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Blue bloater

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Pink puffer COPD with severe emphysema Pink complexion Dyspnea Increased residual lung capacity Decreased elastic recoil High tidal volume Destruction of capillary bed Body compensates for destruction of

pulmonary capillary bed by hyperventilation Retractions

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Pink puffer

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Effect of smoking and smoking cessation

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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

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Medications for COPD Bronchodilators Inhaled corticosteroids Antibiotics Flu vaccine annually Pneumococcal vaccine at age 65 Exercise training Mucolytics and expectorants (e.g.,

Mucomyst, Guaifenesin)

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Treatment of end-stage COPD

Continuous oxygen administration—low flow

Postural drainage Chest percussion Controlled coughing Tracheal suctioning

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Low flow oxygen in COPD Normal stimulus to breathe is rise in CO2

level In COPD, stimulus to breathe is a

decrease in O2 level Oxygen flow that is too high will minimize

or eliminate the stimulus to breathe in a COPD patient CO2

O2

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Tuberculosis in the elderly Elderly the most vulnerable Drug resistant forms prevalent Vulnerability enhanced by multiple risk

factors: Living in an institution, homeless Exposure to drug-resistant form Previous infection Diabetes Use of immunosuppresive drugs (including

corticosteroids) Malnutrition Renal failure

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Treatment of tuberculosis Isoniazid—prevent active disease once

infected Rifampin Side effects can be significant Interrupting treatment can create drug

resistant form

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Lung cancer in the elderly More common in the young-old Initial symptoms are vague and mimic

other pulmonary illnesses Chest xray initial diagnostic test Older, debilitated patients may not be

surgical candidates Chemotherapy Radiation Palliative care

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Respiratory infections: risk factors

History nosocomial pneumonia COPD Recent hospitalization, insitutionalization Smoking Hyperglycemia Use of immunosuppressants and/or

antibiotics and/or oxygen therapy Recent antibiotic use Eating dependency

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Pneumonia symptoms in the elderly

Cough Fever Sputum production Prodromal headache, myalgia, lethargy Changes in behavior and mental

status New onset tachycardia and tachypnea Change in function

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Pneumonia

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Pulmonary embolism risk factors

Clotting disorders Immobility Dehydration Recent surgery Atrial fibrillation Obesity

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Symptoms of pulmonary embolism

Sudden onset Tachypnea Dyspnea Chest pain Hypoxia Hypotension Possible shock

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Recommended vaccinations

Flu vaccination every year Pneumonia vaccination once if given after

the age of 65 Revaccinate in 5 years once only if first

vaccination given before the age of 65

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Formal evaluation What is your nursing

diagnosis for RB? What is your desired

outcome? What are appropriate

interventions pertinent to your desired outcome?