Asthma

Definition:
Chronic inflammatory disorder of the airways characterized by reversible airflow obstruction, bronchial hyperresponsiveness, and inflammation.

Etiology & Triggers:

• Genetic predisposition
• Environmental factors:
  • Allergens (pollen, dust mites, mold, animal dander)
  • Irritants (smoke, pollution, perfumes)
  • Respiratory infections
  • Exercise
  • Cold air
  • Stress
  • Certain medications (e.g., NSAIDs, beta-blockers)

Signs & Symptoms:

• Wheezing
• Cough
• Shortness of breath
• Chest tightness
• Dyspnea (difficulty breathing)
• Increased mucus production
• Use of accessory muscles
• Prolonged expiratory phase
• Anxiety

In severe cases:

• Cyanosis
• Decreased level of consciousness
• Status asthmaticus (severe, prolonged asthma attack that does not respond to usual treatment)

Nursing Assessments:

Respiratory Assessment:

• Assess respiratory rate, depth, and effort.
• Auscultate lung sounds (wheezes, diminished breath sounds).
• Assess for use of accessory muscles.
• Monitor oxygen saturation (SpO2).

History:
Allergies, triggers, medications, previous asthma attacks.

Peak Flow Meter Readings:
Assess airflow limitation.

Arterial Blood Gases (ABGs):
May show hypoxemia (low PaO2) and hypercapnia (high PaCO2) during an acute exacerbation.

Nursing Interventions:

Medication Administration:

• Bronchodilators (short-acting beta2-agonists – SABA): Albuterol, levalbuterol. Used for quick relief of acute symptoms.
• Inhaled Corticosteroids (ICS): Fluticasone, budesonide. Used for long-term control of inflammation.
• Long-Acting Beta2-Agonists (LABA): Salmeterol, formoterol. Used for long-term control (always used in combination with an ICS).
• Leukotriene Modifiers: Montelukast, zafirlukast. Used for long-term control.
• Mast Cell Stabilizers: Cromolyn, nedocromil. Used for long-term control (less common).
• Anticholinergics: Ipratropium, tiotropium. Used for acute exacerbations or long-term control.
• Oral Corticosteroids: Prednisone, methylprednisolone. Used for acute exacerbations.
• Theophylline: Bronchodilator. Used rarely due to side effect profile

Oxygen Therapy:
Administer oxygen to maintain adequate oxygen saturation.

Positioning:
Elevate the head of the bed.

Hydration:
Encourage fluids to help thin secretions.

Patient Education:
Teach patients about their medications, how to use inhalers and spacers properly, trigger avoidance, early recognition of symptoms, and when to seek medical attention.

Monitor for Complications:
Status asthmaticus, respiratory failure.

Chronic Obstructive Pulmonary Disease (COPD)

Definition:
Progressive lung disease characterized by airflow limitation that is not fully reversible. Includes emphysema and chronic bronchitis.

Etiology:

• Smoking (most common cause)
• Exposure to environmental pollutants
• Genetic factors (e.g., alpha-1 antitrypsin deficiency)

Emphysema:
Destruction of the alveoli, leading to hyperinflation of the lungs.

Chronic Bronchitis:
Inflammation and excessive mucus production in the bronchial tubes.

Signs & Symptoms:

• Chronic cough
• Excessive sputum production
• Shortness of breath (dyspnea), especially on exertion
• Wheezing
• Chest tightness
• Fatigue
• Weight loss
• Barrel chest (increased anterior-posterior diameter of the chest)
• Use of accessory muscles
• Pursed-lip breathing
• Cyanosis (late sign)
• Clubbing of the fingers (late sign)

Nursing Assessments:

Respiratory Assessment:

• Assess respiratory rate, depth, and effort.
• Auscultate lung sounds (wheezes, crackles, diminished breath sounds).
• Assess for use of accessory muscles.
• Monitor oxygen saturation (SpO2).

History:
Smoking history, exposure to pollutants, medications, previous respiratory infections.

Pulmonary Function Tests (PFTs):
Assess airflow limitation.

Arterial Blood Gases (ABGs):
May show hypoxemia (low PaO2) and hypercapnia (high PaCO2).

Chest X-ray:
May show hyperinflation, flattened diaphragm.

Nursing Interventions:

Medication Administration:

• Bronchodilators (SABA and LABA)
• Inhaled Corticosteroids (ICS)
• Anticholinergics (ipratropium, tiotropium)
• Phosphodiesterase-4 Inhibitors (roflumilast)
• Antibiotics (for infections)

Oxygen Therapy:
Administer oxygen to maintain adequate oxygen saturation (usually 88-92%). Be careful as high oxygen concentration may remove respiratory drive.

Pulmonary Rehabilitation:
Exercise training, breathing techniques, and education to improve quality of life.

Smoking Cessation:
Encourage and support smoking cessation.

Vaccinations:
Influenza and pneumococcal vaccines to prevent infections.

Nutritional Support:
High-calorie, high-protein diet to maintain weight.

Patient Education:
Teach patients about their medications, breathing techniques (pursed-lip breathing, diaphragmatic breathing), energy conservation, smoking cessation, and when to seek medical attention.

Airway Management:
Suction if patients have difficulty clearing the airway.

Monitor for Complications:
Respiratory infections, respiratory failure, cor pulmonale (right-sided heart failure due to pulmonary hypertension).

Pneumonia

Definition:
Infection of the lung parenchyma (tissue).

Etiology:

• Bacteria (Streptococcus pneumoniae is the most common)
• Viruses (influenza, RSV)
• Fungi
• Aspiration (food, liquid, or gastric contents)
• Chemical irritants

Types of Pneumonia:

1. Community-Acquired Pneumonia (CAP):
   Acquired outside of a healthcare setting.
2. Hospital-Acquired Pneumonia (HAP):
   Acquired in a hospital setting (usually 48 hours or more after admission).
3. Aspiration Pneumonia:
   Caused by aspiration of foreign material.

Signs & Symptoms:

• Cough (may be productive or nonproductive)
• Fever
• Chills
• Shortness of breath
• Chest pain (may worsen with breathing or coughing)
• Fatigue
• Headache
• Muscle aches
• Confusion (especially in elderly patients)
• Crackles or wheezes in the lungs
• Pleuritic pain
• Hemoptysis (coughing up blood)

Nursing Assessments:

Respiratory Assessment:

• Assess respiratory rate, depth, and effort.
• Auscultate lung sounds (crackles, wheezes, diminished breath sounds).
• Assess for use of accessory muscles.
• Monitor oxygen saturation (SpO2).

Vital Signs:
Temperature, heart rate, blood pressure.

History:
Risk factors (age, smoking, underlying medical conditions), exposure to pathogens.

Chest X-ray:
Shows infiltrates (areas of consolidation) in the lungs.

Sputum Culture:
Identifies the causative organism.

Blood Cultures:
To rule out bacteremia.

Arterial Blood Gases (ABGs):
May show hypoxemia (low PaO2).

Nursing Interventions:

Medication Administration:

• Antibiotics (for bacterial pneumonia)
• Antivirals (for viral pneumonia)
• Antifungals (for fungal pneumonia)
• Bronchodilators
• Expectorants
• Analgesics (for pain)

Oxygen Therapy:
Administer oxygen to maintain adequate oxygen saturation.

Hydration:
Encourage fluids to help thin secretions.

Chest Physiotherapy:
Postural drainage, percussion, and vibration to help mobilize secretions.

Positioning:
Elevate the head of the bed.

Patient Education:
Teach patients about their medications, the importance of completing the full course of antibiotics, proper coughing techniques, and preventing the spread of infection.

Monitor for Complications:
Sepsis, respiratory failure, empyema (pus in the pleural space).

Tuberculosis (TB)

Definition:
Infectious disease caused by Mycobacterium tuberculosis. Primarily affects the lungs, but can spread to other parts of the body.

Etiology:

Inhalation of airborne droplets containing Mycobacterium tuberculosis.

Risk Factors:

• Close contact with someone with active TB.
• HIV infection.
• Living in crowded or poorly ventilated conditions.
• Immigrants from countries with high TB prevalence.
• IV drug use.
• Diabetes mellitus.
• End-stage renal disease.
• Malnutrition.

Types of TB:

1. Latent TB Infection (LTBI):
   The bacteria are present in the body, but the immune system is able to control them. The person is not infectious and has no symptoms.
2. Active TB Disease:
   The bacteria are actively multiplying and causing disease. The person is infectious and has symptoms.

Signs & Symptoms:

• Persistent cough (lasting 3 weeks or longer)
• Coughing up blood or sputum
• Chest pain
• Fatigue
• Weakness
• Weight loss
• Loss of appetite
• Fever
• Night sweats
• Chills

Nursing Assessments:

• Respiratory Assessment:
• Assess respiratory rate, depth, and effort.
  Auscultate lung sounds (may be normal or have crackles or wheezes).
• History:
  Exposure to TB, travel to high-risk areas, HIV status.
• Tuberculin Skin Test (TST) or Interferon-Gamma Release Assay (IGRA):
  To detect TB infection.
• Chest X-ray:
  May show infiltrates, cavitations, or lymph node enlargement.
• Sputum Smear and Culture:
  To confirm the presence of Mycobacterium tuberculosis.
• Drug Susceptibility Testing:
  To determine if the bacteria are resistant to antibiotics.

Nursing Interventions:

Medication Administration:
Treatment for active TB typically involves a combination of four drugs:

• Isoniazid (INH)
• Rifampin (RIF)
• Pyrazinamide (PZA)
• Ethambutol (EMB)

Treatment is usually given for 6-9 months.

Treatment for LTBI typically involves INH alone or INH and rifapentine.

Airborne Precautions:
Place patients with active TB in a negative-pressure isolation room. Wear an N95 respirator when entering the room.

Patient Education:
Teach patients about their medications, the importance of completing the full course of treatment, preventing the spread of infection (covering coughs, wearing a mask in public), and the signs and symptoms of drug toxicity.

Monitor for Complications:
Drug toxicity, treatment failure, multi-drug resistant TB.

Pneumothorax

Definition:
Accumulation of air in the pleural space, causing lung collapse.

Etiology:

• Spontaneous: Rupture of a bleb (air-filled blister) on the lung surface.
• Traumatic: Penetrating or non-penetrating chest injury.
• Iatrogenic: Caused by medical procedures (e.g., central line insertion, thoracentesis, mechanical ventilation).
• Tension Pneumothorax: Air enters the pleural space on inspiration but cannot escape on expiration, leading to a rapid increase in pressure in the chest. Life-threatening emergency.

Signs & Symptoms:

• Sudden onset of sharp chest pain
• Shortness of breath
• Cough
• Tachycardia
• Decreased or absent breath sounds on the affected side
• Hyperresonance on percussion on the affected side
• Tracheal deviation (in tension pneumothorax)
• Hypotension (in tension pneumothorax)
• Cyanosis (in tension pneumothorax)

Nursing Assessments:

• Respiratory Assessment:
  Assess respiratory rate, depth, and effort.
  Auscultate lung sounds (decreased or absent on the affected side).
  Percuss the chest (hyperresonance on the affected side).
  Monitor oxygen saturation (SpO2).
• Vital Signs:
  Heart rate, blood pressure.
• Chest X-ray:
  Shows air in the pleural space and lung collapse.
• Arterial Blood Gases (ABGs):
  May show hypoxemia (low PaO2).

Nursing Interventions:

• Oxygen Therapy:
  Administer oxygen to maintain adequate oxygen saturation.
• Chest Tube Insertion:
  To remove air from the pleural space and allow the lung to re-expand.
• Monitor Chest Tube Drainage:
  Assess the amount, color, and consistency of drainage.
• Pain Management:
  Administer analgesics for pain.
• Positioning:
  Elevate the head of the bed.
• Patient Education:
  Teach patients about the chest tube, breathing exercises, and activity restrictions.
• Tension Pneumothorax:
  Immediate treatment is needed to relieve the pressure. May require needle decompression followed by chest tube placement.
• Monitor for Complications:
  Infection, bleeding, subcutaneous emphysema.

Oxygen Therapy

Delivery Device	FiO2 (Fraction of Inspired Oxygen)	Flow Rate (L/min)	Notes
Nasal Cannula	24-44%	1-6	Simple, comfortable. FiO2 varies depending on the patient’s breathing pattern.
Simple Face Mask	40-60%	5-8	Higher FiO2 than nasal cannula. Not well-tolerated by patients with claustrophobia. Flow rate must be at least 5 L/min to flush out CO2.
Non-Rebreather Mask	80-95%	10-15	Delivers the highest FiO2 of the non-invasive devices. Reservoir bag must be inflated.
Venturi Mask	24-50%	4-12	Delivers a precise FiO2. Useful for patients with COPD who are at risk for CO2 retention.
High-Flow Nasal Cannula (HFNC)	21-100%	Up to 60	Can deliver heated and humidified oxygen at high flow rates. Well-tolerated.
Non-Invasive Positive Pressure Ventilation (NIPPV)	21-100%	Varies (set by machine)	CPAP (continuous positive airway pressure) delivers a continuous level of pressure. BiPAP (bilevel positive airway pressure) delivers pressure at different levels in inhalation and exhalation.

Airway Management: Suctioning

Definition:
Removal of secretions from the airway (oral, nasal, or tracheal) using a suction catheter.

Indications:

• Visible or audible secretions in the airway.
• Ineffective cough.
• Increased respiratory rate or effort.
• Decreased oxygen saturation.
• Restlessness or anxiety.
• Adventitious breath sounds (e.g., crackles, wheezes).

Types of Suctioning:

1. Oropharyngeal and Nasopharyngeal Suctioning:
   Used to remove secretions from the mouth and pharynx.
2. Nasotracheal Suctioning:
   Used to remove secretions from the trachea via the nose.
3. Endotracheal Suctioning:
   Used to remove secretions from an endotracheal tube or tracheostomy tube.

Nursing Interventions:

Assessment:

• Assess the patient’s respiratory status (rate, depth, effort, oxygen saturation, lung sounds).
• Determine the need for suctioning based on the indications listed above.
• Explain the procedure to the patient (if conscious).

Equipment Preparation:

Gather necessary equipment:

• Suction machine with collection canister
• Suction catheter of appropriate size (generally, half the diameter of the trachea or endotracheal tube)
• Sterile gloves
• Sterile water or saline
• Water-soluble lubricant (for nasotracheal suctioning)
• Oxygen source (if needed)
• Pulse oximeter

Procedure:

Oropharyngeal/Nasopharyngeal Suctioning:

• Position the patient in semi-Fowler’s or high-Fowler’s position (if possible).
• Don sterile gloves.
• Attach the suction catheter to the suction tubing.
• Test the suction by dipping the catheter tip into sterile water.
• Gently insert the catheter along the side of the mouth or into the nares. Do not apply suction during insertion.
• Apply intermittent suction while rotating and withdrawing the catheter. Limit suctioning to 10-15 seconds at a time.
• Rinse the catheter with sterile water between suction passes.

Nasotracheal/Endotracheal Suctioning:

• Pre-oxygenate the patient with 100% oxygen for 30 seconds to 1 minute (if possible).
• Position the patient in semi-Fowler’s or high-Fowler’s position (if possible).
• Don sterile gloves.
• Attach the suction catheter to the suction tubing.
• Test the suction by dipping the catheter tip into sterile water.
• Lubricate the distal end of the catheter with water-soluble lubricant (for nasotracheal suctioning).
• Gently insert the catheter through the nares or endotracheal tube until resistance is met (approximately 4-5 inches for nasotracheal suctioning). Do not apply suction during insertion.
• Withdraw the catheter 1-2 cm before applying suction.
• Apply intermittent suction while rotating and withdrawing the catheter. Limit suctioning to 10-15 seconds at a time.
• Rinse the catheter with sterile water between suction passes.

Post-Suctioning:

• Reassess the patient’s respiratory status (rate, depth, effort, oxygen saturation, lung sounds).
• Encourage the patient to cough and deep breathe.
• Document the procedure, including the amount, color, and consistency of secretions.

Complications:
Hypoxia, bronchospasm, bleeding, infection.

Chest Physiotherapy (CPT)

Definition:
A set of techniques used to help mobilize secretions from the lungs and improve ventilation.

Components of CPT:

• Postural Drainage:
  Positioning the patient in specific ways to use gravity to drain secretions from different lung segments.
• Percussion:
  Clapping on the chest wall with cupped hands to loosen secretions.
• Vibration:
  Applying a vibrating motion to the chest wall to loosen secretions.
• Coughing and Deep Breathing Exercises:
  To help clear secretions from the airways.

Indications:

• Excessive mucus production
• Ineffective cough
• Conditions that impair mucociliary clearance (e.g., cystic fibrosis, COPD, pneumonia)
• Atelectasis (lung collapse)

Contraindications:

• Unstable cardiovascular status
• Pulmonary embolism
• Fractured ribs
• Recent surgery
• Increased intracranial pressure

Nursing Interventions:

Assessment:

• Assess the patient’s respiratory status (rate, depth, effort, oxygen saturation, lung sounds).
• Identify the areas of the lungs that need to be drained.
• Review the patient’s medical history to identify any contraindications to CPT.
• Explain the procedure to the patient.

Postural Drainage:

• Position the patient in the appropriate position to drain the affected lung segment.
• Maintain the position for 10-15 minutes.

Percussion:

• Cup the hands and clap rhythmically on the chest wall over the affected lung segment.
• Avoid percussing over bony prominences (e.g., spine, ribs).
• Continue percussion for 3-5 minutes per lung segment.

Vibration:

• Place the hands flat on the chest wall over the affected lung segment.
• Apply a vibrating motion to the chest wall during exhalation.
• Continue vibration for 3-5 minutes per lung segment.

Coughing and Deep Breathing:

• Encourage the patient to take deep breaths and cough effectively to clear secretions.
• Teach the patient how to splint the chest with a pillow if they have pain.

Post-CPT:

• Reassess the patient’s respiratory status (rate, depth, effort, oxygen saturation, lung sounds).
• Encourage the patient to cough and deep breathe.
• Document the procedure, including the positions used, the duration of each technique, and the amount and characteristics of secretions.

Complications:
Rib fracture, hypoxemia, vomiting, aspiration

Interpretation of Arterial Blood Gases (ABGs)

ABGs provide information about a patient’s acid-base balance, oxygenation, and ventilation.

ECG Component	Normal Values	Description
pH	7.35-7.45	Measures the acidity or alkalinity of the blood.
PaCO2	35-45 mmHg	Partial pressure of carbon dioxide in arterial blood. Measures ventilation.
PaO2	80-100 mmHg	Partial pressure of oxygen in arterial blood. Measures oxygenation.
HCO3-	22-26 mEq/L	Bicarbonate level in arterial blood. Measures metabolic component.
Base Excess (BE)	-2 to +2 mEq/L	Amount of excess or deficit of base in the blood.
SaO2 (O2 Saturation)	95-100%	Percentage of hemoglobin saturated with oxygen.

Steps for ABG Interpretation:

Look at the pH:

1. 35: Acidic
2. 45: Alkalotic

Look at the PaCO2:

1. 35 mmHg: Alkalotic (respiratory)
2. 45 mmHg: Acidic (respiratory)

Look at the HCO3-:

1. 22 mEq/L: Acidic (metabolic)
2. 26 mEq/L: Alkalotic (metabolic)

Determine the Primary Disturbance:

• If the pH is acidic and the PaCO2 is high, the primary disturbance is respiratory acidosis.
• If the pH is acidic and the HCO3- is low, the primary disturbance is metabolic acidosis.
• If the pH is alkalotic and the PaCO2 is low, the primary disturbance is respiratory alkalosis.
• If the pH is alkalotic and the HCO3- is high, the primary disturbance is metabolic alkalosis.

Assess for Compensation:

• If the pH is abnormal and both the PaCO2 and HCO3- are abnormal, the body is attempting to compensate for the primary disturbance.
• Respiratory Compensation: The lungs can quickly adjust PaCO2 levels by increasing or decreasing the respiratory rate.
• Metabolic Compensation: The kidneys can slowly adjust HCO3- levels by excreting or retaining bicarbonate.
• Full Compensation: The pH is within the normal range.
• Partial Compensation: The pH is still abnormal, but the PaCO2 or HCO3- is moving towards the normal range.
• Uncompensated: The pH is abnormal, and the PaCO2 or HCO3- is normal.

Examples:

pH 7.30, PaCO2 50 mmHg, HCO3- 24 mEq/L: Respiratory Acidosis (uncompensated)
pH 7.50, PaCO2 30 mmHg, HCO3- 24 mEq/L: Respiratory Alkal

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