Upper Respiratory Tract Infections 2

Alterations in Respiratory Function John Bert N. Macato RN,EMT, RM

Sinusitis (Acute/ Chronic) 

URTI Cigarette Smoking Allergic rhinitis

Inflammatory Process

Edema of the mucous membrane

Hypersecretion of mucous

Infection

Assessment 

Pain

Maxillary : Cheek, upper teeth  Frontal : Above the eyebrows  Ethmoid: in and around the eyes  Sphenoid: behind the eye, occiput, top of the head 

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General Malaise Headache Fever Stuffy nose post nasal drip Cough

Nursing Interventions    

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Rest Increase fluid intake Hot wet packs Codeine, avoid ASA- increases the risk of developing nasal polyps Amoxicillin or other antiinfectives (acute- 7-10 days; chronic- upto 21 days)

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Nasal decongestants eg Sudafed, Dimetspp (used for 72 hours)

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Surgical Management  Functional

Endoscopic Sinus Surgery (FESS)  Caldwell- Luc Surgery (Radical Antrum Surgery) Do not chew on affected side  Caution with oral hygiene  Do not wear dentures for 10 days  Do not blow nose or sneeze for 2 weeks after removal of packing 

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Ethmoidectomy Sphenoidotomy/ Ethmoidotomy Osteoplastic flap surgery for frontal sinusitis.

Tonsilitis/ Adenoiditis 

Assessment: Sore throat  Frequent head colds  Fever  Snoring  Dysphagia  Mouth-breathing  Earache  Frequent Head Colds  Bronchitis  Foul Breath  Voice impairment  Noisy Respiration  Draining Ears 

Nursing Interventions     

Promote Rest Increase Fluid Intake Warm saline gargle Analgesic as ordered Antimicrobial as ordered

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Surgery: Tonsillectomy/ adenoidectomy (indicated if tonsillitis recurs 5-6 times a year) PRE-OP care  Assess

for URTI- coughing and sneezing post-op may cause bleeding  Check PT. Bleeding is a common post-op complication

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POST-OP care Prone, head turned to side, or lateral position  When awake, semi-fowler’s position  Oral airway until swallowing reflex returns  Monitor for hemorrhage 

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Promote Comfort 

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Frequent swallowing Bright red vomitus Increased PR Ice collar, Acetaminophen; Avoid ASA

Foods and Fluids  

Ice-cold fluids Bland foods

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Client Education Avoid clearing of throat  Avoid coughing, sneezing, blowing for 12 weeks  2-3 L of fluids/ day until ,outh odor disappears  Avoid hard, scratchy foods until throat is healed  Report s/sx of bleeding  Throat discomfort between 4th to 8th postop day is expected  Stool: Black/ dark for few days due to swallowed blood  Plenty of rest for 2 weeks  Avoid colds, overcrowded public places 

Ca of the Larynx 

Predisposing Factors:  Cigarette

Smoking  Alcohol Abuse  Voice Abuse  Environmental pollutants  Chronic Laryngitis  (+) Family history

Assessment           

Persistent hoarseness of voice Mass on anterior neck Dyspnea Dysphagia Chronic laryngitis Burning sensation with hot/acidic beverages Halitosis Hemoptysis Severe anorexia Severe anemia Severe weight loss

Management  

Surgery: Subtotal/ total laryngectomy Pre-op care:  Psychosocial

support

Effects of total laryngectomy  Loss of voice  Permanent tracheostomy  Loss of sesnse of smell  Establish means of communication to be used post-op  Inability to : 

 Blow,

sip soup and straw, whistle, gargle, do valsalva maneuver( unable to lift heavy objects; constipation)

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POST-OP care  Care

of the Client with tracheostomy 

Establish patient airway  Suction

as necessary  Use sterile technique  Semi-fowler’s position  Use sterile NSS to lubricate suction catheter tip  Apply suction during withdrawal of suction catheter  Apply suction for 5-10 seconds (Max of 15 sec)  Insert 3-5 “ of suction catheter  Instill 2-5 ml of sterile NSS to liquify mucous secretions

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Prevent Infection  Cleanse

stoma and tracheostomy at regular basis  Change dressings and ties as necessary   

Establish means of communication Provide psychosocial support Assist during speech therapy

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Client teaching:  Cover

tracheostomy with poprous material  Avoid swimming  Avoid use of powder, spray aerosol near tracheostomy  Regular follow-up care

Pneumonia 

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An infection of pulmonary tissue , including the interstitial spaces, the alveoli and the bronchioles The alveoli are filled with inflammatory products , creating consolidation The edema associated with inflammation stiffens the lungs , decreases lung compliance and vital capacity and causes hypoxemia

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Features include fever, chills, breathlessness and often dehydration Can be community acquired or hospital acquired Classified according to causative agent: bacterial, viral, fungal or parasitic CXR: presents as diffuse patches throughout the lungs or consolidation in a lobe

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A sputum culture identifies the organism WBC and ESR are elevated

Classifications of Pneumonia 

Bronchopneumonia  Patchy

and scattered , often favoring the lower lobes  Common in the immobile and the elderly  Early signs include dullness to percussion and barely perceptible fine crackles which persist despite deep breathing.

Lobar Pneumonia 

Localized pleuritic pain and bronchial breathing confined to a lobe

Pneumocystis Carinii Pneumonia 

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Due to HIV infection and medications given after an organ transplant Clinical features include dry cough, breathlesness, hypoxemia and features of stiff lungs

Nosocomial Pneumonia 

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Develops in patients confined in the hospital for more than 48 hours – hospital acquired Leading cause of hospitalrelated mortality Caused by cross infections Klebsiella, Pseudomonas, E.coli, Enterobacteriacae, Proteus, Serratia

Legionella Pneumonia 

Occurs in local outbreaks, especially in relation to cooling system, or after a trip abroad

Aspiration Pneumonia 

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Occurs in people who have inhaled unfriendly substances such as vomitus, or gastric acid Clinical signs include coughing, choking, added sounds in auscultation, gurgly voice or loss of voice, tachycardia and sometimes change in color

Chemical Pneumonia 

Seen in ingestion of kerosene or inhalation of irritating gases

Radiation Pneumonitis 

Mat follow radiation therapy for breast or lung cancer and usually occurs 6 weeks or more after completion or radiation therapy

Assessment        

Chills Elevated temperature Pleuritic pain Rales, ronchi and wheezes Use of accessory muscles for breathing Cyanosis Mental status changes Sputum production

Diagnostics      

CBC Creatinine Chest x-ray PA-L Sputum G/S and C/S Sputum AFB 3x (for TB suspect)

Manifestations of Commonly Encountered Pneumonia  Streptococcal p. (streptococcus pneumoniae)

History of previous infections  Sudden onset, shaking and chills  Cough, rusty or green (purulent sputum)  Pleuritic chest pain, chest dull to percussion, crackles, bronchial breath sounds  Treated with: Pen G, erythromycin, clinamycin, cephalosphorins, Cotrimoxazole  Complications: shock, pleural effusion, superinfections, pericarditis, otitis media. 

Staphylococcal Pneumonia (Staphylococcus aureus)  

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Prior history of viral infection Insidious onset of cough, yellow, bloode-streaked mucous Fever, pleuritic chest pain, varied pulse rate, may be slow in proportion to temperature Treated with: Nafcillin, methicillin, clindamycin, vancomycin, cephalotin Complications: effusion/ pneumothorax, lung abscess, empyema, meningitis

Klebsiella pneumonia (Klebsiella pneumoniae)     

Sudden high fever, chills, pleuritic pain, hemoptysis Dyspnea, cyanosis Dark brown, gelatinous sputum Treated with: gentamicin, cefazolin, tobramycin Complications: lung abscesses with cyst formation, empyema, pericarditis

Mycoplasma pneumonia (Mycoplasma pneumoniae) 

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Gradual onset, severe headache Irritating hacking cough, scanty mucoid sputum Anorexia, malaise, fever, congestion, sore throat Treated with : erythromycin, tetracycline

Viral pneumonia 

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Influenza, parainfluenza, RSV, adenovirus, varicella, rubella, rubeola, HSV, cytomegalovirus, Epstein Barr virus Cough Pronounced constitutional symptoms (severe headache, anorexia, fever and myalgia)

Nursing Diagnoses 

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Ineffective airway clearance related to copious tracheobronchial secretions Risk for deficient fluid volume related to fever and dyspnea Activity intolerance related to impaired respiratory function Imbalanced nutrition less than body requirements Deficient knowledge and about treatment regimen and preventive health measures.

Planning and Goals 

The major goals of the patient may include improved airway patency, rest to conserve energy, proper fluid volume, adequate nutrition, an understanding of the treatment protocol and preventive measures, and absence of complications

Therapeutics 

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Antibiotic regimen for a max of 7-8 days only to minimize the emergence of resistance Switch therapy: Intravenous antibiotic treatment may be shifted to oral anti8biotics after 48-72 hours if the following parameters are fulfilled: A.) ther is less cough and resolution of respiratory distress  B.) the temperature is normalizing  C.) the etiology is not a high risk (virulent or resistant) pathogen  D.) there is no unstable co-morbid conditions or life threatening conditions  E.) oral medications are tolerated 

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For abundant secretions, may give acetylcysteine (Fluimucil) 100mg or 200mg sachet dissolved in ½ glass water TID. Discontinue if patient has wheezing.

Nursing Implementation for Pneumonia   

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Administer oxygen as prescribed Monitor respiratory status Monitor for labored respirations, cyanosis ,cold clammy skin Encourage coughing and deep breathing and use of incentive spirometer Position in semi-fowler’s to facilitate breathing and lung expansion

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Change position frequently and ambulate as tolerated to mobilize secretions Provide chest physiotherapy Perform nasotracheal suctioning if the client is unable to clear secretions Monitor pulse oximitry Monitor and record color, consistency, and amount of sputum Provide a high calorie, high protein diet with small frequent feedings

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Encourage fluids upto 3 liters per day to thin secretions unless contraindicated Provide a balance of rest and activity, increasing activity grasdually Administer antibiotics as prescribed Administer asntipyretics, bronchodilators, cough suppressants, mucolytic agents and expectorant as prescribed Prevent the spread of infection by hand washing and proper disposal of secretions.

Client Education for Pneumonia  

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The importance of rest, proper nutrition and adequate fluid intake Avoid chilling and exposure to individual with respiratory infections or viruses Instruct client regarding medications and the use of inhalants as prescribed Instruct the client to notify physician if chills, fever, dyspnea, hemoptysis or increased fatigue occurs Instruct the client in the importance of receiving immunizations as recommended

Prevention and risk factors for Pneumonia 

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Any condition producing mucus or bronchial obstruction and interfering with normal drainage (COPD, CA) Immunosuppressed patients People who smoke, because cigarette smoke disrupts mucociliary and macrophage activity Immobile patients breathing shallowly Patients with depressed cough reflex owing to drugs or weakness, has aspirated foreign material during unconsciousness or those with abnormal swallowing mechanism

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NPO patients receiving antibiotics, has increased pharyngeal colonization of bacteria Frequently intoxicated people. Alcohol suppresses body reflexes, WBC mobilization, trachiobronchial ciliary mobilization Patients receiving sedatives prevention through frequent suctioning of unconscious patients, with poor gag and cough reflexes Elderly people are at risk Patients receiving respiratory therapy using not properly cleaned equipment.

Lung abscess

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A localized lesion in the lung containing pus and necrotic tissue that collapses and forms cavities, or pockets in the lungs May occur from aspiration of vomitus or infected material from the upper respiratory tract; or secondary to bronchial obstruction due to a tumor. May also be a sequela of necrotizing pneumonia ,tuberculosis. Pulmonary embolism, trauma, bronchial neoplasms.

Nursing Assessment 

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Initially cough, with small amount of sputum, a low-grade fever and malaise In time, sputum becomes copious and often foul- smelling, sometimes containing blood Pleuritic chest pain Onset is sudden, with chills, high fever cough and malaise

Measures to reduce risk of suppurative lung disease 

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Antibiotic therapy before dental manipulation. Adequate dental and oral hygiene since anaerobic bacteria play a role in the pathogenesis of lung abscess Give appropriate antimicrobial therapy to those with pneumonia

Management 

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Postural drainage, effective coughing and deep breathing exercises Bronchoscopy may be needed to drain abscess High CHON, high CHO diet Surgery if medical intervention is inadequate Emotional support

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Surgical intervention is rare:  Pulmonary

resection (lobectomy) when there is massive hemoptysis or no response to medical management.

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Pharmacologic Therapy IV: Clindamycin (Cloecin)  meropenem

(Merrem)  piperacillin/tazobaqctam (Zosyn)  May last for 4-8 weeks.

COPD

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Also known as Chronic Obstructive Lung Disease (COLD) and Chronic Airflow Limitation (CAL) Characterized by airflow limitation that is not fully reversible There is progressive airflow limitation into and out of the lungs, elevated airway resistance, irreversible lung distention and ABG imbalance

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Caused by Emphysema and Chronic Bronchitis or a combination of both. Leads to pulmonary insufficiency, pulmonary hypertension and cor pulmonale

Risk factors of COPD: 

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Exposure to tobacco smoke (8090 % of COPD cases) Passive smoking Occupational exposure Ambient air pollution Genetic abnormalities, including a deficiency of alpha 1antitrypsin.

COPD- chronic bronchitis 

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A disease of the airways, defined as the presence of irritating cough (smoker’s cough) and sputum production for at least 3 months is each of 2 consecutive years Develops in heavy smokers In many cases , smoke or other environmental pollutants irritate the airways resulting in hypersecretion of mucous and inflammation

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This constant irritation causes the mucus-secreting glands and goblet cells to increase in number, ciliary function is reduced, and more mucus is produced. Bronchial walls become thickened resulting in narrowing of lumen, and mucus may plug the airway. Adjacent alveoli may become damaged and fibrosed, resulting in altered function of alveolar macrophages. As a result the client becomes more susceptible to respiratory infection

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Clients abandons the fight for normal blood gases and feels less breathless, but pays for symptomatic relief with edema, cyanosis and inadequate gas exchange (Blue bloaters)

COPD- emphysema 

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An abnormal distention of the air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli Commonly caused by smoking Protein breakdown is the villain which causes erosion of the alveolar system, dilation of distal air spaces and destruction of elastic fibers

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Alveoli lose their elastic recoil, then weaken and rupture. Air remains trapped in the lungs, (formation of air pockets or bullae); carbon dioxide accumulates (hypercapnia) with resulting respiratory acidosis Cor pulmonale is one of the complications of emphysema

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Client with emphysema tries to maintain near normal blood gases at the expense of brathlesness and weight loss, no cyanosis occurs (pink puffers) The flat diaphragm works paradoxically and becomes expiratory in action, thus, drawing the lower ribs in inspiration ( Hoover’s sign)

Types of Emphysema 

Centrolobar Emphysema  Affects

the respiratory bronchioles  Most common type of emphysema  Associated with chronic bronchitis and bronchial inflammation  Originates at the center of the lobule and is distinct from the periphery of the acinus with its septae and vessels  Variable and patchy and has a predilection for upper lung zones

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Panlobar or panacinar emphysema  Associated

with severe alpha 1antitrypsin defeciency and affects the alveoli themselves, causing more destruction.  Little association with chronic bronchitis

Clinical syndrome of COPD 

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Patients with empysematous, dyspneic or Type A COPD are referred as PINK PUFFERS Those with bronchitic, tussive or Type B COPD are referred as BLUE BLOATERS

Pink puffers  

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Have predominant emphysema Symptoms of relatively advanced age ( >60 yrs) Progressive exertional dyspnea, weight loss, little or no cough and expectoration. Mild hypoxia, hypocapnia and little improvement in airflow after treatment with bronchodilators. They usually undergo a slowly progressive downhill course

Blue Bloaters   

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Predominant chronic bronchitis At relatively young age Chronic cough and expectoration, episodic dyspnea and weight gain Wheezing and ronchi, cor pulmonale, accompanied by edema and cyanosis Severe hypoxia, hypercapnia, polycythemia Improvede airflow after treatment with bronchodilators and relatively preserved lung volumes.

Nursing implementation for COPD  

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Monitor vital signs Administer a low concentration of oxygen (2-3 L/min) as prescribed ; in emphysema, the stimulus to breathe is a low PO2 instead of an increased in PCO2 Monitor pulse oximetry Provide respiratory treatments and chest physiotherapy

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Instruct the client in diaphragmatic or abdominal and pursed-lip breathing techniques Record the color, amount and consistency of sputum Suction the client, if necessary , to clear airway and prevent infection Monitor weight Encourage small frequent meals to prevent dyspnea

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Provide high CHO and high CHON diet with supplements Encourage fluids up to 3000 ml/day to keep secretions thin unless contraindicated Position in high fowler’s or orthopneic position Allow activity as tolerated Administer bronchodilators as prescribed and instruct the client in the use of both oral and inhalant medications

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Administer corticosteroids as prescribed to reduce inflammation Administer mucolytics as prescribed to thin secretions Administer antibiotics for infection as prescribed

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Coping measures:  Patients

experience anxiety, apprehension, frustration of having to work to breathe  Adapt a hopeful and encouraging attitude  Emphasis should be in controlling his symptoms and increasing self esteem and sense of mastery and well-being

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Patient education and home health care:  Stop

smoking  Tell him what to expect. He and family caring for him will need patience  Help patient accept set realistic short term and long term goals  The objective is to increase exercise tolerance and prevent further loss of pulmonary function  Educate the patient about the disease process

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Recognize the signs and symptoms of respiratory infection and hypoxia Adhere to activity limitations, altering rest periods with activity Avoid exposure to individuals with infections and avoid crowds Instruct to avoid extremes of heat and cold Demonstrate pursed-lip and diaphragmatic or abdominal breathing

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Instruct the client in the use of medications and inhalers Instruct the client in the use of oxygen therapy Instruct the client in nutritional requirements Avoid eating gas-producing foods, spicy foods, and extremely hot and cold foods Instruct in the importance of receiving immunizations as recommended

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When dusting , use a wet cloth Avoid powerful odors Avoid extremes in temperature Avoid fireplaces, pets, and feather pillows

Asthma

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An intermittent reversible airway obstruction characterized by hyperresponsiveness or heperirritability and inflammation of the airways Substances that have no effect when inhaled by normal individuals can cause bronchoconstrictions in patients with asthma

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A principal feature of asthma is its extreme variability, both from patient to patient and from time to time in the same patient. Allergy is the strongest predisposing factor for asthma

Incidence and etiology: 

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Asthma occurs in 3-8 % of the population It is traditionally divided into 3 forms  An

allergic form – extrinsic form  An intrinsic form  Mixed asthma

Extrinsic (allergic)

Intrinsic (infectious / miscellaneous)

Age of Onset

3- 35 y.o

Under 3, over 35-40

Symptoms

Season of perennial, frequently pollen and mold related

Worse in winter, cold seasons, exacerbated by cold air, air pollution, and primarily by infection

Mucus

Clear and foamy

Thick and white or discolored

Family History

positive

No greater than in general population

Skin Tests

Positive and correlating

Negative or positive non-correlating

Serum Ig E

High or normal

normal

Response to therapy

Good response to immunotherapy and bronchodilator

Poor response to bronchodilators, no response to immunotherapy

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The following may trigger an asthma attack:  Allergenic

foods (eggs, nuts, wheat, dairy products)  Chest infection  Drugs e.g. NSAIDS, ASA  Exercise  Car exhaust  Exercise  Frustrated expression of emotion  Premenstruation  Pollen

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Smoking Warm blooded pets Weather Education about these risk factors and prevention is vital in care of patients in asthma

Biochemical mediators 

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Ig E cell mediated, histamine from mast cells Serotonin, prostaglandins, thromboxanes, endoperoxidases, also cause tissue inflammation and maybe particularly important in the pathogenesis of nonallergic asthma

Pathophysiologic basis:  

Get a whole sheet of paper Make a tracing of the pathophysiology of asthma using your book.

Other classification of asthma and their clinical features 

Mild chronic asthma  -manifests

an intermittent dry cough often at night or morning and wheezes once or twice a week

Severe Chronic Asthma -frequent exacerbations and symptoms that significantly affect quality of life

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Unstable- most severe form; also known as brittle asthma which shows greatly fluctuating peak flows, persistent symptoms despite multiple drug treatment and unpredictable severe falls in lung functioning, often without known precipitating factors.

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Acute asthma- large airways are obstructed by bronchospasm and the small airways by edema and mucus plugging.

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Associated with breathlessness, rapid breathing and abdominal paradox

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Severe acute asthma  Most

commonly develops slowly, often after several weeks of wheezing  Alternately, attack is sudden, especially if there has been poor drug control  Can be fatal within minutes

Status asthmaticus 

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Severe asthma attacked prolonged over 24 hours. Clinical manifestations include fatigue, PR > 100bpm and cyanosis Use of accessory muscles Pulsus paradoxus

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Exercise – induced asthma  -hyperventilation

during exercise, especially in cold weather causes bronchospasm

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Nocturnal asthma- 80% in asthmatics  -interferes

with sexual intercourse and sleeping

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Occupational asthma  -may

take weeks or years to develop

Diagnosis: 

Sputum analysis  -may

appear purulent  -reveal Curschmann’s spirals  - reveals Charcot’s Layden crystals 

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Hematologic studies- modest leukocytosis and eosinophilia Pulmonary function testing Chest x-ray

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ABG studies- PCO2 is low less that 36 mmHg. An increased PCO2 or normal PCO2 indicates severe obstruction

Nursing Assessment:         

Cough Dyspnea Wheezing Diaphoresis Tachycardia General chest tightness Hypoxemia Central cyanosis History- + family hx- periodic reversible airflow obstruction

Nursing Implementation:    

Assess airway patency Elevate head Administer humidified O2 Continuously monitor resp status:  Give

Medications as prescribed (Bronchodilators) Sympathomimetics ( B2 agonists)  Methlyxanthines (Theophylline)  Anti cholinergic agents (Ipratropium) 

DO NOT GIVE BETA BLOCKERS!!!!! Anti-inflammatory agents: 

 Corticosteroids

and cromolyn

sodium  Prevent

exacerbations  Teaching: Positioning  Pursed-lip exercises  Nutrition: Avoid over feeding! 