WEST COAST UNIVERSITY NUR 121

WEST COAST UNIVERSITYNUR 121

Respiratory System Disorders

The Respiratory System

The Respiratory System is crucial to every human being. Without it, we would cease to live outside of the womb.

The organs of the respiratory system make sure that oxygen enters our bodies and carbon dioxide leaves our bodies.

It is divided into two sections: Upper Respiratory Tract and the Lower Respiratory Tract.

Included in the upper respiratory tract are the Nostrils, Nasal Cavities, Pharynx, Epiglottis, and the Larynx.

The lower respiratory tract consists of the Trachea, Bronchi, Bronchioles, and the Lungs.

As air moves along the respiratory tract it is warmed, moistened and filtered.

The Respiratory System

Functions - BREATHING or ventilation - EXTERNAL RESPIRATION, which is the exchange of gases

(oxygen and carbon dioxide) between inhaled air and the blood.

- INTERNAL RESPIRATION, which is the exchange of gases between the blood and tissue fluids.

- CELLULAR RESPIRATION In addition to these main processes, the respiratory system

serves for: - REGULATION OF BLOOD pH, which occurs in coordination

with the kidneys, and as a- DEFENSE AGAINST MICROBES - Control of body temperature due to loss of evaporate

during expiration

Respiratory System Anatomy and Physiology

Breathing and Lung Mechanics

Ventilation is the exchange of air between the external environment and the alveoli.

The body changes the pressure in the alveoli by changing the volume of the lungs. As volume increases pressure decreases and as volume decreases pressure increases.

There are two phases of ventilation; inspiration and expiration.

Each lung is completely enclosed in a sac called the pleural sac.

The intrapleural fluid completely surrounds the lungs and lubricates the two surfaces so that they can slide across each other.

The rhythm of ventilation is also controlled by the "Respiratory Center" which is located largely in the medulla oblongata of the brain stem. T

This is part of the autonomic system and as such is not controlled voluntarily (one can increase or decrease breathing rate voluntarily, but that involves a different part of the brain).

While resting, the respiratory center sends out action potentials that travel along the phrenic nerves into the diaphragm and the external intercostal muscles of the rib cage, causing inhalation.

Relaxed exhalation occurs between impulses when the muscles relax. Normal adults have a breathing rate of 12-20 respirations per minute.

When one breathes air in at sea level, the inhalation is composed of different gases. These gases and their quantities are Oxygen which makes up 21%, Nitrogen which is 78%, Carbon Dioxide with 0.04% and others with significantly smaller portions.

Air enters into the nasal cavity through the nostrils and is filtered by coarse hairs (vibrissae).

Dust, pollen, smoke, and fine particles are trapped in the mucous that lines the nasal cavities

The Pathway of Air

Air then travels past the nasopharynx, oropharynx, and laryngopharynx, which are the three portions that make up the pharynx.

The pharynx is a funnel-shaped tube that connects our nasal and oral cavities to the larynx.

The tonsils which are part of the lymphatic system, form a ring at the connection of the oral cavity and the pharynx. Here, they protect against foreign invasion of antigens. Therefore the respiratory tract aids the immune system through this protection.

Then the air travels through the larynx.

The larynx closes at the epiglottis to prevent the passage of food or drink as a protection to our trachea and lungs.

The larynx is also our voicebox; it contains vocal cords, in which it produces sound. Sound is produced from the vibration of the vocal cords when air passes through them.

The Pathway of Air

Inspiration

Inspiration is initiated by contraction of the diaphragm and in some cases the intercostals muscles when they receive nervous impulses. During normal quiet breathing, the phrenic nerves stimulate the diaphragm to contract and move downward into the abdomen. This downward movement of the diaphragm enlarges the thorax. When necessary, the intercostal muscles also increase the thorax by contacting and drawing the ribs upward and outward.

Expiration

Expiration It is normally a passive process and does not require muscles to

work (rather it is the result of the muscles relaxing).

When the lungs are stretched and expanded, stretch receptors within the alveoli send inhibitory nerve impulses to the medulla oblongata, causing it to stop sending signals to the rib cage and diaphragm to contract.

The muscles of respiration and the lungs themselves are elastic, so when the diaphragm and intercostal muscles relax there is an elastic recoil, which creates a positive pressure (pressure in the lungs becomes greater than atmospheric pressure), and air moves out of the lungs by flowing down its pressure gradient.

Respiratory System DisordersUpper respiratory ProblemsStructural and Traumatic Disorders of the Nose

Deviated Septum

Definition: Deflection of the normally straight nasal septum.Etiology: Trauma to the noseCongenital disproportion, a condition where size

of the septum is not proportional to the size of the nose.

Assessment

Inspection – the septum is vent to one side, altering the air passage.

Symptoms:Pt. may experience obstruction of nasal

breathing, edema, or dryness of the nasal mucosa with crusting and bleeding (epistaxis).

Medical management:Nasal allergy control.Severe symptoms – nasal septoplasty to

reconstruct and properly align the deviated septum.

Nasal Allergy Control

Identifying and avoiding triggers of allergic reaction.

- avoid house dust - avoid dust mites - avoid mold spores - avoid pollens - avoid pet allergens - avoid smoke

Nasal Fracture

Incidence: Occurs approx. 46% of bone injuries incases of facial traumas.

Etiology: TraumaComplications: airway obstruction, epistaxis,

menigeal tear, septal hematoma, and cosmetic deformity.

Classification: unilateral bilateral – flattened look. Epistaxis – most common sign. Complex

Nasal Fracture

Assessment: Inspection – assess pt.’s ability to breathe through each side of the nose and note for sign of edema, bleeding or hematoma. Ecchymosis under one or both eyes (raccoon eyes).

Inspect internally for presence of septal deviation, hemorrhage, or leakage of clear fluid indicating leakage of CSF.

Quick test – done to test for CSF leak if noted leakage is clear.

Nursing Management

Keeping the pt. on upright position to promote maintenance of airway.

Application of ice pack on the face to reduce edema and bleeding

Medical management is to realign the fracture using close or open reduction ( septoplasty or rhinoplasty

Rhinoplasty – reestablish cosmetic appearance anmd proper function of the nose and adequate airway. .

Rhinoplasty

Performed as an outpatient procedure using regional anesthesia.

Plastic implants are sometimes use dto re-shape the nose.

Nasal packing maybe reinserted to prevent bleeding or septal hematoma formation.

Nasal septal splints maybeinserted to help prevent scar tissue betwee surgical site and lateral nasal wall.

Nasal Surgery Nsg. Management

No aspirin or NSAIDS for 2 weeks prior to surgery to reduce risk of bleeding.

Immediate post-op - - maintenance of airway - assessment of

respiratory status - pain management - observation surgical site for bleeding, infection and edema.

Allergic Rhinitis

Definition – reaction of the nasal mucosa to a specific allergen.

Types: Intermittent – s/s less than 4 days a week or less than 4 weeks a year Persistent – s/s occurs more than 4 days a week or more than 4 weeks a year.Etiology: pet saliva, dust mites, molds, or cockroaches.Occurrence: s/s can occur whenever a patient is exposed to a specific allergen. Sensitization to an allergen occurs with initial

allergen exposure, which results in production of antigen-specific immunoglobulin E (IgE).

Allergic Rhinitis

Pathophysiology: After exposure, mast cells and basophils release histamine, prostaglandins and leukotrienes, which causes early symptoms of sneezing, itching, rhinorrhea, and moderate congestion.

2 -4 hours after exposure, there is infiltration of inflammatory cells into the nasal tissues causing and maintaining inflammatory response.

Resembles common colds.

Allergic Rhinitis Drug Therapy

Corticosteroids Nasal Spray ex. Flonase, Nasonex. Inhibits inflammatory response. begins 2 weeks pollen season. Use on regular

basis and not prn. D/C if nasal infection develops.

Mast Cell Stabilizer – Cromolyn Spray inhibits degranulation of sensitized mast cells.

If isolated exposure such as cat, use prophyllactically (10-15 min before exp.).

Leukotriene Receptor Antagonist and Inhibitor antagonist – Singulair. Monitor LFT periodically. Administer on empty stomach.

Allergic Rhinitis Drug Therapy

Anticholinergic Nasal spray – Atrovent. Blocks hypersecretory effects by competing

for binding sites on the cell. Dryness of mouth and nose may occur. Prevents symptoms with onset of action

after 1 hour of use.Antihistamines ( 1st generation agents)-

Tavist, Benadryl. Bind with H1 receptors on target cells blocking histamine binding.

Cross blood brain barrier casuing sedation.

Influenza (Flu)

Cause of significant morbidity and mortality each year. Death ave. 36,000 per year in the U.S.

Occurs most in persons over 60 year of age.Two main groups of Influenza Virus A and BClinical Manifestations:CoughFeverMyalgia accompanied by headache and

sore throat.

Influenza

Pathophysiology – uncomplicated s/s will rsubside in 7 days. In older person may experience weakness that persist for weeks.

Convalescent phase may markby hyperactive airways and chronic cough.

Most common complication of influenza is Pneumonia.

Nursing and Collaborative Management.

Vaccines administration – two types inactivated and live attenuated.

Vaccines should be given in the fall ( mid Oct to End of Winter late March).

High priority is given to groups like elderly > 50 year old and to group that can transmit influeza – healthcare workers.

S/E – soreness at the injection site. C/I – history of Guillain-Barre syndrome and

sensitivity to eggs because the vaccine is produced in eggs.

Target Groups for Influenza Immunization

Inactivated VaccineGroups at High RiskAnyone >50 years old.Adult at any age with chronic cardiac or pulmonary disease.Adults who had regular medical follow-up or were hospitalized during the

preceding year.Residents of long term care facilities.Immunocompromised adultsWomen who will be in second or third trimester of pregnancy during influenza

season.

Groups who can transmit Influenza to high risk personHealthcare workersProviders of home care to high risk personsHousehold members of high risk persons.

Live Attenuated Influenza vaccine All persons 5-49 years of ageGiven intranasally

Obstruction of the Nose and Paranasal Sinuses

Polyps

Polyps – benign mucous membrane masses that form slowly in response to repeated inflammation of sinus or nasal mucosa.

S/S nasal obstructionNasal discharges (clear mucus)Speech distortionTx.Removal via endoscopic or laser surgeryTopical or systemic cortecosteroids may

slsow polyp growth.

Problem Related to trachea and Larynx

TracheostomySurgical incision into the trachea for the

purpose of establishing an airway.Stoma opening resulting from the tracheotomy.Indications:- Bypass an upper airway obstruction- Facilitate removal of secretions- Permits long term mechanical ventilation- Permits oral intake and speech in the pt. who

requires long-term mechanical ventilation

Tracheostomy

Can be performed as an emergency procedure or as a scheduled surgical procedure. It can be permanent or temporary.

A double lumen trach has 3 major parts. - Outer cannula - Inner cannula - ObturatorAir flow in and out of tracheostomy

without air leakage

Tracheostomy

Uncuffed tubes and fenestrated tubes that are in place or capped allow the client to speak.

Swallowing is possible with a tracheostomy tube in place however laryngeal elevation is affected and it is important to assess the client’s risk for aspiration prior to intake.

ADVANTAGESLess risk of long term damage to the airway.Increased client comfort(no tube in the mouth).Decreased incidence of pressure ulcer in the oral

cavity and upper airway.Client can eat.Allows client to talk.

Types of tracheostomy Tube

Cuffed – protect the lower airway by producing a seal between upper and lower airway. Use to client receiving mechanical ventilation.

Uncuffed – cuffless, when the client can protect the airway from aspiration and children under 8 y/o.

Single lumen tube – client with long or extra thick neck. Tracheostomy tube with cuff and pilot balloon – low

pressure, high volume cuff distributes cuff pressure over large area, minimizing pressure on tracheal wall.

Uncuffed fenestrated – used when client weaning client from trach tube.

Cuffed fenestrated – facilitates ventilation and speech. For client who does not require ventilation at all times.

Metal tracheostomy – cuffless double lumen tube. used for permanent tracheostomy. Can be cleaned and reused.

Talking/speaking trach- Foam filled cuff

Tracheostomy Nursing Management

Assess /monitor - oxygenation and ventilation and V/S hourly.- Thickness, quantity, odor, and color of

mucous secretions.- Stoma and skin surrounding stoma for s/s

of infection (redness, swelling, or drainage).

Provide adequate humidification and hydration to reduce mucus plugging.

Maintain surgical aseptic technique when suctioning to prevent infection.

Tracheostomy Nursing Management

Provide the client with emergency call system. Provide the client with methods to communicate. Provide emotional support. If cuffless tube keep pressure below 20 mmHg to reduce

the risk of tracheal necrosis due to prolonged compression of tracheal capillaries.

Provide trach care every 8 hours. Change non-disposable trach tube q 6-8 weeks or per

protocol. Reposition client q 2 hour to prevent atelectasis or

pneumonia. Provide oral hygiene q 2 hour to maintain mucosal

integrity. Minimize dust in client’s room If client is able to eat, position in an upright position and

tip the client’s chin to chest to enable swallowing. Administer prescribed medications.

Complications and Nursing Implications

Accidental decannulation - keep the trach obturator and spare trach

tube at the bedside at all times. - call for assistance. - first 72 hours after surgery is am

emergency because trach has not matured and replacement maybe difficult.

- mature tracheostomy- nurseshould insert obturator immediately into the tracheostomy trach and insert a new trach tube around the obturator.

Nursing Diagnosis

Ineffective Airway ClearanceIneffective therapeutic regimen

management.Impaired verbal communicationRisk for infectionImpaired swallowing

Nursing Management Lower Respiratory

Pneumonia

Definition: Pneumonia is an inflammatory process in the lungs that produces excess fluid. Triggered by infectious organism or by the aspiration of an irritant.

Lung parenchyma inflammation process results in edema and exudate that fills the alveoli.

Pneumonia can be a primary or complication of another disease or condition.

It affects all ages but the young, older adults clients, and clients who are immunocompromised are more susceptible.

Common Risk Factors

Advanced ageRecent exposure to viral or influenza infectionsTobacco use.Chronic lung disease (asthma)AspirationMechanical ventilation (ventilator acquired

pneumonia). Impaired ability to mobilize secretions (decreased

level of consciousness, immobility, recent abdominal or thoracic surgery.

Immunosuppressive drugsMalnutritionUpper respiratory infections.

Diagnostic Procedures

Chest X –Ray – shows consolidation of lung tissue.

Pulse Oximetry – Decreased O2 saturation levels.

CBC – elevated WBC count ( may not be present in older adult clients).

Sputum culture – obtain from suctioning if client unable to cough. Direct identification of responsible organism.

Arterial Blood Gases (ABGs) Decreased PaO2 and increased PaCo2 due to

impaired gas exchange in the aveoli.

Assessments

Monitor for s/s- Fever- Dyspnea/tachypnea- Pleuritic chest pain- Sputum production- Crackles and wheezes- Coughing- Dull chest percussion over areas of

consolidation- Poor oxygen saturation ( low SaO2)

Assess/monitor

Respiratory status (airway patency, breath sounds, respiratory rate, use of accessory muscles, oxygenation status) before and following interventions.

Sputum (amount and color)History of smoking and chronic lung conditions.Recent exposure to influenzaFactor that increase the risk for aspirations

( swallowing problem – stroke).Difficulty mobilizing secretions (generalized

weakness).General appearance (temp. skin color), lab findings.

NANDA Nursing Diagnosis

Impaired gas exchangeIneffective airway clearanceActivity intoleranceImbalance nutrition: less than body

requirements.Acute pain

Nursing Intervention

Administer heated and humidified Oxygen therapy as prescribed.

Position the client in high-Fowler’s position to facilitate air exchange.

Encourage coughing, or suction to remove secretions.Encourage deep breathing with incentive spirometer

to prevent alveolar collapse. Administer medications as prescribed:- Antibiotics penicillins and cephalosporins.- Initially given as IV then switched to an oral form as

client’s improves.- Obtain any Cx specimens prior to giving the first dose

of ATB. ATB can be given while waiting for the results of the ordered culture.

Nursing Interventions

BronchodilatorsShort acting beta agonist – albuterol(proventil, ventolin)quickly bronchodilation.Methylxanthines- theophyline (Theo-Dur),

requires close monitoring of serum medications level due to narrow therapeutic range.

Corticosteroids – prednisones, decrease airway inflammation. Monitor for s/e

immunosuppression, fluid retention, hyperglycemia, poor wound healing.


Immunization can decrease a client’s risk of development of community acquired pneumonia.

Influenza vaccinePneumococcal vaccine – administered one time

and helps prevent pneumococcal infections including pneumonia. Recommended for older adults and those with chronic illnesses.

Determine the client’s physical limitations and structure activity to include periods of rest.

Promote adequate nutrition.Provide support to client and family.Encourage verbalization of feelings.


Atelectasis – Airway inflammation and edema leads to alveolar collapse and increase the risk for hypoxemia.

- Diminish or absent breath sounds over affected area.

- Chest X- ray shows area of density.Acute respiratory failure – Persistent hypoxemia.Monitor oxygenation levels and acid-base balance.Prepare for intubation and mechanical ventilation

as indicated.Bacteremia – (sepsis) can occur if pathogens enter

the bloodstream from the infection in the lungs.

Obstructive Pulmonary Diseases

Chronic Obstructive Pulmonary Diseases.

COPD encompasses two diseases1. Emphysema2. Chronic bronchitis

Emphysema – loss of lung elasticity and hyperinflation of lung tissue. Emphysema cases destruction of the alveoli leading to decrease surface area for gas exchange, carbon dioxide retention and respiratory acidosis.

Chronic Bronchitis – is an inflammation to the bronchi and bronchioles due to chronic exposure to irritants.

Risk Factors

COPD usually affects middle age to older adults.

Risk Factors:Cigarette smoking – primary risk factor for

the development of COPD.Alpha-antitrypsin deficiencyExposure to air pollution.

Diagnostic tests

Pulmonary Function tests – comparison of forced expiratory volume (FEV) to forced vital capacity (FVC) are used to classify COPD as mild to severe. As COPD advance the FEV and FVC decreases.

Chest X-ray – reveals hyperinflation and flattened diaphragm in late stages of emphysema.

Arterial Blood Gases – ABGs are monitored to evaluate respiratory status. Increase PaCo2 and decrease PaO2/.

Respiratory acidosis, metabolic alkalosis (compensation).

Pulse oximetry Monitor Os saturation levelsLess than normal (normal = 94-98%) O2 saturation

levels.

Diagnostic tests

Peak Expiratory Flow Meters - Used to monitor treatment effectiveness. - decrease with obstruction, increase with relief of obstructions. AAT levels are used to assess for AAT

deficiency.Monitor hemoglobin and hematocrit to

recognize polycythemia (compensation to chronic hypoxia).

Evaluate sputum and WBC coun ts for diagnosis of acute respiratory infections.

Assessments

Monitor for s/s. Chronic Dyspnea Chronic cough Hypoxemia Hypercarbia (increased PaCo2) Respiratory acidosis and compensatory metabolic acidosis Crackles Rapid shallow respirations Use of accessory muscles Barrel chest or increase chest diameter Hyperresonance on percussion due to trapped air(emphysema) Asynchronous breathing Thin extremities and enlarge neck muscles Dependent edema secondary to right sided heart failure. Pallor and cyanosis of nail beds and mucuous membranes

( late state of disease.

Assess and monitor

Client history (occupational Hx, smoking Hx)Respiratory rate, symmetry, and effortBreath soundsActivity tolerance level and dyspnea.Nutrition and weight lossVital signsHearth rhythmPallor and cyanosisABGs, SaO2, CBC, WBC, and Chest X-Ray

results.

NANDA Nursing Diagnosis

Impaired gas exchangeIneffective breathing patternIneffective airway clearanceImbalance nutritionAnxietyActivity intoleranceFatigue


Position the client in high Fowler’s position for proper ventilation.

Encourage effective coughing, or suction to remove secretions.

Encourage deep breathing Administer breathing treatments and medications

as prescribed - Bronchodilators – short acting beta agonists (albuterol),cholenergic antagonists

(Atrovent), Methylxanthines - Antiinflammtory – Cortocosteroids, leukotrienes

antagonist, Mast cells stabilizers, monoclonal antibodies and combination agents.


Administer heated and humidified O2 therapy. Monitor skin breakdown fro O2 device.

Instruct client to practice breathing techniques to control dyspneic episodes.

- diaphragmatic or abdominal breathing. - pursed-lip breathing.Provide O2 therapy may need 2-4 L/min per nasal

cannula or up to 40% per venturi mask.Clients with chronic hypercarbia usually requires 1-2 L/min via nasal cannula. It is important to recognize that low arterial levels of O2 serve as their primary drive for breathing.

Determine the client’s physical limitations and structure activity to include period of rest.


Promote adequate nutrition.Provide support to client and familyEncourage verbalization of feelings.Encourage smoking cessation if

applicable.


Respiratory Infections results from increased mucus production and

poor oxygenation.Administer O2 therapy, monitor oxygenation,

administer antibioticsand other medication as prescribed.

Right Sided Heart Failure (Cor pulmonale) air trapping, stiff alveoli lead to increased

pulmonary pressure. Blood flow through lungs tissue is difficult. This increased work load leading to enlargement and thickening of the right strium and ventricle.

Cor Pulmonary Manifestations

Hypoxia, hypoxemiaCyanotic lipsEnlarge and tender liverDistended neck veinsDependent edemaNursing InterventionsMonitor respiratory status administer O2.Monitor HR and rhythm.Administer positive inotropic and contractility

medications as prescribedAdminister IV fluids and diuretics to maintain

fluid balance.

Reactive Airway Disease (Asthma)

Reactive Airways Dysfunction Syndrome or RADS (also known as Reactive Airway Disease or RAD) is a term todescribe an asthma-like syndrome developing after a single exposure to high levels of an irritating vapor, fume, or smoke. In time, however, it has evolved to be mistakenly used as a synonym for asthma.

Asthma – Is chronic inflammatory disorder of the airways. It is an intermittent and reversible airflow obstruction that affects the bronchioles

RAD

Mortality/MorbidityOne third of all children younger than 18 years are

significantly affected.Reactive airway disease accounts for 13 million health

care visits annually in the United States and 200,000 hospitalizations.

RaceReactive airway disease is more common in black and

Hispanic children; hospitalization rates in African Americans are 4 times greater than in the white population.

No correlation exists with income or education level from a retrospective review.

RAD Sign and Symptoms

Sign and SymptomsRespiratory condition characterized by

wheezing, shortness of breath, and coughing.

Client with Reactive Airway Disease generally develop respiratory symptoms after exposure to an irritant which causes inflammation in their respiratory tracts.

RAD

Etiology:Inhalation of irritating substances such as

smoke, dust, fumes, gases, and vapors.Symptoms of RADS appear within 24 hours

after exposure is terminated, but typically not until after exposure. Symptoms continue for several days, weeks, or months, usually on a more-or-less daily basis.

The term RADS is for irritant induced asthma wherein the symptoms initially appear within 24 hours of first exposure.

Clinical Manifestations

Fever Tachycardia Tachypnea, dyspnea Wheezing Coughing Flushing, cyanosis Flaring of nasal alae Nasal secretions Intercostal retractions Poor feeding in children Diaphoresis Distant breath sounds, hyperresonance (Beware of "silent chest," too

little air movement to hear wheezing.) Pulsus paradoxus (mild asthma pulsus paradoxus = 10, moderate = 10-

20, severe >20) Altered mental status Decreased peak expiratory flow rate Inspiratory-to-expiratory ratio (An increased inspiratory-to-expiratory

ratio is a bad sign.) Allergic shiner (ie, dark semicircles of skin under the eyes) Transverse nasal skin fold from repeatedly rubbing the nose

Clinical Manifestations

Increased anteroposterior diameter or pectus carinatum Murmur Clubbing Subcutaneous emphysema Mild asthma: the child can speak in sentences and is not

short or breath at rest, slight increase in respiratory rate but no accessory muscle usage

Moderate asthma: the child is short of breath while talking and speaks in short phrases, respiratory and heart rate increased, loud wheezes throughout expiratory phase

Severe asthma: the child is short of breath at rest, very agitated, sitting upright and not speaking or using only one single word, wheezes throughout inspiration and expiration

Respiratory arrest imminent if child is drowsy and wheezes are absent

Course of the Disease RAD

Client may start coughing and wheezing in the wake of a serious wildfire, as a result of irritation caused by the smoke and particulates.

Typically, mucus production is increased, which leads to additional inflammation and discomfort for the patient.

The irritation to the airways leads to a chronic syndrome of symptoms.

Causes

Causes Precipitants of asthma exacerbation

◦ Infection -Respiratory syncytial virus (RSV) most commonly isolated from infants and preschool-aged children; Mycoplasma pneumoniae most commonly isolated from school-aged children

◦ Tobacco smoke◦ Pet dander, cockroach and dust mite allergen◦ Molds◦ Pollen◦ Exercise◦ Weather changes◦ Stress◦ Drugs

A precipitant of bronchiolitis is respiratory infection, usually due to RSV.

Gastroesophageal fistula Mediastinal mass (external compression of the airway)

Diagnostic tests

A CBC (complete blood count) will reveal the presence of viral or bacterial illness when dealing with respiratory symptoms that mimic asthma.

If there is no family history of asthma and fever is present, an X-ray may reveal the presence of fluid or infiltrate in the lungs to help differentiate the cause.

Allergy and exercise tolerance tests can also help pinpoint the source of symptoms.

Children over age 5 should have a spirometry test--a simple, noninvasive test that measures the volume of air forcibly exhaled when blowing into a cylinder through a mouthpiece.

A pediatric lung specialist for children--or a pulmonologist for adults--should be consulted to find the underlying cause of reactive airway disease.

Targeted treatment and diagnosis should help if it's asthma, virus or other causes of reactive airway disease.

Laboratory Studies

A complete blood count (CBC) may be indicated for a suspected viral infection (lymphocytosis, leukopenia), parasitic infection (eosinophilia), or hemosiderosis.

An arterial blood gas (ABG) determination should be performed for any patient in status asthmaticus to check for hypoxia, hypercarbia, or acidosis; alternatively, a venous blood gas measurement can be used to assess for hypercarbia and acidosis and combined with pulse oximetry monitoring.

An assessment of electrolyte levels may reveal hypokalemia in patients who are using albuterol.

Although theophylline is prescribed less frequently, a theophylline level is useful for those on the drug.

Imaging Studies

Routine radiography does not need to be part of the initial routine workup of asthma.

Consider chest radiography if increased temperature, absence of family history of asthma, and the presence of localized wheezes or rales. ◦Hyperinflation◦Peribronchial thickening◦Atelectasis◦Radiographs may provide evidence of foreign body,

associated vascular anomalies, cardiac enlargement, pulmonary hypertension, infiltrates, or masses.

Procedures

Spirometry (decreased forced expiratory volume in one second [FEV1]) ◦ Bedside spirometry is the primary procedure for children with RAD

who are older than 5 years.◦ Patients with decreased FEV require further evaluation and treatment.

A barium swallow may be indicated to determine any esophageal, pulmonary, or vascular pathology, particularly a tracheoesophageal fistula.

Bronchoscopy (rarely indicated)

Peak expiratory flow (PEF) is the most common form of pulmonary function test monitoring. Record the best of 3 attempts. Possible life-threatening asthma exacerbation with PEF predicted of less than 30%; severe exacerbation, with less than 50%; and moderate exacerbation, with less than 80%.

Diagnostic Procedures

Pulmonary Function tests are the most accurate test for diagnosing Asthma and its severity.

- Force Vital capacity - Forced expiratory Volume in the first

second (FEV1) - Peak Expiratory Rate Flow Arterial Blood gasesChext X-Ray

Sign and symptoms

DyspneaChest tightnessCoughingWheezingMucus productionUse of accessory musclePoor O2 sat ( low SaO2)

Assess and Monitor

Client Respiratory statusClient History regarding current previous

asthma exacerbations

NANDA Nursing DiagnosisImpaired gas exchangeIneffective Airway clearanceIneffective breathing patternanxiety


Administer O2 therapy as prescribed Place on high Fowler’s position Monitor cardiac Rate and Rhythm. Initiate and maintain an IV access. Administer medications as prescribed Short acting beta 2 agopnists Cholenergic antagonists Methylxanthines Antiinflammatories-Corticosteroids- Leukotriene agonists- Mast cells stabilizers monoclonal antibodies- Combination agents bronchodilators and antiinflamatory- Maintain a calm and reassuring demeanor.

Client Education

Instruct clients how to recognize and avoid triggering agents

How to properly self-administer medicationsInfections prevention tecniquesEffects of smoking on asthma and possible

cessation of smoking strategies.Encourage regular exercises as part of asthma

therapy.Complications Respiratory FailureStatus Asthmaticus

WEST COAST UNIVERSITY NUR 121

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