Question

Describe some of the factors that are most important for the clinical nurse to know in treating patients with asthma and COPD?

Answer 1

Asthma:

• Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. Inflammation ultimately leads to recurrent episodes of asthma symptoms.
• Asthma, the most common chronic disease of childhood, can begin at any age.

Some of the factors to be kept in mind in treatment of asthma are:

To determine the diagnosis of asthma, the clinical nurse must determine that episodic symptoms of airway obstruction are present.

• Positive family history. Asthma is a hereditary disease, and can be possibly acquired by any member of the family who has asthma within their clan.
• Environmental factors. Seasonal changes, high pollen counts, mold, pet dander, climate changes, and air pollution are primarily associated with asthma.
• Comorbid conditions. Comorbid conditions that may accompany asthma may include gastroeasophageal reflux, drug-induced asthma, and allergic broncopulmonary aspergillosis.

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.

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.

COPD

• Chronic Obstructive Pulmonary Disease (COPD) is a condition of chronic dyspnea with expiratory airflow limitation that does not significantly fluctuate.

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.

Management of patients with COPD should be incorporated with teaching and improving the respiratory status of the patient.

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 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.