RN101
Home of the Registered Nurses (RN) and
Licensed Practical Nurses (LPN)
ASTHMA
●Asthma, Attack ●Signs and symptoms. ●Triggers. ●Help (support groups, family member involvement). ●Medication, Monitoring, Medical alert bracelet. ●Activity.
Asthma: Chronic inflammatory disease of the airways. Cause is unknown. Hyperresponssiveness to multiple stimuli or triggers.
Causing airway: “3 hallmarks/Main problems”: ●Bronchoconstriction – Ventolin – Blue ●Mucus production increase – Atrovent – Green ●Inflammation – Flovent – Orange “1 min same meds interval – 3-5 minutes for other meds”.
Attack: ●Stop any activity, sit down, take a rest and do purse lip breathing. ●Take rescue inhaler (ventolin-blue), if no effect should call 911 (more or less after 15 mins).
Signs and symptoms: ●Cyanosis. ●Shortness of breath. ● Use of accessory muscles. ● Slow capillary refill (>2sec). ●Substernal and subclavicular retractions. ● Change in LOC/alertness. ● Audible adventitious sound. ● Inability to complete a sentence. ● Restlessness. ● Anxiety. ● Oxygen saturation decrease. ● Tachycardia. ● Cold and clammy skin. ●Wheezing. ● Expectoration. ●Chest pain. ●Diaphoresis. ● Nasal discharge/obstruction. ●Nasal flaring.
Triggers: Allergens-(animal dander, pollen, house dust mites, moulds, cockroaches). Air pollutants-(fumes, perfumes, cigarette smoke, aerosol spray). Viral upper respiratory infection – cold and flu– yearly flu vaccine. Exercise-Exercise induced asthma. Cold, dry air. Stress. GERD. Drugs-(aspirin, NSAIDS, beta blockers).
Help: Support groups (Asthma association). CLSC. School. Involve family. MD-regular check up.
Medications: S/E: ●Ventolin - Hyperactivity, restlessness, tremors, and tachycardia. S/E is temporary-reassure-medication is base on weight. ●Atrovent - anticholinergic effects-dry mouth, dizziness, nausea, upset stomach. ●Flovent - oral thrush-rinse mouth.
Ventolin first before Flovent -opens the airway so that the Flovent will penetrate deeper and be more effective. Flovent effect is slow and gradual-24-48 hrs-use as maintenance anti-inflammatory therapy.
Why don’t stop corticosteroids abruptly? Prevention of adrenal insuffiency.
Can you stop it if s/s is gone? Action is slow and gradual, respect tx-even without symptoms there still inflammation in the respiratory tract, must be completed to prevent relapse of inflammation, tx of choice for reducing symptoms.
Effect on growth? – Inhaler has little systemic effect, prescribe in a very low dose-low risk-based by patient weight.
Pediapred-oral prednisolone-(rarely more than 5 days) for short period of time to quickly reduce the bronchial inflammation-given as soon as prescribed, then every morning, for blood cortisol levels are at their highest at this time.
Teach patient and family to bring medication at all times.
Activity: ●Notify coach or teacher, bus driver. ●Activity with rest periods. ●Take meds before activity (15 mins). ●Baseball and swimming are good. ●No strenuous exercises. ●If s/s occurs, stop activity. ●Avoid extreme weather during activity – windy, cold, humid, and very hot.
Status asthmaticus: is a severe life-threatening asthma episode that is refractory to treatment and may result in pneumothorax, acute cor pulmonale, or respiratory arrest.
ACUTE ASTHMA ATTACK
1. Position patient in semi-fowlers. 2. Administer bronchodilator and corticosteroids. 3. Administer oxygen by nasal prong or mask. 4. Monitor patient SPO2 and arterial blood gas. 5. Monitor patient vital signs, observe for expectoration (record COCA), and assess pulmonary system. 6. Reassure patient, encourage to relax, and do pursed lip breathing.
Infants and very young children:
1. Determine what medications had been given before admission (involve parents in the treatment). 2. Administer humidified oxygen by tent, mask or nasal cannula. 3. If necessary position the patient in Sims or side-lying. 4. Monitor SPO2 (and percentage of oxygen given). 5. Offer warm liquids (never give cold can cause bronchospasm).
Extra pointers for asthma:
●Is the inhaler full? – Shake into ear several times back and forth – you will hear and feel the contents – swishing sound because it was a liquid form. Keep track in a notebook of number of puffs most canister has 200 puffs, so if using 2 puffs 2x a day in 50 days would need to replace.
●Special instruction for children under 9 cannot use MDI – need a spacer/aero-chamber – reduces yeast infection.
●Hints for patient – Spacers need weekly cleaning because repeated use will cause powder to collect inside the spacer. To clean, soak in soapy warm tap water, shake off excess water and allow it to air dry overnight.
Chronic Obstructive Pulmonary Disease
A disease state characterized by airflow obstruction caused by chronic bronchitis or emphysema.
Chronic Bronchitis
Characterized by inflammation of the bronchi and excessive mucus production, which hinders the flow of air to the lungs. When obstruction becomes significant, the lungs cannot empty completely and the air gets trapped in the alveoli.
Emphysema
Emphysema affects the pulmonary alveoli. Emphysema causes the alveoli to dilate and destroys the alveoli walls. Air remains trapped inside the damaged alveoli. The exchange of oxygen (O2) and carbon dioxide (CO2) is more difficult, reducing the amount of oxygen available to the body.
Assessments:
1. Cough. 2. Exertional dyspnea. 3. Wheezing and crackles. 4. Sputum production. 5. Weight loss. 6. Barrel chest. 7. Use of accessory muscles for breathing. 8. Prolong expiration. 9. Orthopnea. 10. Cardiac dysrythmias. 11. Congestion and hyperinflation seen on chest x-ray. 12. ABG levels that indicate respiratory acidosis and hypoxemia. 13. PFT-decreased vital capacity.
Sign and symptoms of deterioration of respiratory condition for patients with COPD, asthma or other respiratory problems!
●Use of accessory muscle for breathing
●Inability to complete a sentence
●Diaphoresis
●Cool, pale limbs
●Audible adventitious sound
●Peripheral Cyanosis: lips and nails
●Abnormal breath sound on auscultation
●Altered LOC
COPD: Treatment, management, and teaching.
C-igarette smoking cessation, Crowded area must be avoided and people with infection. O-xygen therapy, Overexertion must be avoided and Over temperature (extremely cold/hot) avoid. P-neumococcal vaccine and Flu vaccine, Pulmonary rehabilitation, Pursed lip breathing, coughing and diaphragmatic breathing. D-ilators (Bronchodilators), mucolytics, antibiotics, and corticosteroids, Diet-have a small frequent meal (high calorie, high protein), Dust must be avoided such as fireplaces, pets, feather pillows, and other environmental allergens.
PNEUMONIA
Assessments:
Chills, fever, cough, pleuritic pain, tachypnea, rhonchi and wheezes, use of accessory muscle for breathing, mental status changes, sputum production. Rusty sputum – infection.
Infection of the pulmonary tissue, including the interstitial spaces, the alveoli, and the bronchioles. The edema associated with inflammation stiffens the lung, decreases lung compliance and vital capacity, and causes hypoxemia.
Types: Community-acquired and hospital-acquired pneumonia.
Nursing interventions:
1. Administer Oxygen as prescribed. 2. Monitor respiratory status. 3. Monitor for labored respirations, cyanosis, and cold and clammy skin. 4. Encourage coughing and deep breathing. 5. Place the client in a semi-Fowler’s position to facilitate breathing and lung expansion. 6. Change the patient’s position frequently and ambulate as tolerated to mobilize secretions. 7. Provide CPT, IS. 8. Perform nasotracheal suctioning if the patient is unable to clear secretions. 9. Monitor pulse oximetry. 10. Monitor COCA. 11. Provide high-calorie, high protein diet with small frequent meals. 12. Encourage fluids, up to 3L/day, to thin secretions unless contraindicated. 13. Provide a balance of rest and activity, increasing activity gradually. 14. Administer medications as prescribed. 15. PROPER HANDWASHING AND DISPOSAL OF SECRETIONS. 16. IMMUNIZATION.
Pneumonia: Risk Factors “INSPIRATION”
Immunosupression
Nicotine abuse (cigarette)
Secretion retention
Positioning supine
ICU admission – using mechanical ventilation
Respiratory tract infection (prior)
Alcohol abuse
Tracheal intubation, Tracheostomy
Immobility, Influenza infection
Other diseases (Pulmonary, renal, cardiac, liver diseases)
No swallowing (or difficulty)
Pneumonia: interventions “PNEUMONIA”
P-osition semi fowlers.
N-ote for COCA.
E-ncourage coughing and breathing exercise.
U-se antibiotics as prescribed and other medications. Use CPT and IS.
M-onitor respiratory status (O2 sat, RR, labored respirations, cyanosis). Mobilize – activity increase.
O-xygen administer as prescribed.
N-asotracheal suctioning.
I-ncrease fluids, protein, calorie diet with small frequent feedings.
A-dvice handwashing and proper disposal of secretion. Avoid people with respiratory infection.
FLU
Main problem: An infectious or contagious disease caused by influenza type virus A,B,/C.
Sign and symptoms: Generally appear in 4-5 days when infected.
Usual S/S: High fever, Headache, High risk of complication (chest pain/cough).
Prevention:
●Vaccination.
●Handwashing.
●Covering cough and sneeze (proper disposal of used tissue [Kleenex]) ●Avoid crowded areas.
●Keep immune system strong – eating well, getting enough sleep, and exercise.
People who are high risk in contacting the flu:
1. >65 y/o, <5 y/o. 2. People with medical condition (CV, pulmonary, immunocompromised, diabetics). 3. Pregnant women-safe to give flu shot. 4. Living in home care facilities or hospitalized.
COLD
Main problem: Upper respiratory infection caused usually by rhinovirus.
Signs and symptoms: Generally appear in 2 days when infected.
Usual S/S: SNS – Sneezing, Nasal congestion/discharge, Sore throat.
Prevention:
●Handwashing.
●Covering cough and sneeze (proper disposal of used tissue [Kleenex]) ●Avoid crowded areas.
●Keep immune system strong – eating well, getting enough sleep, and exercise.
TREATMENTS FOR FLU AND COLD: “WARDS”
W-ater increase. A-cetaminophen / Analgesics. R-est (stay at home).
D-iet adequate and balanced. S-ymptoms, watch warning signs of severe flu (SOB, chest pain, seizures, cyanosis, severe vomiting).
TUBERCULOSIS
●A contagious disease caused by Mycobacterium tuberculosis, an acid-fast bacillus.
●Non-compliance to treatment can cause Multi-drug resistant strain of Mycobacterium tuberculosis.
●Transmission: Airborne
●Incidence: Increase in urban low income areas, nonwhites or ethnic groups, and first generation immigrants from endemic country.
Assessments:
1. Patient may be asymptomatic. 2. Malaise. 3. Low grade fever. 4. Cough. 5. Weight loss. 6. Anorexia. 7. Lymphadenopathy. 8. Asymmetrical expansion of the lungs. 9. Decrease breath sounds. 10. Crackles. 11. Dullness on percussion. 12. Night sweats and chills.
Note: Specific symptoms r/t the site of infection, such as the lungs, brain or bone may be present.
DIAGNOSTIC TESTS
1. Mantoux test, Tuberculin Skin Test (TST): 0.1 mL of tuberculin Purified Protein Derivative (PPD) intradermally – creating a wheal – should be read between 48-72 hours – should be measured in millimeters of the INDURATION (palpable, raised, hardened area or swelling) DO NOT read/measure the erythema (redness) – measured across the forearm (perpendicular to the long axis).
-standard method of determining whether a person is infected with Mycobacterium tuberculosis.
Note: a positive reaction does not confirm the presence of active disease (exposure vs. presence).
●Once react positive – it will always react positive. – A positive reaction in a previously negative patient indicates that the patient has been infected since the last test.
●Cannot be done at the same time as measles immunization (viral interference from the measles vaccine may cause a false-negative result (wait 4-6 weeks).
PATIENT TEACHINGS
1. Provide the patient and family with information about TB and allay concerns about the contagious aspect of the infection.
2. Instruct the patient to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand.
3. Advise the patient of the side effects of the medication and ways of minimizing them to ensure compliance.
4. Reassure the patient that after 2-3 weeks of medication therapy, it is unlikely that the patient will infect anyone.
5. Inform the patient to resume activities gradually.
6. Instruct the patient about the need for adequate nutrition and a well-balanced diet to promote healing and to prevent recurrence of the infection.
7. Instruct the patient to increase intake of foods rich in iron, protein, and vitamin C.
8. Inform the patient and family that respiratory isolation is not necessary because family members already have been exposed.
9. Instruct the patient to cover the mouth and nose when coughing or sneezing and to put used tissues into plastic bags.
10. Instruct the patient and family about thorough hand washing.
11. Inform the patient that a sputum culture is needed every 2 – 4 weeks once medication therapy is initiated.
12. Inform the patient that when the results of three sputum cultures are negative, the patient is no longer considered infectious and usually can return to former employment.
13. Advise the patient to avoid excessive exposure to silicone or dust because these substances can cause further lung damage.
14. Instruct the patient regarding the importance of compliance with the treatment, follow-up care, and sputum cultures, as prescribed.
NORMAL LUNG SOUNDS
●Bronchia breathe sounds- loud, harsh, high-pitch (heard over the trachea, bronchi – between clavicles and midsternum and over the main bronchus.)
●Bronchovesicular breathe sounds- blowing sounds, moderate intensity and pitch. (Heard over large airways, on either side of sternum, at the Angle of Louis, and between scapulae.)
●Vesicular breathe sounds-soft, breezy quality, low-pitched. (Heard over the peripheral lung area, heard best at the base of the lungs.)
ADVENTITIOUS LUNG SOUNDS
Crackles:
Popping, crackling, bubbling, moist sounds on inspiration.
(Pneumonia, pulmonary edema, pulmonary fibrosis, CHF.)
Rhonchi:
Rumbling sound on expiration.
(Pneumonia, emphysema, bronchitis, bronchiectasis.)
Wheezes:
High-pitched musical sound during both inspiration and expiration (louder).
(Emphysema, asthma, foreign bodies, anaphylaxis.)
Pleural Friction Rub:
Dry grating sound on both inspiration and expiration.
(Pleurisy, pneumonia, pleural infarction.)
●Crackles-Fluid ●Rhonchi-Secretions/mucus. ●Wheezing-Narrowing/blockage. ●Pleural friction rub-inflamed pleura.
2. Sputum culture
A definitive diagnosis is made by demonstrating the presence of mycobacteria in a culture.
3. Chest x-ray
Supplemental to sputum culture and are not definitive alone.
4. Gastric washing (aspiration of lavaged contents from the fasting stomach).
Infant and young children only – because an infant or young child often swallows sputum rather than expectorates it.
Specimen is taken in the early morning before breakfast.
Mantoux test interpretation
An induration of 5 or more millimeters
is considered positive in
●HIV-infected persons.
●A recent contact of a person with TB disease.
●Persons with fibrotic changes on chest radiograph consistent with prior TB.
●Patients with organ transplants.
●Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of >15 mg/day of prednisone for 1 month.
An induration of 10 or more millimeters
is considered positive in
●Recent immigrants (< 5 years) from high prevalence countries.
●Injection drug users.
●Residents and employees (us nurses) of high-risk congregate settings.
●Mycobacteriology laboratory personnel.
●Persons with clinical conditions that place them at high risk.
●Children < 4 years of age.
An induration of 15 or more millimeters
is considered positive in any person, including persons with no known risk factors for TB. However, targeted skin testing programs should only be conducted among high-risk groups.
INTERVENTIONS
1. Medications: RIPES – Rifampin (RMP), Isoniazid (INH), Pyrazinamide (PZA), Ethambutol (EMB), Streptomycin
9 month course (INH) – 12 months for patient with HIV ●Isoniazid – body fluids may turn orange. ●Rifampin – urine may turn orange red.
●Advice to take the full course as directed to prevent drug-resistant. ●Direct Observed Treatment program – for patient’s compliance to medication – watch patient to take their medication, look for S/E and answer their questions.
2. Isolation – AIIR Airborne Infection Isolation Room, negative pressure room.
3. PPE use: N-95 – done prior to entry and removed after exiting. – Special individually fitted mask. Gloves gown and goggles/face shield for possible contamination exist.
4. If the patient needs to leave the room, they are required to wear a mask.
5. Handwashing before and after touching the patient.
6. Stress the importance of adequate rest and diet.
7. Instruct patient about measures to prevent transmission of tuberculosis.
8. Respiratory isolation is discontinued when the patient is no longer considered infectious.
9. Two to three weeks of taking the TB medications, the risk of transmission will greatly reduced.
10. Case finding and follow-up with known contacts is critical to decrease the number of cases of individuals with active TB.
Note: Rifampin: Monitor liver or renal function, CBC, ophthalmologic exam. INH – LFT should be done before therapy. Administer with Vitamin B6 to prevent peripheral neuropathy.
UNIVERSAL PRECAUTION: Standard precautions used for all clients regardless of the diagnosis.
Gloves:
Required whenever contact with body fluids is likely. Blood, secretions, excretions, mucous membrane, non-intact skin (except sweats)
Gown:
Required if soiling is likely.
Mask:
Required if splashes of blood or body fluids are likely
Handwashing:
ALWAYS: ●Before and after contact with the clients. ●Immediately after gloves are removed/exposure to body fluids. ●Before touching non-contaminated surface or item. ●After contact with patient’s surrounding.
DONNING PERSONAL PROTECTIVE EQUIPMENT:
• Gowns
• Mask or Respirator
• Goggles or Face shields
• Gloves
REMOVING PERSONAL PROTECTIVE EQUIPMENT
• Gloves
• Goggles or Face Shields
• Gown
• Mask or Respirator
Blood-Borne Virus Infection (BBVI): HIV, Hepatitis B virus and Hepatitis C virus.
Immediate actions after exposure to blood or potentially infectious body fluids include:
• Removing any contaminated clothing
• Allowing the exposed site to bleed freely
• Cleansing the site (e.g. NEEDLE STICK or cut) by washing with soap and water. A skin antiseptic can be applied, when available, as a first aid measure
• Flushing splashes or sprays to skin, nose, or mouth with water or saline.
• Irrigating splashes to the eyes with clean water, saline or sterile irrigants.
Note: Cleansing with skin antiseptics or bleach is not advised and “squeezing” the wound will not reduce the potential for acquiring BBVI.
Treatment after Exposure: Treatment after exposure depends on the susceptibility of the recipient (person exposed) and the infectivity of the blood/body fluid from the source.
-
HBV-Hepatitis B immune Globulin (HBIG) – vaccine is available.
-
HCV-No vaccine. Consult specialist.
-
HIV-No vaccine. HIV PEP-Post-Exposure Prophylaxis (within 1-2hrs). Consult specialist.
PATIENT TEACHING POST-OPERATIVE
Incentive spirometry:
1. Instruct the patient to assume a sitting or upright position.
2. Instruct the patient to blow slowly first away from the mouthpiece.
3. Instruct the patient to place his/her mouth tightly around the mouthpiece.
4. Instruct the patient to inhale slowly to raise and maintain the flow rate indicator (ball) between 600 and 900 marks or as far the patient can do.
5. Instruct the patient to hold his/her breath 5 seconds, and then exhale through pursed lips. Instruct the patient to repeat this process 10 x every hour.
Deep-breathing and coughing exercises:
1. Position patient in sitting position (best for lung expansion and DBE).
2. Instruct the patient to breathe deeply 3x, inhaling through the nostrils and exhaling slowly through pursed lips.
3. Instruct the patient that the 3rd breath should be held for 3 seconds, then, cough deeply 3x. Perform exercise q1-2 hours.
Leg and foot exercises:
1. Calf pumping – Instruct the patient to move both ankles by pointing the toes up and then down.
2. Thigh setting – Instruct the patient to press the back of the knees against the bed, and then relax the knees, this contracts and relaxes the thigh and calf muscle to prevent thrombus formation.
3. Foot circles – Instruct the patient to rotate each foot in a circle.
4. Hip and knee movements – Instruct the patient to flex the knee and thigh and to straighten the leg and hold the position for 5 seconds before lowering (not performed if the patient is having abdominal surgery or if the patient has a back problem).
Splinting the incision:
1. If the surgical incision is abdominal or thoracic, instruct the patient to place a pillow, or one hand with the other hand on top, over the incisional area.
2. During deep breathing and coughing, the patient presses gently against the incisional area to splint or support it.
RESPIRATORY MEDICATIONS: CHECK
Ventolin (albuterol)
C- Bronchodilator
H- as ordered, before activity and PRN
E- Increased ability to breathe because of bronchodilation, prevention of asthma attack.
C- No OTC drugs without MD advice always administer first before other medication then wait 1min for the same meds and 3-5 mins for other medication.
●Limit caffeine products such as chocolate, coffee, tea and cola.
●Avoid getting aerosol in the eyes (blurring/irritation).
●Use spacer for elderly and young children.
●Stop the product and notify MD if bronchospasm occurs.
●Instruct the patient how to use the inhaler properly.
●Tract the number of inhalation used and always brings the inhaler with him/her.
●Watch out for S/E: Palpitation, tachycardia, hypertension, anxiety, N/V, heart burn and tremor. Restlessness – temporary, reassure patient/guardian.
K- Assess respiratory function; Vital capacity, FEV, ABG’s, lung sounds, heart rate and rhythm; BP, sputum.
●Determine the patient has not received theophylline therapy before giving the dose, to prevent additive effect.
●Assess patient ability to self medicate.
●Monitor evidence of allergic reaction to medication, paradoxical bronchospasm, withhold dose, and notify prescriber.
Flovent (fluticasone)
C-Corticosteroids, anti-asthmatics.
H-As prescribed, bronchodilator first before Flovent.
E-Decreased inflammation and severity of asthma.
C-Advise patient to use bronchodilator first 3-5 mins before taking the Flovent (if taking both).
●Advice patient to avoid smoking, those with URTI’s, and those not immunized against chicken pox or measles.
●Advice patient to rinse mouth after taking the medication to prevent oral candidiasis (thrush).
●Common S/E: pharyngitis, dysphonia, hoarseness, oral thrush, URI. Uncommon: Angioedema, bronchospasm, hyperglycemia, cushingoid features, growth retardation
K-Assess respiratory status: lung sounds and PFT.
●Assess withdrawal symptoms from ORAL corticosteroids: depression, joint pains, fatigue.
●Monitor adrenal insufficiency: nausea, weakness, fatigue, hypotension, hypoglycemia, anorexia may occur; may be life-threatening. -Monitor growth rate in children.
REFERENCES:
Preparation guide for professional examination of the OIIQ, PRN comprendre pour intervenir guide d'evaluation, de surveillance clinique, et d'intervention infermieres, Fundamentals of nursing potter-perry, Ultimate learning guide nursing review , The ABC's of passing philippine nursing exam, Medical-surgical nursing assessment and management of clinical problem, Saunders Comprehensive review for the NCLEX-RN examination, Mosby drug guide for nurses, Critical thinking in nursing Winningham & Pressure
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