Lewis: Medical-Surgical Nursing, 10th Edition

Chapter 28

Nursing Management: Postoperative Care

KEY POINTS

ASTHMA
 Asthma is a chronic inflammatory disorder of the airways that results in recurrent
episodes of airflow obstruction that it is usually reversible.

Etiology and Pathophysiology

 The primary pathophysiologic process in asthma is persistent but variable inflammation
of the airways. The airflow is limited because the inflammation results in
bronchoconstriction, airway hyperresponsiveness (hyperreactivity), and edema of the
airways.
 Although the exact mechanisms that cause asthma remain unknown, often exposure to a
trigger, such as an allergen or irritant, initiates the inflammatory cascade. Respiratory
infections are also precipitating factors of an acute asthma attack. Asthma is not a
psychosomatic disease.
 Genetics and one’s immune responses may influence asthma development.
 Common allergens include tree or weed pollen, dust mites, molds, furry animals,
and cockroaches.
 Asthma that is induced or exacerbated after physical exertion is called exercise-
induced asthma.
 Various air pollutants, cigarette or wood smoke, vehicle exhaust, elevated ozone
levels, sulfur dioxide, and nitrogen dioxide can trigger asthma attacks. The role of
outdoor air pollution as a cause of asthma is controversial.
 Occupational asthma occurs after exposure to agents in the workplace. These
agents are diverse and include wood dusts, laundry detergents, metal salts,
chemicals, paints, solvents, and plastics.
 Most patients with asthma have a history of allergic rhinitis. Gastroesophageal
reflux disease (GERD) is more common in persons with asthma.
 Certain drugs may precipitate asthma.

Clinical Manifestations and Complications

 The characteristic clinical manifestations of asthma are wheezing, cough, dyspnea, and
chest tightness, particularly at night or early in the morning. Expiration may be
prolonged. Examination of the patient during an acute attack usually reveals signs of
hypoxemia.
 Asthma can be classified as intermittent, mild persistent, moderate persistent, or severe
persistent, based upon current impairment of the patient and their risk for exacerbations.
 Severe exacerbations of asthma can result in complications such as severe hypoxia,
“silent chest,” and peak flow less than 40% of personal best.
Diagnosis
 A diagnosis of asthma is usually made based upon the presence of various indicators (i.e.,
clinical manifestations, health history, spirometry, peak flow variability).

Interprofessional Care
 The goal of asthma treatment is to achieve and maintain control of the disease.
Established guidelines give direction on the classification of severity of asthma at initial
diagnosis and help determine which types of medications are best suited to control the
asthma symptoms.
 A stepwise approach to drug therapy is based initially on the asthma severity and then on
level of control. Persistent asthma requires daily long-term (controller) therapy in
addition to appropriate medications to manage acute symptoms (rescue). Even persons
with intermittent asthma should always carry rescue medication.
 Medications are divided into two general classifications: (1) long-term–control
medications to achieve and maintain control of persistent asthma and (2) quick-relief
(rescue) medications to treat symptoms and exacerbations.
 Because chronic inflammation is a primary component of asthma, inhaled
corticosteroids are more effective in improving asthma control than any other
long-term drug. Inhaled (ICS) agents, such as fluticasone (Flovent) and
budesonide (Pulmicort), are first-line therapy for patients with persistent
asthma.
 Orally administered corticosteroids are indicated for acute exacerbations of
asthma. Maintenance doses of oral corticosteroids may be necessary to control
asthma in a minority of patients with severe chronic asthma.
 Short-acting inhaled β2-adrenergic agonists, including albuterol, are the most
effective drugs for relieving acute bronchospasm. They are also used for acute
exacerbations of asthma.
 Long-acting inhaled β2-adrenergic agonists, including salmeterol (Serevent)
and formoterol (Foradil), are never to be used as monotherapy in asthma due
to an increased risk of death. However, they are quite safe when combined
with ICS such as fluticasone/salmeterol (Advair) or budesonide/formoterol
(Symbicort).
 Leukotriene modifiers can be used in milder asthma successfully as add-on
therapy to reduce the dose of inhaled corticosteroids.
 The only anti-IgE drug, which is omalizumab (Xolair), is used for difficult to
treat moderate to severe asthma unable to be controlled by inhaled
corticosteroids.
 Methylxanthine (theophylline) preparations are less effective long-term
control bronchodilators as compared with β2-adrenergic agonists and carry a
high incidence of side effects.
 Anticholinergic agents are not used in asthma treatment, except for
ipratropium (Atrovent), which is only used in the ED for acute attacks.

NURSING MANAGEMENT
  The overall goals are that the patient with asthma will have asthma control as evidenced
by minimal symptoms during the day and night, acceptable activity levels (including
exercise and other physical activity), maintenance greater than 80% of personal best peak
expiratory flow rate (PEFR) or forced expiratory volume in 1 second (FEV1), few or no
adverse effects of therapy, no recurrent exacerbations of asthma, and adequate knowledge
to participate in and carry out management.
 Education remains the cornerstone of asthma management. Your role in preventing
asthma attacks or decreasing the severity focuses primarily on teaching the patient and
caregiver.
 One of the major factors determining success in asthma management is the correct
administration of drugs.
 Inhalation devices include metered-dose inhalers, dry powder inhalers, and
nebulizers.
 Teaching should include information about medications, including the name,
purpose, dosage, method of administration, schedule, side effects, appropriate
action if side effects occur, how to properly use and clean devices, and
consequences for breathing if not taking medications as prescribed.
 Several nonprescription combination drugs are available over the counter. An
important teaching responsibility is to warn the patient about the dangers
associated with nonprescription combination drugs.
 A goal in asthma care is to maximize the ability of the patient to safely manage acute
asthma episodes via an asthma action plan developed in conjunction with the HCP. An
important nursing goal during an acute attack is to decrease the patient’s sense of panic.
 Develop written asthma action plans together with the patient and family, especially
those with moderate or severe persistent asthma or a history of severe exacerbations.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

 Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease
state characterized by airflow limitation that is not fully reversible. It is usually
progressive and associated with an abnormal inflammatory response of the lungs to
noxious particles or gases, primarily caused by cigarette smoking.

Etiology and Pathophysiology

 In addition to cigarette smoke, occupational chemicals, air pollution, severe recurring
respiratory infections, and α1-antitrypsin deficiency (an autosomal recessive disorder) are
risk factors for developing COPD.
 Some degree of emphysema has been thought to occur as a person ages. It is caused by
changes in the lung structure and the respiratory muscles, even in a nonsmoker.
 COPD is characterized by chronic inflammation found in the airways, lung parenchyma
(respiratory bronchioles and alveoli), and pulmonary blood vessels.
 The pathogenesis of COPD is complex and involves many mechanisms, with an
inflammatory process different from that of asthma. COPD has systemic manifestations.
 The defining features of COPD are not fully reversible airflow limitation during forced
exhalation that is caused by loss of elastic recoil and airflow obstruction secondary to
mucus hypersecretion, mucosal edema, and bronchospasm. Gas exchange abnormalities
result in hypoxemia and hypercapnia.
Clinical Manifestations and Complications
 A diagnosis of COPD should be considered in any patient over the age of 40 who has
symptoms of cough, sputum production, or dyspnea, and/or a history of exposure to risk
factors for the disease.
 A chronic intermittent cough is the earliest symptom. As the disease progresses, the
cough is present every day.
 Sputum may or may not be produced. Symptoms are progressive.
 COPD can be classified as mild, moderate, severe, and very severe, depending on the
severity of the obstruction.
 Complications of COPD include the following:
 Cor pulmonale is hypertrophy of the right side of the heart, with or without heart
failure, resulting from pulmonary hypertension and is a late manifestation of
chronic pulmonary heart disease.
 Exacerbations of COPD are signaled by a change in the patient’s usual dyspnea,
cough, and/or sputum that is different than the usual daily patterns. These flares
require changes in management and can have significant mortality if not
appropriately treated.
 Patients with severe COPD who have exacerbations are at risk for the
development of respiratory failure.

Diagnosis
 The diagnosis of COPD is confirmed by spirometry.
 Goals of the diagnostic workup are to (1) confirm the diagnosis of COPD via
spirometry and (2) determine the impact of the disease on the patient’s quality of
life.
 A diagnosis of COPD is made when the FEV1/FVC ratio is less than 70% and
related symptoms are present.
 Other evaluations may be used to assess the patient as outlined by the Global
Initiative for COPD (GOLD), which lay the groundwork for management of
COPD. Assessment of a patient may include the level of symptoms (using COPD
Assessment Test [CAT]), severity of disease (FEV1), exacerbation risk, and
presence of co-morbidities.

Interprofessional Care
 The primary goals of care for the COPD patient are to prevent disease progression,
relieve symptoms and improve exercise tolerance, prevent and treat complications,
promote patient participation in care, prevent and treat exacerbations, and improve
quality of life and reduce mortality.
 Cessation of cigarette smoking in all stages of COPD is the intervention that can have the
biggest impact to reduce the risk of developing COPD and influence the natural history of
the disease.
 Although patients with COPD do not respond as dramatically as those with asthma to
bronchodilator therapy, bronchodilator therapy can reduce the dyspnea and increase the
FEV1.
 Presently no drug modifies the decline of lung function in patients with COPD.
  Inhaled anticholinergics or long-acting β2 agonists may be used or combined with inhaled
corticosteroids.
 All these medications decrease exacerbations of COPD with no one better than the other.
 Monotherapy with inhaled corticosteroids is not recommended due to the side effects.
 Four different surgical procedures have been used in severe COPD.
 Lung volume reduction surgery is used to reduce the size of the lungs by
removing the most diseased lung tissue so that the remaining healthy lung tissue
can perform better.
 Bronchoscopic lung volume reduction surgery works by placing one-way valves
in the airways leading to the diseased parts of the lung. The valves let air out but
not in. This collapses a certain segment of the lung and has a similar result as
LVRS.
 A bullectomy is used for certain patients and can result in improved lung function
and reduction in dyspnea.
 Lung transplantation can improve functional capacity and enhance quality of life
in appropriately selected patients with very advanced COPD.
 Breathing retraining such as pursed-lip breathing is a technique that is used to prolong
exhalation and thereby prevent bronchiolar collapse and air trapping.
 Airway clearance techniques include effective coughing techniques, chest physiotherapy,
and airway clearance devices. No one is better than the other, but it depends on patient
preference.
 Effective coughing conserves energy, reduces fatigue, and facilitates removal of
secretions. Huff coughing is an effective technique that the patient can be easily
taught.
 Chest physiotherapy consists of percussion, vibration, and postural drainage.
 Airway clearance devices include those using positive airway pressure, such as
Flutter, Acapella, or TheraPEP. High frequency chest wall oscillation, such as
SmartVest, helps to clear airways.
 Weight loss and malnutrition are commonly seen in the patient with severe
emphysematous COPD. The patient with weight loss needs extra protein and calories and
tips on energy conservation while eating and preparing food.

NURSING MANAGEMENT
 The patient with COPD will require acute care for complications such as exacerbations of
COPD, pneumonia, cor pulmonale, and acute respiratory failure.
 Pulmonary rehabilitation should be considered for all patients with COPD or having
functional limitations. The overall goal is to increase the quality of life and improve
exercise capacity.
 Walking is an inexpensive, effective exercise for the COPD patient. Also, adequate sleep
is extremely important.

OXYGEN THERAPY
 O2 therapy is frequently used in the treatment of COPD and other problems associated
with hypoxemia. Long-term O2 therapy (>15 hr/day) improves survival, exercise capacity,
cognitive performance, and sleep in hypoxemic patients.
  Goals for O2 therapy are to reduce the work of breathing, maintain the PaO2, and/or
reduce the workload on the heart, keeping the SaO2 more than 90% during rest, sleep, and
exertion, or PaO2 more than 60 mm Hg.
 O2 delivery systems are classified as low- or high-flow systems. Most methods of O2
administration are low-flow devices that deliver O2 in concentrations that vary with the
person’s respiratory pattern.
 Dry O2 has an irritating effect on mucous membranes and dries secretions. Therefore it is
important that O2 be humidified when administered, either by humidification or
nebulization.
 Medical complications associated with O2 therapy include CO2 narcosis, O2 toxicity, and
infection. The risk of combustion-related injury is also a possibility requiring specific
precautions for patient safety.

CYSTIC FIBROSIS
 Cystic fibrosis (CF) is an autosomal recessive, multisystem disease characterized by
altered function of the exocrine glands primarily involving the lungs, pancreas, and sweat
glands.
 Initially, CF is an obstructive lung disease caused by the overall obstruction of the
airways with mucus. Later, CF also progresses to a restrictive lung disease because of the
fibrosis, lung destruction, and thoracic wall changes.
 The major goals of therapy in CF are to promote clearance of secretions, control infection
in the lungs, and provide adequate nutrition.
 Nursing care for the patient with CF revolves around the diagnoses of ineffective airway
clearance, impaired gas exchange, ineffective breathing patterns, imbalanced nutrition,
and ineffective coping.

BRONCHIECTASIS
 Bronchiectasis is characterized by permanent, abnormal dilation of one or more large
bronchi. The pathophysiologic change that results in dilation is destruction of the elastic
and muscular structures supporting the bronchial wall.
 The hallmark of bronchiectasis is persistent or recurrent cough with production of large
amounts of purulent sputum that may exceed 500 mL/day.
 Bronchiectasis is difficult to treat. Therapy is aimed at treating acute flare-ups and
preventing a decline in lung function.
 Antibiotics are the mainstay of treatment and are often given empirically, but attempts are
made to culture the sputum. Long-term suppressive therapy with antibiotics is reserved
for those patients who have symptoms that recur a few days after stopping antibiotics.
 An important nursing goal is to promote drainage and removal of bronchial mucus. Rest,
good nutrition, and adequate hydration are also important.