● Instruct the client to use hot water
CHAPTER 21 to eliminate dust mites in bed linens.
UNIT 3 NURSING CARE OF CLIENTS WHO
HAVE RESPIRATORY DISORDERS
SECTION: RESPIRATORY SYSTEM DISORDERS
CHAPTER 21 Asthma
Asthma is a chronic inflammatory disorder of the
airways that results in intermittent and reversible
airflow obstruction of the bronchioles. The
obstruction occurs either by inflammation or
airway hyperresponsiveness.
Asthma can occur at any age. The cause is unknown.
Manifestations of asthma include mucosal
edema, bronchoconstriction, and excessive
mucus production.
HEALTH PROMOTION AND
DISEASE PREVENTION
● If the client smokes, promote smoking cessation.
● Advise the client to use protective equipment (mask) and
ensure proper ventilation while working in environments
that contain carcinogens or particles in the air.
● Encourage influenza and pneumonia vaccinations for
older adults and all clients who have asthma.
● Instruct the client how to
recognize and avoid triggering
agents.
21.1 Normal and asthmatic bronchioles
◯ Environmental factors, such as
changes in temperature (especially
warm to cold) and humidity
◯ Air pollutants
◯ Strong odors (perfume)
◯ Seasonal allergens (grass, tree,
and weed pollens) and perennial
allergens (mold, feathers, dust,
roaches, animal dander, foods
treated with sulfites)
◯ Stress and emotional distress
◯ Medications (aspirin, NSAIDs,
beta-blockers, cholinergics)
◯ Enzymes, including those in
laundry detergents
◯ Chemicals (household cleaners)
◯ Sinusitis with postnasal drip
◯ Viral respiratory tract infection
● Teach the client how to self-
administer medications (nebulizers
and inhalers).
● Educate the client regarding infection
prevention techniques.
● Encourage regular exercise as part
of asthma therapy.
◯ Promotes ventilation and perfusion.
◯ Maintains cardiac health.
◯ Enhances skeletal muscle strength.
◯ Clients can require pre-medication.
, ASSESSMENT
Diagnosis is based on symptoms and classified into one of
the following four categories.
● Mild intermittent: Symptoms occur less than
twice a week.
● Mild persistent: Symptoms arise more than twice a
week but not daily.
● Moderate persistent: Daily symptoms occur
in conjunction with exacerbations twice a
week.
● Severe persistent: Symptoms occur continually, along
with frequent exacerbations that limit physical
activity and quality of life.
RISK FACTORS
● Older adult clients have decreased pulmonary
reserves due to physiologic lung changes that occur
with the aging process.
◯ Older adult clients are more susceptible to infections.
◯ The sensitivity of beta-adrenergic receptors
decreases with age. As the beta receptors age and
lose sensitivity, they are less able to respond to
agonists, which relax smooth muscle and can result
in bronchospasms.
● Family history of asthma
● Smoking
● Secondhand smoke exposure
● Environmental allergies
● Exposure to chemical irritants or dust
● Gastroesophageal reflux disease (GERD)
,EXPECTED FINDINGS PATIENT-CENTERED CARE
● Dyspnea
● Chest tightness NURSING CARE
● Anxiety or stress ● Position the client to maximize ventilation
PHYSICAL ASSESSMENT FINDINGS (high-Fowler’s).
● Coughing ● Administer oxygen therapy as prescribed.
● Wheezing ● Monitor cardiac rate and rhythm for changes during an
● Mucus production acute attack (can be irregular, tachycardic, or with PVCs).
● Use of accessory muscles ● Initiate and maintain IV access.
● Prolonged exhalation ● Maintain a calm and reassuring demeanor.
● Poor oxygen saturation (low SaO2) ● Provide rest periods for older adult clients who have
● Barrel chest or increased chest diameter dyspnea. Design room and walkways with opportunities
for rest. Incorporate rest into ADLs.
Obtain history regarding current and previous asthma
● Encourage prompt medical attention for infections and
exacerbations.
appropriate vaccinations.
● Onset and duration
● Administer medications as prescribed.
● Precipitating factors (stress, exercise, exposure
to irritant)
● Changes in medication regimen MEDICATIONS
● Medications that relieve symptoms
● Other medications taken Bronchodilators (inhalers)
● Self-care methods used to relieve symptoms
● Short-acting beta 2 agonists, such as albuterol,
provide rapid relief of acute symptoms and prevent
LABORATORY TESTS exercise-induced asthma.
● Anticholinergic medications, such as ipratropium, block
Arterial blood gases the parasympathetic nervous system. This allows for
the sympathetic nervous system effects of increased
Hypoxemia (decreased PaO2 less than 80 mm Hg)
bronchodilation and decreased pulmonary secretions.
Hypocarbia (decreased PaCO2 less than 35 mm Hg: early These medications are long-acting and used to
in attack) prevent bronchospasms.
● Methylxanthines, such as theophylline, require close
Hypercarbia (increased PaCO2 greater than 45 mm Hg:
monitoring of serum medication levels due to a narrow
later in attack)
therapeutic range. Use only when other treatments
are ineffective.
Sputum cultures ● Long-acting beta2 agonists, such as salmeterol,
Bacteria can indicate infection. primarily are used for asthma attack prevention.
NURSING CONSIDERATIONS
DIAGNOSTIC PROCEDURES ● Albuterol: Watch for tremors and tachycardia.
● Ipratropium: Observe for dry mouth.
● Pulmonary function tests (PFTs) are the most accurate ● Theophylline: Monitor serum levels for toxicity. Side
tests for diagnosing asthma and its severity.
effects include tachycardia, nausea, and diarrhea.
◯ Forced vital capacity (FVC) is the volume of air
exhaled from full inhalation to full exhalation. CLIENT EDUCATION
◯ Forced expiratory volume in the first second (FEV1) ● Ipratropium: Advise the client to suck on hard candies
is the volume of air blown out as hard and fast as to help relieve dry mouth; increase fluid intake; and
possible during the first second of the most forceful report headache, blurred vision, or palpitations, which
exhalation after the greatest full inhalation. can indicate toxicity of ipratropium. Monitor heart rate.
◯ Peak expiratory flow is the fastest airflow rate ● Salmeterol: Advise the client to use to prevent an
reached during exhalation. asthma attack and not at the onset of an attack.
◯ A decrease in FEV1 by 15% to 20% below the expected
value is common in clients who have asthma. An Anti-inflammatory agents
increase in these values by 12% following the
These medications are for prophylaxis and are used to
administration of bronchodilators is diagnostic
decrease airway inflammation.
for asthma. ● Corticosteroids, such as fluticasone and prednisone
● A chest x-ray is used to diagnose changes in chest ● Leukotriene antagonists, such as montelukast
structure over time. ● Mast cell stabilizers, such as cromolyn
● Monoclonal antibodies, such as omalizumab
, NURSING CONSIDERATIONS INTERPROFESSIONAL CARE
● Watch for decreased immunity function.
● Respiratory services should be consulted for inhalers
● Monitor for hyperglycemia.
and breathing treatments for airway management.
● Advise the client to report black, tarry stools. ● Nutritional services can be contacted for weight loss or
● Observe for fluid retention and weight gain. This can
gain related to medications or diagnosis.
be common. ● Rehabilitation care can be consulted if the client
● Monitor the throat and mouth for aphthous lesions
has prolonged weakness and needs assistance with
(canker sores).
increasing level of activity.
● Omalizumab can cause anaphylaxis.
CLIENT EDUCATION
● Encourage the client to drink plenty of fluids to COMPLICATIONS
promote hydration.
● Encourage the client to take prednisone with food. Respiratory failure
● Advise the client to use this medication to prevent
Persistent hypoxemia related to asthma can lead to
asthma, not for the onset of an attack.
respiratory failure.
● Encourage the client to avoid people who have
respiratory infections. NURSING ACTIONS
● Remind the client to use good mouth care. ● Monitor oxygenation levels and acid-base balance.
● Warn the client to not discontinue this type of ● Prepare for intubation and mechanical ventilation.
medication suddenly.
Status asthmaticus
Combination agents (bronchodilator
This is a life-threatening episode of airway obstruction
and anti-inflammatory)
that is often unresponsive to common treatment. It
If prescribed separately for inhalation administration at involves extreme wheezing, labored breathing, use of
the same time, administer the bronchodilator first in order accessory muscles, distended neck veins, and creates a
to increase the absorption of the anti-inflammatory agent. risk for cardiac and/or respiratory arrest.
● Ipratropium and albuterol
NURSING ACTIONS
● Fluticasone and salmeterol
● Prepare for emergency intubation.
● Administer IV fluids, oxygen, bronchodilators, and
epinephrine. Initiate systemic steroid therapy.
Application Exercises
1. A nurse in the emergency department 3. A nurse is providing discharge 5. A nurse is reinforcing teaching with
is caring for a client who is having teaching to a client who has a a client on the purpose of taking
an acute asthma attack. Which of new prescription for prednisone a bronchodilator. Which of the
the following assessments indicates for asthma. Which of the following following client statements indicates
that the respiratory status is client statements indicates an an understanding of the teaching?
declining? (Select all that apply.) understanding of the teaching? A. “This medication can decrease
A. SaO2 95% A. “I will decrease my fluid intake my immune response.”
B. Wheezing while taking this medication.” B. “I take this medication to
C. Retraction of sternal muscles B. “I will expect to have prevent asthma attacks.”
black, tarry stools.” C. “I need to take this
D. Pink mucous membranes
C. “I will take my medication medication with food.”
E. Premature ventricular with meals.”
complexes (PVCs) D. “This medication has a slow
D. “I will monitor for weight loss onset to treat my symptoms.”
2. A nurse is caring for a client 2 hr after while on this medication.”
admission. The client has an SaO2 of
91%, exhibits audible wheezes, and 4. A nurse is assessing a client who
is using accessory muscles when has a history of asthma. Which of
breathing. Which of the following the following factors should the
classes of medications should the nurse identify as a risk for asthma?
nurse expect to administer? A. Gender
A. Antibiotic B. Environmental allergies
B. Beta-blocker C. Alcohol use
C. Antiviral D. Race
D. Beta2 agonist
CHAPTER 21 to eliminate dust mites in bed linens.
UNIT 3 NURSING CARE OF CLIENTS WHO
HAVE RESPIRATORY DISORDERS
SECTION: RESPIRATORY SYSTEM DISORDERS
CHAPTER 21 Asthma
Asthma is a chronic inflammatory disorder of the
airways that results in intermittent and reversible
airflow obstruction of the bronchioles. The
obstruction occurs either by inflammation or
airway hyperresponsiveness.
Asthma can occur at any age. The cause is unknown.
Manifestations of asthma include mucosal
edema, bronchoconstriction, and excessive
mucus production.
HEALTH PROMOTION AND
DISEASE PREVENTION
● If the client smokes, promote smoking cessation.
● Advise the client to use protective equipment (mask) and
ensure proper ventilation while working in environments
that contain carcinogens or particles in the air.
● Encourage influenza and pneumonia vaccinations for
older adults and all clients who have asthma.
● Instruct the client how to
recognize and avoid triggering
agents.
21.1 Normal and asthmatic bronchioles
◯ Environmental factors, such as
changes in temperature (especially
warm to cold) and humidity
◯ Air pollutants
◯ Strong odors (perfume)
◯ Seasonal allergens (grass, tree,
and weed pollens) and perennial
allergens (mold, feathers, dust,
roaches, animal dander, foods
treated with sulfites)
◯ Stress and emotional distress
◯ Medications (aspirin, NSAIDs,
beta-blockers, cholinergics)
◯ Enzymes, including those in
laundry detergents
◯ Chemicals (household cleaners)
◯ Sinusitis with postnasal drip
◯ Viral respiratory tract infection
● Teach the client how to self-
administer medications (nebulizers
and inhalers).
● Educate the client regarding infection
prevention techniques.
● Encourage regular exercise as part
of asthma therapy.
◯ Promotes ventilation and perfusion.
◯ Maintains cardiac health.
◯ Enhances skeletal muscle strength.
◯ Clients can require pre-medication.
, ASSESSMENT
Diagnosis is based on symptoms and classified into one of
the following four categories.
● Mild intermittent: Symptoms occur less than
twice a week.
● Mild persistent: Symptoms arise more than twice a
week but not daily.
● Moderate persistent: Daily symptoms occur
in conjunction with exacerbations twice a
week.
● Severe persistent: Symptoms occur continually, along
with frequent exacerbations that limit physical
activity and quality of life.
RISK FACTORS
● Older adult clients have decreased pulmonary
reserves due to physiologic lung changes that occur
with the aging process.
◯ Older adult clients are more susceptible to infections.
◯ The sensitivity of beta-adrenergic receptors
decreases with age. As the beta receptors age and
lose sensitivity, they are less able to respond to
agonists, which relax smooth muscle and can result
in bronchospasms.
● Family history of asthma
● Smoking
● Secondhand smoke exposure
● Environmental allergies
● Exposure to chemical irritants or dust
● Gastroesophageal reflux disease (GERD)
,EXPECTED FINDINGS PATIENT-CENTERED CARE
● Dyspnea
● Chest tightness NURSING CARE
● Anxiety or stress ● Position the client to maximize ventilation
PHYSICAL ASSESSMENT FINDINGS (high-Fowler’s).
● Coughing ● Administer oxygen therapy as prescribed.
● Wheezing ● Monitor cardiac rate and rhythm for changes during an
● Mucus production acute attack (can be irregular, tachycardic, or with PVCs).
● Use of accessory muscles ● Initiate and maintain IV access.
● Prolonged exhalation ● Maintain a calm and reassuring demeanor.
● Poor oxygen saturation (low SaO2) ● Provide rest periods for older adult clients who have
● Barrel chest or increased chest diameter dyspnea. Design room and walkways with opportunities
for rest. Incorporate rest into ADLs.
Obtain history regarding current and previous asthma
● Encourage prompt medical attention for infections and
exacerbations.
appropriate vaccinations.
● Onset and duration
● Administer medications as prescribed.
● Precipitating factors (stress, exercise, exposure
to irritant)
● Changes in medication regimen MEDICATIONS
● Medications that relieve symptoms
● Other medications taken Bronchodilators (inhalers)
● Self-care methods used to relieve symptoms
● Short-acting beta 2 agonists, such as albuterol,
provide rapid relief of acute symptoms and prevent
LABORATORY TESTS exercise-induced asthma.
● Anticholinergic medications, such as ipratropium, block
Arterial blood gases the parasympathetic nervous system. This allows for
the sympathetic nervous system effects of increased
Hypoxemia (decreased PaO2 less than 80 mm Hg)
bronchodilation and decreased pulmonary secretions.
Hypocarbia (decreased PaCO2 less than 35 mm Hg: early These medications are long-acting and used to
in attack) prevent bronchospasms.
● Methylxanthines, such as theophylline, require close
Hypercarbia (increased PaCO2 greater than 45 mm Hg:
monitoring of serum medication levels due to a narrow
later in attack)
therapeutic range. Use only when other treatments
are ineffective.
Sputum cultures ● Long-acting beta2 agonists, such as salmeterol,
Bacteria can indicate infection. primarily are used for asthma attack prevention.
NURSING CONSIDERATIONS
DIAGNOSTIC PROCEDURES ● Albuterol: Watch for tremors and tachycardia.
● Ipratropium: Observe for dry mouth.
● Pulmonary function tests (PFTs) are the most accurate ● Theophylline: Monitor serum levels for toxicity. Side
tests for diagnosing asthma and its severity.
effects include tachycardia, nausea, and diarrhea.
◯ Forced vital capacity (FVC) is the volume of air
exhaled from full inhalation to full exhalation. CLIENT EDUCATION
◯ Forced expiratory volume in the first second (FEV1) ● Ipratropium: Advise the client to suck on hard candies
is the volume of air blown out as hard and fast as to help relieve dry mouth; increase fluid intake; and
possible during the first second of the most forceful report headache, blurred vision, or palpitations, which
exhalation after the greatest full inhalation. can indicate toxicity of ipratropium. Monitor heart rate.
◯ Peak expiratory flow is the fastest airflow rate ● Salmeterol: Advise the client to use to prevent an
reached during exhalation. asthma attack and not at the onset of an attack.
◯ A decrease in FEV1 by 15% to 20% below the expected
value is common in clients who have asthma. An Anti-inflammatory agents
increase in these values by 12% following the
These medications are for prophylaxis and are used to
administration of bronchodilators is diagnostic
decrease airway inflammation.
for asthma. ● Corticosteroids, such as fluticasone and prednisone
● A chest x-ray is used to diagnose changes in chest ● Leukotriene antagonists, such as montelukast
structure over time. ● Mast cell stabilizers, such as cromolyn
● Monoclonal antibodies, such as omalizumab
, NURSING CONSIDERATIONS INTERPROFESSIONAL CARE
● Watch for decreased immunity function.
● Respiratory services should be consulted for inhalers
● Monitor for hyperglycemia.
and breathing treatments for airway management.
● Advise the client to report black, tarry stools. ● Nutritional services can be contacted for weight loss or
● Observe for fluid retention and weight gain. This can
gain related to medications or diagnosis.
be common. ● Rehabilitation care can be consulted if the client
● Monitor the throat and mouth for aphthous lesions
has prolonged weakness and needs assistance with
(canker sores).
increasing level of activity.
● Omalizumab can cause anaphylaxis.
CLIENT EDUCATION
● Encourage the client to drink plenty of fluids to COMPLICATIONS
promote hydration.
● Encourage the client to take prednisone with food. Respiratory failure
● Advise the client to use this medication to prevent
Persistent hypoxemia related to asthma can lead to
asthma, not for the onset of an attack.
respiratory failure.
● Encourage the client to avoid people who have
respiratory infections. NURSING ACTIONS
● Remind the client to use good mouth care. ● Monitor oxygenation levels and acid-base balance.
● Warn the client to not discontinue this type of ● Prepare for intubation and mechanical ventilation.
medication suddenly.
Status asthmaticus
Combination agents (bronchodilator
This is a life-threatening episode of airway obstruction
and anti-inflammatory)
that is often unresponsive to common treatment. It
If prescribed separately for inhalation administration at involves extreme wheezing, labored breathing, use of
the same time, administer the bronchodilator first in order accessory muscles, distended neck veins, and creates a
to increase the absorption of the anti-inflammatory agent. risk for cardiac and/or respiratory arrest.
● Ipratropium and albuterol
NURSING ACTIONS
● Fluticasone and salmeterol
● Prepare for emergency intubation.
● Administer IV fluids, oxygen, bronchodilators, and
epinephrine. Initiate systemic steroid therapy.
Application Exercises
1. A nurse in the emergency department 3. A nurse is providing discharge 5. A nurse is reinforcing teaching with
is caring for a client who is having teaching to a client who has a a client on the purpose of taking
an acute asthma attack. Which of new prescription for prednisone a bronchodilator. Which of the
the following assessments indicates for asthma. Which of the following following client statements indicates
that the respiratory status is client statements indicates an an understanding of the teaching?
declining? (Select all that apply.) understanding of the teaching? A. “This medication can decrease
A. SaO2 95% A. “I will decrease my fluid intake my immune response.”
B. Wheezing while taking this medication.” B. “I take this medication to
C. Retraction of sternal muscles B. “I will expect to have prevent asthma attacks.”
black, tarry stools.” C. “I need to take this
D. Pink mucous membranes
C. “I will take my medication medication with food.”
E. Premature ventricular with meals.”
complexes (PVCs) D. “This medication has a slow
D. “I will monitor for weight loss onset to treat my symptoms.”
2. A nurse is caring for a client 2 hr after while on this medication.”
admission. The client has an SaO2 of
91%, exhibits audible wheezes, and 4. A nurse is assessing a client who
is using accessory muscles when has a history of asthma. Which of
breathing. Which of the following the following factors should the
classes of medications should the nurse identify as a risk for asthma?
nurse expect to administer? A. Gender
A. Antibiotic B. Environmental allergies
B. Beta-blocker C. Alcohol use
C. Antiviral D. Race
D. Beta2 agonist
