tortuous, or calcified. Auscultation over the main arteries is useful, as a bruit (sound produced by turbulent flow of blood through an irregular or stenotic lumen) often indicates an atheroma- tous plaque. A bruit over the right side of the neck is a possible indication of innominate artery involvement.
PSYCHOSOCIAL. Occlusive diseases are chronic or lead to chronic illness. They are usually slow in onset, and much irreversible vascular damage may have occurred before symptoms are severe enough to bring the patient for treatment. Treatment is often long and tedious and brings additional concerns regarding finances, curtailment of usual social outlets, and innumerable other problems. Assess the patient’s ability to cope with a chronic illness.
104 Arterial Occlusive Disease
PERIOPERATIVE CARE. In the preoperative stage, assess the patient’s circulatory status by observing skin color and temperature and checking peripheral pulses. Provide analgesia as needed. Use an infusion monitor or pump to administer heparin intravenously. Note any signs of cerebrovascular accident, such as periodic blindness or numbness in a limb.
Arterial Occlusive Disease 105
Medication or
Drug Class Dosage Description Rationale
Pharmacologic Highlights Aspirin
Anticoagulants Fibrinolytics
80–325 mg
Varies by drug Varies by drug
Antiplatelet
Prolongs clotting time Dissolves existing thrombi
Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2.
Prevents extension of a clot and inhibiting further clot formation Used when required to preserve organ and limb function.
Other Drugs: Intermittent claudication caused by chronic arterial occlusive disease may be treated with pentoxifylline (Trental), which can improve blood flow through the capillaries by increasing red blood cell flexibility. Antiplatelet agents: dipyridamole, ticlopidine, clopidogrel bisulfate (Plavix); Anticoagulant: enoxaparin sodium (Lovenox).
Independent
PREVENTION AND TEACHING. Emphasize to the patient the need to quit smoking or using tobacco and limit caffeine intake. Recommend maintaining a warm environmental temperature of about 21°C (70°F) to prevent chilling. Teach the patient to avoid elevating the legs or using the knee Gatch on the bed, to keep legs in a slightly dependent position for periods during the day, to avoid crossing the legs at the knees or ankles, and to wear support stockings. Explain why the patient needs to avoid pressure on the affected extremity and vigorous massage, and recom- mend the use of padding for ischemic areas.
Stress the importance of regular aerobic exercise to the patient. Explain that activity improves circulation through muscle contraction and relaxation. Exercise also stimulates collateral circula- tion that increases blood flow to the ischemic area. Recommend 30 to 40 minutes of activity with warm-up and cool-down activities on alternate days. Also suggest walking at a slow pace and per- forming ankle rotations, ankle pumps, and knee extensions daily. Recommend Buerger-Allen exer- cises, if indicated. If intermittent claudication is present, stress to the patient the importance of allowing adequate time for rest between exercise and of monitoring one’s tolerance for exercise.
Provide good skin care, and teach the patient to monitor and protect the skin. Recommend the use of moisturizing lotion for dry areas, and demonstrate meticulous foot care. Advise the patient to wear cotton socks and comfortable, protective shoes at all times and to change socks daily. Advise the patient to seek professional advice for thickened or deformed nails, blisters, corns, and calluses.
Stress the importance of avoiding the application of direct heat to the skin. The patient also needs to know that arterial disorders are usually chronic. Medical follow-up is necessary at the onset of skin breakdown such as abrasions, lesions, or ulcerations to prevent advanced disease with necrosis.
DOCUMENTATION GUIDELINES
• Physical findings: Presence of redness, pallor, skin temperature, peripheral pulses, trophic changes, asymmetrical changes in pulse quality, capillary blanch, condition of skin
• Neurological deficits: Tenderness to touch, lameness, sensory or motor dysfunction
• Response to balanced activity: Lameness, pain, level of activity that produces pain
• Presence of complications: Infection, ulcers, gangrene, loss pulses
DRG Category: 096 Mean LOS: 5.2 days
Description: MEDICAL: Bronchitis and Asthma, Age !17 with CC
• Adherence to the rehabilitation program: Attitude toward exercise, changes in symptoms as response to exercise
DISCHARGE AND HOME HEALTHCARE GUIDELINES
PREVENTION. To prevent arterial occlusive disease from progressing, teach the patient to decrease as many risk factors as possible. Quitting cigarette smoking and tobacco use is of utmost importance and may be the most difficult lifestyle change. Behavior modification tech- niques and support groups may be of assistance with lifestyle changes.
MEDICATIONS. Be sure the patient understands all medications, including the dosage, route, action, adverse effects, and need for routine laboratory monitoring for anticoagulants.
ADHERENCE TO THE REHABILITATION PROGRAM. Ensure that the patient under- stands that the condition is chronic and not curable. Stress the importance of adhering to a bal- anced exercise program, using measures to prevent trauma and reduce stress. Include the patient’s family in the plans.
106 Asthma
Asthma
A
sthma is classified as an intermittent, reversible, obstructive disease of the lungs. It is a grow- ing health problem in the United States, with approximately 20 million people affected. In the past 20 years, the number of children with asthma has increased markedly, and it is not the lead- ing serious chronic illness in children. Unfortunately, approximately 75% of children with asthma continue to have chronic problems in adulthood. The total deaths annually from asthma has increased by over 100% since 1979 in the United States.Asthma is a disease of the airways that is characterized by airway inflammation and hyper- reactivity (increased responsiveness to a wide variety of triggers). Hyper-reactivity leads to air- way obstruction due to acute onset of muscle spasm in the smooth muscle of the tracheo- bronchial tree, thereby leading to a narrowed lumen. In addition to muscle spasm, there is swelling of the mucosa, which leads to edema. Lastly, the mucous glands increase in number, hypertrophy, and secrete thick mucus.
In asthma, the total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV) increase, but the hallmark of airway obstruction is a reduction in ratio of the forced expiratory volume in 1 second (FEV1) and the FEV1 to the forced vital capacity (FVC).
Although asthma can result from infections (especially viral) and inhaled irritants, it often is the result of an allergic response. An allergen (antigen) is introduced to the body, and sensitizing antibodies such as immunoglobulin E (IgE) are formed. IgE antibodies bind to tissue mast cells and basophils in the mucosa of the bronchioles, lung tissue, and nasopharynx. An antigen-anti- body reaction releases primary mediator substances such as histamine and slow-reacting sub- stance of anaphylaxis (SRS-A) and others. These mediators cause contraction of the smooth muscle and tissue edema. In addition, goblet cells secrete a thick mucus into the airways that causes obstruction. Intrinsic asthma results from all other causes except allergies, such as infec- tions (especially viral), inhaled irritants, and other causes or etiologies. The parasympathetic nervous system becomes stimulated, which increases bronchomotor tone, resulting in bron- choconstriction. The classification for asthma is described in Table 9.
Asthma 107
•TABLE 9 Classification of Asthma CLASSIFICATION DESCRIPTION Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
• Less than twice a week: cough, wheeze, chest tightness, difficulty breathing
• Brief flare-ups with varying intensity; no symptoms between flare-ups
• Less than twice a month: nighttime symptoms
• Lung function tests: FEV1 ≥80% normal values; peak flow "20% variability a.m.-to-a.m. or a.m.-to-p.m., day-to-day
• Three to six times a week: cough, wheeze, chest tightness, difficulty breathing
• Flare-ups may affect activity level
• Three to four times a month: nighttime symptoms
• Lung function tests: FEV1 )80% normal values; peak flow
"20–30% variability a.m.-to-a.m. or a.m.-to-p.m., day-to-day
• Daily: cough, wheeze, chest tightness, difficulty breathing
• Flare-ups may affect activity level
• Five or more times a month: nighttime symptoms
• Lung function tests: FEV1 !60% but "80% normal values; peak flow !30%
variability a.m.-to-a.m. or a.m.-to-p.m., day-to-day
•Continual: cough, wheeze, chest tightness, difficulty breathing
• Frequently: nighttime symptoms
• Lung function tests: FEV1 &60% normal values; peak flow !30% variability a.m.-to-a.m. or a.m.-to-p.m., day-to-day
CAUSES
The main triggers for asthma are allergies, viral infections, autonomic nervous system imbal- ances that can cause an increase in parasympathetic stimulation, medications, psychological factors, and exercise. Of asthmatic conditions in patients under 30 years old, 70% are caused by allergies. Three major indoor allergens are dust mites, cockroaches, and cats. In older patients, the cause is almost always nonallergic types of irritants such as smog. Heredity plays a part in about one-third of the cases.
GENETIC CONSIDERATIONS
The genetic contributions to the development of asthma have been estimated at between 30%
and 50% for various asthma phenotypes and up to 70% for overall IgE levels in plasma. Candi- date genes are being investigated, but analysis of families with several affected members sug- gests that asthma is most likely related to the activity of a few genes that have a moderate effect rather than a large number of genes, each making a small contribution.
GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS
Although the incidence of asthma is estimated at 1% to 5% in the general population, children have a higher incidence of 12%. Children make up more than a third of the people with asthma.
Asthma is diagnosed more frequently in males under 14 years and over 45 years of age and in females between the ages of 15 and 45. Inner-city children of color have higher morbidity and mortality rates than white chldren. Approximately 80% to 85% of childhood asthma episodes are associated with a prior exposure to a virus.
ASSESSMENT
HISTORY. Because patients (especially children) with asthma have a history of allergies, obtain a thorough description of the response to allergens or other irritants. The patient may
describe a sudden onset of symptoms after exposure, with a sense of suffocation. Symptoms include dyspnea, wheezing, and a cough (either dry or productive) and also chest tightness, restlessness, anxiety, and a prolonged expiratory phase. Ask if the patient has experienced a recent viral infection. Children with an impending asthma attack may have been vomiting because of the tendency to swallow coughed up mucus rather than expectorating it.
PHYSICAL EXAMINATION. The patient with an acute attack of asthma appears ill, with short- ness of breath so severe that he or she can hardly speak. In acute airway obstruction, patients use their accessory muscles for breathing and are often profoundly diaphoretic. Some patients have an increased anteroposterior thoracic diameter. Children with asthma often prefer standing or sitting leaning forward to ease breathing. As airway obstruction becomes more serious, children may develop sternocleidomastoid contractions that indicate an increased expiratory effort, supraclavic- ular contractions that indicate an increased expiratory effort, and nasal flaring. If the patient has marked color changes such as pallor or cyanosis or becomes confused, restless, or lethargic, respi- ratory failure may be on the horizon. Percussion of the lungs usually produces hyper-resonance, and palpation may reveal vocal fremitus. Auscultation reveals high-pitched inspiratory and expira- tory wheezes, but with a major airway obstruction, breath sounds may be diminished. As the obstruction improves, breath sounds may actually worsen as they can be auscultated throughout the lung fields. Usually, the patient also has a prolonged expiratory phase of respiration. A rapid heart rate, mild systolic hypertension, and a paradoxic pulse may also be present.
PSYCHOSOCIAL. The emergency situation and an unfamiliar environment can aggravate the symptoms of the disease, especially if this is the patient’s first experience with the condition. If the patient is a child and the parent is anxious, the child’s level of anxiety increases and the attack may worsen.
108 Asthma
Abnormality with
Test Normal Result Condition Explanation
Diagnostic Highlights
Forced vital capacity (FVC): Maxi- mum volume of air that can be forcefully expired after a maximal lung inspiration
Forced expiratory volume in 1 second (FEV1): Volume of air expired in 1 second from the beginning of the FVC maneuver
Forced expiratory flow (FEF): Max- imal flow rate attained during the middle (25%–75%) of FVC maneuver
Residual volume (RV): Volume of air remaining in lungs at end of a maximal expiration
Functional residual capacity (FRC):
Volume of air remaining in lungs at end of a resting tidal volume
4.0 L
3.0 L
Varies by body size
1.2 L
2.3 L
Decreased
Decreased
Decreased
Increased up to 400% normal Increased up to 200%
Airway obstruction decreases flow rates
Airway obstruction decreases flow rates; hospitalization is recommended if FVC is less than 1 L; FEV1/FVC should be 80% normally, but in asthma, it decreases to as low as 25%
Predicts obstruction of smaller airways
Increased RV indicates obstruc- tion; may remain increased for up to 3 weeks after the attack Increased FRC indicates air trapping
Other Tests:Chest x-ray, skin testing, pulse oximetry, arterial blood gases, serum IgE.
Peak expiratory flow rates (PEFR; maximal flow rate attained during the FVC maneuver;
decreased from baseline during periods of obstruction) may be used at home daily for patients who require daily medications.
PRIMARY NURSING DIAGNOSIS
Ineffective airway clearance related to obstruction from narrowed lumen and thick mucus OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level
INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy; Airway suc- tioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Posi- tioning; Respiratory monitoring
PLANNING AND IMPLEMENTATION Collaborative
Patients often require intravenous fluid replacement. Unless contraindicated by a cardiac prob- lem, 3000 to 4000 mL/day of fluid is usually administered intravenously, which helps loosen secretions and facilitates expectoration of the secretions. Low-flow oxygen therapy based on arte- rial blood gas results is often administered to treat hypoxemia. For the patient with increasing air- way obstruction, endotracheal intubation and perhaps mechanical ventilation may be needed to maintain adequate airway and breathing. Close follow-up is needed when patients are discharged from the hospital because airway hyperactivity usually persists for 4 to 6 weeks after the event.
Asthma 109
Medication or
Drug Class Dosage Description Rationale
Pharmacologic Highlights Bronchodilators
Systemic cortico- steroids
Leukotriene antagonists
Varies by drug
Varies by drug
Varies by drug
Inhaled beta2-adrenergic agonists by metered- dose inhaler (MDI) such as albuterol Methylprednisolone IV;
prednisone PO
Montelukast 10 mg PO daily; zafirlukast, 20 mg PO daily
Reversal of airflow obstruction
Decrease inflammatory response.
Ideal dose is not defined well, but desired outcome is to speed recov- ery and limit symptoms
Inhibits leukotrienes, fatty acids that mediate inflammation, from binding to airway smooth muscle cells; pre- vents rather than reduces symptoms;
used for long-term prevention.
Other Drugs: Xanthines such as theophylline have been used successfully in treating chronic severe steroid-dependent asthmatics. Cromolyn sodium decreases broncho- spasm, but it is not effective for acute bronchospasms and is used as a preventive measure.
Independent
Maintenance of airway, breathing, and circulation is the primary consideration during an acute attack. Patients should be on bedrest to minimize their oxygen consumption and to decrease the work of breathing. Note that patients usually assume a position to ease breathing; some patients breathe more easily while sitting in an upright position: do not impose bedrest on a patient who can breathe only in another position. Ask questions that can be answered by nodding or a brief one-word answer so the patient can conserve energy for breathing. If the patient is a child, allow the parents to stay with the child during acute attacks. Have the parents identify a security item that reassures the child, such as a special blanket or toy, and keep the item with the child at all times. Reinforce cop- ing strategies to the parents, and allow them to express any feelings of guilt and helplessness.
DRG Category: 101 Mean LOS: 4.6 days
Description: MEDICAL: Other Respiratory System Diagnoses with CC For strategies to prevent future attacks, discuss triggers that can induce asthma attacks and ways to avoid them. If the attack is triggered by an allergen, explore with the patient or family the source and discuss possible strategies for eliminating it. Cold air and exercise may increase symptoms.
Aspirin and nonsteroidal anti-inflammatory agents can cause sudden, severe airway obstruction.
Outline the signs and symptoms that require immediate attention. Instruct the patient to notify the physician should she or he develop a respiratory infection that could trigger an attack.
Instruct patients regarding their medications, particularly metered-dose inhalers (MDIs), and the indications for use. It is important that the patient use the bronchodilator MDIs first, then use the steroid inhalers. Explain to patients on steroid inhalers need to rinse their mouths out after using them to avoid getting thrush.
DOCUMENTATION GUIDELINES
• Respiratory status: Patency of airway, auscultation of the lungs, presence or absence of adven- titious breath sounds, respiratory rate and depth
• Response to medications, oxygen therapy, hydration, bedrest
• Presence of complications: Respiratory failure, ruptured bleb that may result in a pneumothorax
DISCHARGE AND HOME HEALTHCARE GUIDELINES
To prevent asthma attacks, teach patients the triggers that can precipitate an attack. Teach the patient and family the correct use of medications, including the dosage, route, action, and side effects. Provide instructions about the proper use of MDIs. In rare instances, asthma can lead to respiratory failure if patients are not treated immediately or are unresponsive to treatment (sta- tus asthmaticus). Explain that any dyspnea unrelieved by medications, and accompanied by wheezing and accessory muscle use, needs prompt attention from a healthcare provider.
110 Atelectasis
Atelectasis
A
telectasis means “incomplete expansion,” and is defined as the collapse of lung tissue because of airway obstruction, an abnormal breathing pattern, or compression of the lung tissue.Obstructive atelectasis is the most common type. When the airway becomes completely obstructed, the gas distal to the obstruction becomes absorbed into the pulmonary circulation and the lung collapses. When gas is removed from portions of the lungs, unoxygenated blood passes unchanged through capillaries, and hypoxemia results.
The obstruction, which occurs at the level of the larger or smaller bronchus, can be caused by a foreign body, tumor, or mucous plugging.
Nonobstructive atelactasis is caused by loss of contact between the parietal and the visceral pleurae, as well as compression, loss of surfactant, and replacement of parenchymal tissue by scarring or infiltrative disease. Abnormal breathing patterns, such as hypoventilation and a slow respiratory rate, can also lead to atelectasis. In such cases, the lung does not fully expand, which causes the lower airways to collapse.
CAUSES
Atelectasis occurs most frequently after surgery and is a major concern for acute care nurses.
Patients with abdominal and/or thoracic surgery are the most susceptible, especially in the older
age group. The duration of the surgery is also a risk factor. Patients in surgery for more than 4 hours have a 50% incidence of severe atelectasis, compared with a 19% incidence for those in surgery for 2 hours. Other causes of atelectasis are mucous plugs in patients who smoke heavily and inflammation from inflammatory lung disease. Atelectasis also occurs in patients with cen- tral nervous system depression following a drug overdose or a critical cerebral event such as a cerebrovascular accident.
GENETIC CONSIDERATIONS
Atelectasis may be seen as a feature of a number of inherited disorders with pulmonary compo- nents including cystic fibrosis.
GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS
Premature infants with idiopathic respiratory distress syndrome develop atelectasis. Atelectasis, however, can occur at any age and equally in men and women and in people of all ethnicities and races. It can occur with a complete obstruction of the lung because of a foreign object, although foreign body aspiration is more common in children under age 4 than in adults. Generally, how- ever, atelectasis occurs most often in the elderly because the aging lung is less compliant.
ASSESSMENT
HISTORY. Assess the patient for such preoperative risk factors as obesity, pre-existing respira- tory problems, and smoking. Because surgical patients are at risk, be alert for component of the postoperative history that may contribute to atelectasis: a decrease in total lung volume because of pain and splinting, changes in breathing patterns from incisional discomfort or medications, advanced age, and a need for an increased fraction of inspired oxygen (FiO2). Other factors include use of narcotic analgesics that depress the respiratory drive, immobility, a decrease in consciousness, muscular weakness, hypotension, sepsis, and use of a nasogastric tube.
PHYSICAL EXAMINATION. The patient may appear asymptomatic if small areas of the lung are involved, or they may appear acutely ill with extreme shortness of breath and clinical signs of oxygen deficit such as confusion, agitation, rapid heart rate, and even combative behavior when large areas are affected. Suprasternal, substernal, and intercostal retractions may be pres- ent, depending on the severity of atelectasis. Percussion reveals a dullness over the affected lung area. When the patient’s breath sounds are auscultated, you may hear decreased breath sounds or even find breath sounds to be absent. In addition, many patients have fine, late inspiratory crack- les and coarse crackles or wheezes with airway obstruction.
PSYCHOSOCIAL. The patient with atelectasis may be very anxious if breathing becomes too difficult. If the atelectasis is a result of foreign body aspiration by a child, the parents may be upset and guilty. Determine the patient’s and parents’ abilities to cope with the stressful situation.
Atelectasis 111
Abnormality with
Test Normal Result Condition Explanation
Diagnostic Highlights
Chest x-ray Clear lung fields Areas of increased density at
the site of alveolar collapse Air-filled lungs are radiolucent (x-rays pass through tissue, which appears as a dark area) but collapsed areas appear more dense. Findings may occur on the second day after the occurrence of atelectasis Other Tests:Pulmonary function tests (PFTs); arterial blood gases (ABGs); fiberoptic bronchoscopy.