Chronic airflow limitation (CAL)
is a group of chronic lung diseases that includes asthma, chronic bronchitis, and pulmonary emphysema.
chronic obstructive pulmonary disease (COPD)
Any lung disease characterized by bronchospasm and dyspnea, such as emphysema and chronic bronchitis.
Asthma,
unlike COPD, is a chronic disease with intermittent reversible airflow obstruction and wheezing.
Airway obstruction can occur in two ways:
(1) inflammation and (2) airway hyperresponsiveness that leads to bronchoconstriction.
Bronchospasm
is a narrowing of the bronchial tubes through constriction of the smooth muscle around and within the bronchial walls.
The patient with asthma usually has a pattern of
intermittent episodes of dyspnea (shortness of breath), chest tightness, coughing, wheezing, and increased mucus production.
The most accurate tests for asthma are
the pulmonary function tests (PFTs) measured using spirometry.
The most important PFTs for a patient with asthma are:
� Forced vital capacity (FVC) (volume of air exhaled from full inhalation to full exhalation)
� Forced expiratory volume in the first second (FEV1) (volume of air blown out as hard and fast as possible during the first second of the most forceful exhalati
What kind of medications can trigger asthma?
aspirin, NSAIDs, beta blockers
Control therapy drugs (formerly called preventive drugs)
are drugs used to reduce airway responsiveness to prevent asthma attacks from occurring. They are used every day, regardless of symptoms.
Reliever drugs
are those used to actually stop an attack once it has started.
Bronchodilators
increase bronchiolar smooth muscle relaxation. They have no effect on inflammatory processes.
Corticosteroids
decrease inflammatory and immune responses in many ways, including by preventing the synthesis of mediators.
Status asthmaticus
is a severe, life-threatening acute episode of airway obstruction that intensifies once it begins and often does not respond to usual therapy.
The two major changes that occur with emphysema are
loss of lung elasticity and hyperinflation of the lung
Emphysema is classified as
panlobular, centrilobular, or paraseptal depending on the pattern of destruction and dilation of the gas-exchanging units (acini)
Bronchitis
is an inflammation of the bronchi and bronchioles caused by exposure to irritants, especially cigarette smoke. The irritant triggers inflammation, vasodilation, mucosal edema, congestion, and bronchospasm. Bronchitis affects only the airways, not the alve
Greatest risk factor for COPD
Smoking
Major problems that occur with COPD,
hypoxemia, acidosis, respiratory infection, cardiac failure, and dysrhythmias.
Hypoxemia and acidosis occur because the patient with COPD has
reduced gas exchange, leading to decreased oxygenation and increased carbon dioxide levels. These problems reduce cellular function.
Respiratory infection risk increases because
of the increased mucus and poor oxygenation.
Cardiac failure, especially cor pulmonale (right-sided heart failure caused by pulmonary disease), occurs with bronchitis or emphysema because
Air trapping, airway collapse, and stiff alveolar walls increase the lung tissue pressure, making blood flow through lung vessels more difficult.
Key Featues of Cor Pulmonale
� Hypoxia and hypoxemia
� Increasing dyspnea
� Fatigue
� Enlarged and tender liver
� Warm, cyanotic hands and feet, with bounding pulses
� Cyanotic lips
� Distended neck veins
� Right ventricular enlargement (hypertrophy)
� Visible pulsations below the st
Cardiac dysrhythmias are common in patients with COPD because
They result from hypoxemia (from decreased oxygen to the heart muscle), other cardiac disease, drug effects, or acidosis.
A silent chest may indicate
serious airflow obstruction or pneumothorax.
The lung volumes measured for COPD are
vital capacity (VC), residual volume (RV), and total lung capacity (TLC)
The RV increase reflects
the trapped, stale air remaining in the lungs.
The priority problems for patients with chronic obstructive pulmonary disease (COPD) are:
1 Hypoxemia with hypercapnia related to alveolar-capillary membrane changes, reduced airway size, ventilatory muscle fatigue, excessive mucus production, airway obstruction, diaphragm flattening, fatigue, and decreased energy
2 Weight loss related to dysp
The mainstays of nursing management for patients with COPD include
airway maintenance, monitoring, breathing techniques, positioning, effective coughing, oxygen therapy, exercise conditioning, suctioning, hydration, and use of a vibratory positive-pressure device.
Coughing effectively can
improve gas exchange by helping increase airflow in the larger airways.
teach the patient with COPD to drink at least
2 to 3 L/day.
The more common surgical procedure for patients with emphysema is
lung reduction surgery.
The purpose of lung reduction surgery is
to improve gas exchange through removal of hyperinflated lung tissue.
What is one of the most common complications of COPD?
Pneumonia
Cystic fibrosis (CF)
is a genetic (autosomal recessive) disease that affects many organs and lethally impairs pulmonary function.
The underlying problem of CF is
blocked chloride transport in the cell membranes. The error in chloride transport causes the formation of mucus that has little water content and is thick. The thick, sticky mucus causes problems in the lungs, pancreas, liver, salivary glands, and testes.
The pulmonary problems of CF result from
the constant presence of thick, sticky mucus and are the most serious complications of the disease. The mucus narrows airways, reducing airflow and interfering with oxygenation. The constant presence of mucus results in chronic respiratory tract infection
The major diagnostic test for CF is
sweat chloride analysis. The defect in chloride movement prevents absorption of sodium chloride in the sweat glands; thus more chloride than normal is present in the sweat. The sweat chloride test is positive for CF when the chloride level in the sweat ra
Nonpulmonary manifestations of CF include
abdominal distention, gastroesophageal reflux, rectal prolapse, foul-smelling stools, and steatorrhea (excessive fat in stools).
Pulmonary manifestations caused by CF are
progressive. Respiratory infections are frequent or chronic with exacerbations. Patients usually have chest congestion, limited exercise tolerance, cough, sputum production, use of accessory muscles, and decreased pulmonary function (especially forced vit
A serious bacterial infection for patients with CF is
Burkholderia cepacia. The organism lives in the respiratory tracts of patients with CF and becomes resistant to antibiotic therapy relatively quickly. It is spread by casual contact from one CF patient to another.
The surgical management of the patient with CF involves
lung and/or pancreatic transplantation.
The most common incision used for lung transplantation is
a transverse thoracotomy ("clamshell").
Major problem areas after lung transplantation are
bleeding, infection, and transplant rejection.
General pulmonary hypertension can occur as a
complication of other lung disorders.
Primary pulmonary arterial hypertension (PAH) (also known as idiopathic pulmonary hypertension) occurs
in the absence of other lung disorders, and its cause is unknown although exposure to some drugs increases the risk.
SEVERITY CLASSIFICATION FOR PRIMARY PULMONARY ARTERIAL HYPERTENSION
CLASS I
Pulmonary hypertension diagnosed by pulmonary function tests and right-sided cardiac catheterization
No limitation of physical activity
Moderate physical activity does not induce dyspnea, fatigue, chest pain, or light-headedness
SEVERITY CLASSIFICATION FOR PRIMARY PULMONARY ARTERIAL HYPERTENSION
CLASS II
No manifestations at rest
Mild to moderate physical activity induces dyspnea, fatigue, chest pain, or light-headedness
SEVERITY CLASSIFICATION FOR PRIMARY PULMONARY ARTERIAL HYPERTENSION
CLASS III
No or slight manifestations at rest
Mild (less than ordinary) activity induces dyspnea, fatigue, chest pain, or light-headedness
SEVERITY CLASSIFICATION FOR PRIMARY PULMONARY ARTERIAL HYPERTENSION
CLASS IV
Dyspnea and fatigue present at rest
Unable to carry out any level of physical activity without manifestations
Manifestations of right-sided heart failure apparent (dependent edema, engorged neck veins, enlarged liver)
With restrictive disease, the lung tissues
thicken, causing reduced gas exchange and "stiff" lungs that do not expand well (Pruitt, 2008). Unlike obstructive problems, air trapping does not occur and the patient does not develop a "barrel chest." Often the onset of these disorders is slow and dysp
sarcoidosis
A granulomatous disorder of unknown cause that can affect any organ but most often involves the lung.
Sarcoidosis Manifestations include
enlarged lymph nodes in the hilar area of the lungs, lung infiltrate on chest x-ray, skin lesions, and eye lesions. The first indication of disease may be an abnormal chest x-ray in an otherwise healthy patient. The most common symptoms include cough, dys
Idiopathic pulmonary fibrosis
is a common restrictive lung disease. The typical patient is an older adult with a history of cigarette smoking or chronic exposure to inhalation irritants such as metal particles, dust, organic chemicals, wood fires, or exposure to the drug amiodarone (C
Latency (allergic) asthma
Airway narrowing related only to workplace exposures
Atopic allergic response to industrial irritants
Develops after a period of exposure (from several weeks to several years)
Characterized by airflow limitation
Usually resolves when exposure ceases
Obstr
Irritant-induced asthma
Manifestations appear only in the workplace
First onset usually occurs within 24 hours of exposure
Common irritants are chlorine, ammonia, and phosgene
Characterized by sloughing of epithelium, thickening of the basement membranes, and mucosal inflammatio
Silicosis
Chronic fibrosis from long-term inhalation of silica dust
Found among people working in mines, stone quarries, and foundries. Also found in people working in these industries: glass making, pottery, sandblasting, tile and brick making, soap and polishes,
Coal Miner's Disease (Black Lung Disease)
Massive deposits of coal dust in the lungs leading to diffuse fibrosis
Develops earlier among miners who smoke
Early manifestations are similar to bronchitis
Emphysema is a late development
Restrictive disease
Asbestosis
Occurs among people who work in asbestos mines, building construction/remodeling, and shipyards
Characterized by diffuse pleural thickening and diaphragmatic calcification
Restrictive disease
Talcosis
Occurs among people who work in industries that manufacture paint, ceramics, roofing materials, cosmetics, and rubber goods
Restrictive disease
Berylliosis
Occurs among people who work in industries in which metal is heated (steel mills, welding) or metal is machined, creating dust
Has a genetic component for increased susceptibility to disease after beryllium exposure
Restrictive disease
Extrinsic Allergic Alveolitis
"Farmer's Lung"
"Bird Fancier's Lung"
"Machine Operator's Lung
Hypersensitivity pneumonitis as an immunologic response to inhaling dust or chemical that contains bacterial or fungal antigens
Characterized by formation of granulomas with central necrosis in the alveoli and surrounding blood vessels
Restrictive disease
Bronchiolitis obliterans organizing pneumonia (BOOP)
is an inflammatory process that allows connective tissue plugs to form in the lower airways and the tissue between the alveoli. The luminal inflammation triggers white blood cell clumping with fibroblast (connective cell) growth that occludes and eventual
Most primary lung cancers arise from
the bronchial epithelium.
WARNING SIGNALS ASSOCIATED WITH LUNG CANCER
� Hoarseness
� Change in respiratory pattern
� Persistent cough or change in cough
� Blood-streaked sputum
� Rust-colored or purulent sputum
� Frank hemoptysis
� Chest pain or chest tightness
� Shoulder, arm, or chest wall pain
� Recurring episodes of ple
wedge resection
Removal of small, localized areas of disease.
lobectomy
Surgical removal of an entire lung lobe.
pneumonectomy
Removal of an entire lung, including all blood vessels.
All of these clients are being cared for on the intensive care step-down unit. Which client should the charge nurse assign to an RN who has floated from the pediatric unit?
A. Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-
Client with acute asthma episode who is receiving oxygen at FiO2 of 60% by non-rebreather mask.
The RN and the nursing assistant are working together to provide care for a group of clients. Which of these nursing activities could the RN delegate to the nursing assistant?
A. Auscultate for improvement in breath sounds in a client who has had a right
Reinforce the use of slow expiration through pursed lips to maximize gas exchange for a client with sarcoidosis.
A client has just been admitted to the intensive care unit (ICU) after having a left lower lobectomy with a video-assisted thoracoscopic surgery (VATS). Which of these requests will the nurse implement first?
A. Adjust oxygen flow rate to keep O2 saturati
Adjust oxygen flow rate to keep O2 saturation at 93% to 100%.
The change-of-shift report has just been completed on the medical-surgical unit. Which of the following clients will the oncoming nurse plan to assess first?
A. Client with COPD who is ready for discharge but is not able to pay for prescribed home medicat
Client with cystic fibrosis (CF) who has an elevated temperature and a respiratory rate of 38.
A client with asthma has pneumonia, is reporting increased shortness of breath, and has inspiratory and expiratory wheezes. All of these medications are prescribed. Which medication should the nurse administer first?
A. Albuterol (Proventil) 2 inhalations
Albuterol (Proventil) 2 inhalations
Your client has been diagnosed with chronic bronchitis and started on a mucolytic. What is the rationale for ordering a mucolytic for this client?
A. Mucolytics decrease secretion production.
B. Mucolytics increase gas exchange in the lower airways.
C. Mu
Mucolytics thin secretions, making them easier to expectorate.
The client has asthma that only gets worse during the summer. She tells the nurse she will be taking a medicine every day so she does not get short of breath when she walks to work. About which medicine does the nurse need to educate the client?
A. Albute
Montelukast (Singulair)
The client is a marathon runner who has asthma. Which category of medication is used as a rescue inhaler?
A. Corticosteroids
B. Long-acting beta agonists
C. NSAIDs
D. Short-acting beta agonists
Short-acting beta agonists
A client has been diagnosed with asthma. Which statement below indicates that he correctly understands how to use an inhaler with a spacer correctly?
A. "I don't have to wait between the two puffs if I use a spacer."
B. "If the spacer makes a whistling so
If the spacer makes a whistling sound, I am breathing in too rapidly.
What does the nurse do first when setting up a safe environment for the new client on oxygen?
A. Ensures that staff wear protective clothing
B. Ensures that no combustion hazards are present in the room
C. Sets the oxygen delivery to maintain no fewer tha
Ensures that no combustion hazards are present in the room
For relief of hypoxemia in the newly admitted client with chronic obstructive pulmonary disease (COPD), what does the client most likely need?
A. Oxygen flow rate of 1 to 2 L/min via nasal cannula
B. Oxygen flow rate of 2 to 4 L/min via nasal cannula
C. O
Oxygen flow rate of 1 to 2 L/min via nasal cannula
Because clients with cystic fibrosis (CF) are at increased risk for infection, what does the nurse advise the client with CF to do?
A. Avoid Cystic Fibrosis Foundation-sponsored events.
B. Avoid the hospital.
C. Stay at home most of the time.
D. Use an an
Avoid Cystic Fibrosis Foundation-sponsored events.
While the nurse is talking with the postoperative thoracic surgery client, the client coughs and the chest tube collection water seal chamber bubbles. What does the nurse do?
A. Calmly continues talking
B. Checks the tube for blocks or kinks
C. Immediatel
Calmly continues talking
An environmental assessment of a factory is conducted, and inhalation exposure with a high level of particulate matter is found. What does the factory nurse do to generate the quickest compliance?
A. Encourages proper building ventilation
B. Refers worker
Teaches workers how to use a mask
After receiving education on the correct use of emergency drug therapy for asthma, which statement by the client indicates understanding of the nurse's instructions?
A. "Asthma drugs help everybody breathe better."
B. "I must carry my emergency inhaler on
I must have my emergency inhaler with me at all times.
The client says, "I hate this stupid COPD." What is the best response by the nurse?
A. "Then you need to stop smoking."
B. "What is bothering you?"
C. "Why do you feel this way?"
D. "You will get used to it.
What is bothering you?
Which statement by the client with chronic obstructive pulmonary disease (COPD) indicates the need for additional follow-up instruction?
A. "I don't need to use my oxygen all the time."
B. "I don't need to get the flu shot."
C. "I need to eat more protein
I don't need to get the flu shot.
A client is admitted with asthma. How is this disease differentiated from other chronic lung disorders?
A. It affects only young people.
B. The client has dyspnea.
C. The client is coughing.
D. The client is symptom free between exacerbations.
The client is symptom free between exacerbations.
In a presentation to middle school students, what does the nurse teach as the major risk factor for lung cancer?
A. Alcohol consumption
B. Asbestos exposure
C. Cigarette smoking
D. Smoking marijuana
Cigarette smoking
The nurse has been teaching improved airflow techniques to the client, who has continued to have restrictive breathing problems. Which is the best indicator of success?
A. Peak flowmeter readings that are yellow after the third reading
B. Productive cough
SpO2 level of 92% after ambulating 50 feet
A newly diagnosed client with asthma says that his peak flow meter is reading 82% of his personal best. What does the nurse do?
A. Nothing. This is in the green zone.
B. Provides the rescue drug and reassesses
C. Provides the rescue drug and seeks emergen
Repeats the peak flow test
The nurse is teaching the client who has been newly diagnosed with cancer. For which side effect specific to radiation does the nurse teach prevention techniques?
A. Hair loss
B. Increased risk for sunburn
C. Loss of appetite
D. Pain at site of treatment
Increased risk for sunburn
After surgery for placement of a chest tube, the client reports burning in the chest. What does the nurse do first?
A. Assesses airway, breathing, and circulation
B. Calls for the Rapid Response Team
C. Checks the patency of the chest tubes
D. Listens for
Assesses airway, breathing, and circulation