Transcript west coast university nur 121

WEST COAST UNIVERSITY
NUR 121
Respiratory System Disorders
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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.
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Included in the upper respiratory tract are the Nostrils,
Nasal Cavities, Pharynx, Epiglottis, and the Larynx.
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The lower respiratory tract consists of the Trachea,
Bronchi, Bronchioles, and the Lungs.
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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
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The Respiratory System
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Breathing and Lung Mechanics
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Ventilation is the exchange of air between the external environment and the alveoli.
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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.
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There are two phases of ventilation; inspiration and expiration.
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Each lung is completely enclosed in a sac called the pleural sac.
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The intrapleural fluid completely surrounds the lungs and lubricates the two surfaces so that
they can slide across each other.
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The rhythm of ventilation is also controlled by the "Respiratory Center" which is located largely
in the medulla oblongata of the brain stem. T
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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).
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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.
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Relaxed exhalation occurs between impulses when the muscles relax. Normal adults have a
breathing rate of 12-20 respirations per minute.
Respiratory System Anatomy and Physiology
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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
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Air then travels past the nasopharynx, oropharynx, and laryngopharynx,
which are the three portions that make up the pharynx.
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The pharynx is a funnel-shaped tube that connects our nasal and oral
cavities to the larynx.
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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.
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Then the air travels through the larynx.
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The larynx closes at the epiglottis to prevent the passage of food or drink
as a protection to our trachea and lungs.
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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
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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.
Inspiration
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Expiration
It is normally a passive process and does not require
muscles to work (rather it is the result of the muscles
relaxing).
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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.
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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.
Expiration
Respiratory System Disorders
Upper respiratory Problems
Structural and Traumatic Disorders of the
Nose
Deviated Septum
Definition:
Deflection of the normally straight nasal
septum.
Etiology:
Trauma to the nose
Congenital disproportion, a condition where
size of the septum is not proportional to
the size of the nose.
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.
Assessment
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Identifying and avoiding triggers of
allergic reaction.
- avoid house dust
- avoid dust mites
- avoid mold spores
- avoid pollens
- avoid pet allergens
- avoid smoke
Nasal Allergy Control
Incidence: Occurs approx. 46% of bone
injuries incases of facial traumas.
Etiology: Trauma
Complications: 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.
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Nasal Fracture
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. .
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Nursing Management
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.
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Rhinoplasty
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.
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Nasal Surgery Nsg. Management
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
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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.
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Allergic Rhinitis Drug Therapy
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 B
Clinical Manifestations:
 Cough
 Fever
 Myalgia accompanied by headache and
sore throat.
Influenza (Flu)
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.
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Influenza
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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.
Nursing and Collaborative
Management.
Inactivated Vaccine
Groups at High Risk
Anyone >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 adults
Women who will be in second or third trimester of pregnancy during
influenza season.
Groups who can transmit Influenza to high risk person
Healthcare workers
Providers of home care to high risk persons
Household members of high risk persons.
Live Attenuated Influenza vaccine
All persons 5-49 years of age
Given intranasally
Target Groups for Influenza Immunization
Obstruction of the Nose and
Paranasal Sinuses
Polyps – benign mucous membrane masses
that form slowly in response to repeated
inflammation of sinus or nasal mucosa.
 S/S
 nasal obstruction
 Nasal discharges (clear mucus)
 Speech distortion
Tx.
Removal via endoscopic or laser surgery
Topical or systemic cortecosteroids may slsow
polyp growth.
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Polyps
Tracheostomy
Surgical 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
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Problem Related to trachea and
Larynx
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
- Obturator
 Air flow in and out of tracheostomy
without air leakage
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Tracheostomy
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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.
ADVANTAGES
Less 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.
Tracheostomy
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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 trachFoam filled cuff
Types of tracheostomy Tube
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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
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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.
Tracheostomy Nursing Management
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.
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Complications and Nursing Implications
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Ineffective Airway Clearance
Ineffective therapeutic regimen
management.
Impaired verbal communication
Risk for infection
Impaired swallowing
Nursing Diagnosis
Nursing Management Lower
Respiratory
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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.
Pneumonia
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Advanced age
Recent exposure to viral or influenza infections
Tobacco use.
Chronic lung disease (asthma)
Aspiration
Mechanical ventilation (ventilator acquired
pneumonia).
Impaired ability to mobilize secretions
(decreased level of consciousness, immobility,
recent abdominal or thoracic surgery.
Immunosuppressive drugs
Malnutrition
Upper respiratory infections.
Common Risk Factors
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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.
Diagnostic Procedures
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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)
Assessments
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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 influenza
Factor that increase the risk for aspirations (
swallowing problem – stroke).
Difficulty mobilizing secretions (generalized
weakness).
General appearance (temp. skin color), lab
findings.
Assess/monitor
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Impaired gas exchange
Ineffective airway clearance
Activity intolerance
Imbalance nutrition: less than body
requirements.
Acute pain
NANDA Nursing Diagnosis
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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 Intervention
Bronchodilators
Short 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.
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Nursing Interventions
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Immunization can decrease a client’s risk of
development of community acquired
pneumonia.
Influenza vaccine
Pneumococcal 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.
Nursing Interventions
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.
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Complications and Nursing Implications
Obstructive Pulmonary
Diseases
 COPD encompasses
1. Emphysema
2. Chronic bronchitis
two diseases
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.
Chronic Obstructive Pulmonary
Diseases.
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COPD usually affects middle age to older
adults.
Risk Factors:
Cigarette smoking – primary risk factor
for the development of COPD.
Alpha-antitrypsin deficiency
Exposure to air pollution.
Risk Factors
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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 levels
Less 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.
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Diagnostic tests
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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.
Assessments
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Client history (occupational Hx, smoking
Hx)
Respiratory rate, symmetry, and effort
Breath sounds
Activity tolerance level and dyspnea.
Nutrition and weight loss
Vital signs
Hearth rhythm
Pallor and cyanosis
ABGs, SaO2, CBC, WBC, and Chest X-Ray
results.
Assess and monitor
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Impaired gas exchange
Ineffective breathing pattern
Ineffective airway clearance
Imbalance nutrition
Anxiety
Activity intolerance
Fatigue
NANDA Nursing Diagnosis
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.
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Nursing Interventions
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.
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Nursing Interventions
Promote adequate nutrition.
 Provide support to client and family
 Encourage verbalization of feelings.
 Encourage smoking cessation if
applicable.
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Nursing Interventions
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.
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Complications and Nursing Implications
Hypoxia, hypoxemia
Cyanotic lips
Enlarge and tender liver
Distended neck veins
Dependent edema
Nursing Interventions
 Monitor respiratory status administer O2.
 Monitor HR and rhythm.
 Administer positive inotropic and contractility
medications as prescribed
 Administer IV fluids and diuretics to maintain
fluid balance.
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Cor Pulmonary Manifestations
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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
Reactive Airway Disease (Asthma)
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Mortality/Morbidity
One 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.
Race
Reactive 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
 Respiratory 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 Sign and Symptoms
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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.
RAD
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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-toexpiratory 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
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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
Clinical Manifestations
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.
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Course of the Disease RAD
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Causes
Precipitants of asthma exacerbation
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A precipitant of bronchiolitis is respiratory infection, usually
due to RSV.
Gastroesophageal fistula
Mediastinal mass (external compression of the airway)
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◦ 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
Causes
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A CBC (complete blood count) will reveal the presence of viral or
bacterial illness when dealing with respiratory symptoms that
mimic asthma.
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If there is no family history of asthma and fever is present, an Xray may reveal the presence of fluid or infiltrate in the lungs to
help differentiate the cause.
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Allergy and exercise tolerance tests can also help pinpoint the
source of symptoms.
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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.
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A pediatric lung specialist for children--or a pulmonologist for
adults--should be consulted to find the underlying cause of
reactive airway disease.
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Targeted treatment and diagnosis should help if it's asthma, virus
or other causes of reactive airway disease.
Diagnostic tests
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A complete blood count (CBC) may be indicated for a
suspected viral infection (lymphocytosis, leukopenia),
parasitic infection (eosinophilia), or hemosiderosis.
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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.
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An assessment of electrolyte levels may reveal
hypokalemia in patients who are using albuterol.
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Although theophylline is prescribed less frequently, a
theophylline level is useful for those on the drug.
Laboratory Studies
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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.
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Hyperinflation
Peribronchial thickening
Atelectasis
Radiographs may provide evidence of foreign body,
associated vascular anomalies, cardiac
enlargement, pulmonary hypertension, infiltrates,
or masses.
Imaging Studies
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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.
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A barium swallow may be indicated to determine any
esophageal, pulmonary, or vascular pathology, particularly
a tracheoesophageal fistula.
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Bronchoscopy (rarely indicated)
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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%.
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 gases
 Chext X-Ray
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Diagnostic Procedures
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Dyspnea
Chest tightness
Coughing
Wheezing
Mucus production
Use of accessory muscle
Poor O2 sat ( low SaO2)
Sign and symptoms
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Client Respiratory status
Client History regarding current previous
asthma exacerbations
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NANDA Nursing Diagnosis
Impaired gas exchange
Ineffective Airway clearance
Ineffective breathing pattern
anxiety
Assess and Monitor
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.
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Nursing Interventions
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Instruct clients how to recognize and avoid
triggering agents
How to properly self-administer medications
Infections prevention tecniques
Effects of smoking on asthma and possible
cessation of smoking strategies.
Encourage regular exercises as part of
asthma therapy.
Complications
Respiratory Failure
Status Asthmaticus
Client Education