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Hello! Welcome to the Module 4, Section B presentation on Respiratory Function. 1

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Page 1: Hello! Welcome to the Module 4, Section B presentation on ...app1.unmc.edu/Nursing/conweb/GeroPPT/PDFs/M4SC_Respiratory.pdf · Hello! Welcome to the Module 4, Section B presentation

Hello! Welcome to the Module 4, Section B presentation on Respiratory Function.

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Our learning objectives are to distinguish between the common age-related structure/function changes and pathological conditions experienced by older adults, and explore nursing assessments and nursing interventions related to the respiratory system.

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We will reach these objectives by learning about the common age-related changes, comparing these with pathological conditions, and then looking at some general nursing interventions to help increase respiratory function.

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Please review this picture from your book on page 436. This provides a general overview of respiratory wellness in adults, which consists of nursing assessment of age-related changes in the upper and lower respiratory tract, respiratory risk factors, and resulting negative functional consequences of decreased respiratory status. It touches on nursing interventions and wellness outcomes. It is a very nice visual to help you remember the material presented for your certification exam.

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Before we start talking about the age-related changes in the respiratory system, let’s review the structures involved, and also some of the terminology. The upper respiratory system is composed of the nose and nasal cavity, the pharynx, and the larynx. The lower respiratory system is comprised of the trachea, bronchi, and the lung tissues. Air exchange occurs within the alveoli. The pulmonary blood vessels branch out among the lung tissue, ending in the capillaries which wrap around the alveolar sacs. The air is breathed in, and diffuses across the alveolar tissues into the capillaries. Waste gases from the body diffuse out through the alveolar tissue and are breathed out.

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Balance of gases in the body is maintained by chemoreceptors in the medulla, the carotids and the aorta. The act of moving air in and out of the lungs is called ventilation. Perfusion is the movement of blood through the respiratory vessels. Gas exchange relies on a balance between ventilation and perfusion. Age-related changes can cause interference in both ventilation and perfusion. Pair this with pathological changes, and respiratory decline can be accelerated.

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So, what are the age-related changes? This table provides an overview of the common changes that occur as we age in the upper respiratory system. Nose: the nasal connective tissue changes, causing the columna (the lower edge of the septum) to retract, resulting in a rounded downward turn to the tip of the nose. Blood flow to the nose is reduced, causing smaller nasal turbinates. The submucosal glands reduce output of the thin watery discharge, resulting in thicker and dryer mucous. This can stimulate the feeling of blockage, creating either a tickle in the throat or coughing. The dryer nature of the internal nasal structures can cause a perception of stiffness of the nasal tissues. Trachea: Calcification of the cartilage can cause tracheal stiffening. Reductions in the number of laryngeal nerve endings contributing to diminished efficiency of the gag reflex. Chest Wall: Stiffness due to calcification of costal cartilage, osteoporotic changes in the rib cage, and decreased muscle strength reduce respiratory output Chest: Increased anteroposterior diameter Thorax: Shortened due to musculoskeletal changes, curvature of spine can result in altered thoracic cavity/capacity r/t kyphosis

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This table is a continuation of the previous in that it provides an overview of the common changes that occur as we age, concentrating in the lower respiratory system. Many of the changes occur in the lung parenchyma, consisting of the structures that are involved in gas exchange. These changes start in young adulthood, and continue at about 4% per decade! Starting in the alveoli, there is a progressive loss of alveolar surface resulting in increased anatomical dead space. This causes changes in the pulmonary artery, such as a wider diameter with thicker and less extensible walls. This makes gas exchange more difficult. Elastic recoil, which is the mechanism in which the airway is kept open during inspiration (via positive pressure and resistance), is reduced, causing air trapping and reduced lung capacity. Gas exchange is compromised more in lower lung regions than the upper due to the changes mentioned thus far. To review, it is because ventilation and perfusion are compromised due to collective changes. Ventilation to perfusion ration can be mismatched, resulting in decrease of arterial oxygen pressure (PaO2) in the blood. The overall response to hypoxia is altered. This is due to the reduced response by the medulla and chemoreceptors to mismatched gas ratios. In the younger adult, this would result in the body attempting to restore balance via increased ventilation. The older adult does not compensate in this manner; therefore, the mismatch results in mental status changes.

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Some of the more common conditions that put one’s respiratory status at risk are

tobacco use, second hand smoke exposure, and environmental exposure. Although

these are risks at any age, older adults may have had longer exposure and thus more

opportunity for adverse effects.

First hand tobacco use causes bronchoconstriction, early airway closure,

inflammation of mucosa throughout the respiratory tract, and inhibited ciliary action.

Extended use leads to increased coughing and mucous secretions, yet diminished

protection from harmful organisms. This can lead to a host of respiratory infection

and/or diseases, particularly COPD and carcinoma.

Exposure to secondhand smoking may be as harmful as primary, especially

considering the culture of smoking encountered generations ago. Secondhand

exposure increases the risk of respiratory disorders similar to those encountered by

smokers, such as lung cancers and CAD by 20-30 percent, increases the risk of stroke,

atherosclerosis, breast cancer, nasal sinus cancer, COPD, asthma, chronic respiratory

symptoms and impaired lung function.

Environmental exposure includes contact with such substances as air pollutants,

occupational substance exposure (such as firefighters to smoke, or miners to harmful

dusts). Obviously prolonged exposure can eventually cause harmful effects in the

lungs leading to disease.

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In considering respiratory decline, older adults who did not attain high peak level of respiratory function during their 20’s will experience the effects of age-related changes earlier in their later years than those who did. Consider factors that may have or currently interfere with function, such as obesity or immunocompromise from medications or disease. One more thing to consider for respiratory level is the effect certain medications may have on respiratory status. Two classes of drugs in particular to think about are sedatives, which contribute to rate and depth of respirations, and anticholinergics, which contribute to consistency of respiratory secretions. Thick and dry secretions resulting from anticholinergic use (in addition to possible cognitive effects) can cause coughing and other adventitious consequences.

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The age-related changes, compounded with pathological interference, results in functional consequences for the client. Table 21-2 on page 440 of your text connects respiratory changes with the resulting consequences. Take some time to review this table, as it is the basis for physical assessment and subsequent intervention.

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This slide shows the respiratory functional consequences of symptomology affecting the older adult, many of which we are already familiar. Physical stressors may cause dyspnea and overall fatigue which decreases respiratory function. There are various symptomologies that can lead to pneumonia, a serious respiratory consequence form the older adult. Some of these include: malnutrition, use of tobacco, lung disease, neurologic disease, sedative medications, congestive heart failure, and finally, residing in a nursing home. There are various symptomologies that can lead to aspiration pneumonia, a serious respiratory consequence for the older adult. Some of these include: dysphagia, achlorhydria (absence of hydrochloric acid in gastric secretions), tube feeding, malnutrition, poor oral hygiene, decreased cough reflex, diminished salivary flow, compromised immune function, and diminished level of consciousness The functional consequence of COPD (emphysema, chronic bronchitis and asthma) include longer and more frequent hospitalizations and an impaired quality of life.

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Nursing assessment of the respiratory system is crucial to nursing care planning. We will review 5 aspects of respiratory assessment, to include physical assessment, identifying risk factors, assessing smoking behaviors, detecting lower respiratory infections, and health promotion.

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Physical assessment in the older adult follows the same technique as the younger client. There are some findings that may be seen in older clients that can differ. These include: slight increase in normal RR (from 16-24/min), increased anteroposterior diameter, increased forward leaning posture (from kyphosis of the spine), decreased resonance on percussion and decreased intensity of lung sounds, and increased presence of adventitious sounds in lower lungs. The last three in particular makes the assessment of the older adult more challenging. Take your time and follow proper procedure in a quiet, undisturbed environment. It is helpful to encourage a deep cough and clearing of the upper respiratory tract prior to auscultating the lungs…this will help distinguish adventitious sounds of the upper from the lower tracts. Be sure to document exactly what you hear. Knowing your client’s baseline can be the difference in knowing what is harmless decreased sounds in the bases versus a possible developing pneumonia. Report changes to the PCP. For an interesting exercise, compare your current respiratory assessment technique with the sample questions provided in Box 21-3 on page 443 in your text.

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Nursing assessment of the respiratory tract include documenting findings from both the upper and lower. The lower was just addressed, and the upper includes such symptomology as itchy nose, sneezing, rhinorrhea, facial pain (in sinus regions), coughing (either dry or productive), etc. Some of the common causes of assessed symptomology are listed here. Treatment of each is discrete, so it is important to document your assessment findings accurately and clearly for the health records.

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A mismatched perfusion to ventilation ratio due to air trapping in lungs can occur. The result is reduced arterial oxygen pressure (PaO2)(4mm HG/decade) A decline in ventilation drive controlled by O2/CO2 ratio occurs, as sensed by the medulla and chemoreceptors (about 40-50% between ages 30-80). The result as we discussed, is less ability to regulate the gas ratio via increased ventilation. Remember your respiratory function testing definitions and techniques. Tidal volume is the normal movement of air during ventilation. Forced expiratory volume is what can be exhaled over 1 second after maximal inspiration. Forced inspiratory volume is what can be inhaled in addition to tidal volume. Forced vital capacity is the maximum amount of air expelled after a maximum inspiration. Total lung capacity is the max capacity of air after a forced inspiratory effort. All of these are generally decreased as we age. You may be asked to obtain measurements to assess respiratory changes from baseline. Be sure to follow you facility’s policy for preforming the tests.

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As we mentioned earlier, current respiratory health status can be a result of years of history. It is important to assess for factors in the client’s history that may over time cause decline in function now. It was mentioned earlier that if peak respiratory function was not achieved in early adulthood, symptoms may occur earlier and more severely as an older adult. We also learned in comprehensive assessment that staring at the beginning may not be the most effective way to uncover risks in the past. Starting with current symptomology from the physical assessment can help to “peel the history layers” backwards so that applicable risks are noted (such as previous environmental exposure verus current) and included in the care plan. These, combined with other comorbid conditions currently experienced, can create an accurate assessment from which to plan care.

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Assessing Smoking Behaviors: Yes, we are going to mention this again, simply because today’s elders were engaged in a culture in which smoking was entrenched. Research is showing that the benefits of smoking cessation are more immediate and more lasting than previously thought, regardless of age; therefore, it is important to get an accurate assessment of how much risk smoking has and is causing to the client. Assess the client’s current attitudes about smoking? Do they even view it as bad for them at this stage in their life? What are their current smoking behaviors? Frequency? Amount? Is it a social event? What are their thoughts on quitting? Are they even considering smoking cessation activities? Do they view their smoking as one of the only activities in which they still have power and control? I have to comment on this, because I have seen this particular situation often: clients will go out to smoke with staff because staff also smoke, and so it is viewed by clients as a privilege. Lastly, are their ageist attitudes either from the client or the staff? Is it just assumed that smoking cessation in older age is not worth it? That there are no health benefits because of current health status, that older clients are not willing to change, etc.? These are very real considerations. For more thoughts and example questions for assessment, see box 21-3 P.444 of your Miller text.

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It is important to assess for developing respiratory infections, as early intervention can prevent devastating short and long term effects. In particular, look for evolving pneumonia. It is important to note that the presentation of pneumonia in older adults is not the typical presentation, as younger adults. Some of the symptoms of pneumonia are fatigue, tachypnea, cough, dyspnea, hx of fever, sputum, tachycardia, pleuritic chest pain, hemoptysis, and in particular, mental status change (remember the etiology of this as we discussed). Remember the importance of comparing baseline to current physical assessment. What are the changes between the two? This can help you detect evolving issues. Another indicator could be a history of uncharacteristic recent falls or incontinence. These can be a sign of changes in perfusion related to respiratory infection.

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Effective health promotion can prevent costly respiratory decline. After assessing for risks and identifying existing respiratory problems, provide health education r/t these assessed risks. Be sure to assess attitudes r/t willingness to change current health behaviors. This is the first thing to address when preparing for health promotion related change. Be sure to stress the importance of influenza and pneumonia vaccines for respiratory wellness, and to encourage TB testing as well. See boxes 21-4 & 5 p. 446-7 in your Miller text for sample assessment questions related to health promotion.

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This slide shows nursing diagnoses commonly used pertaining to respiratory wellness. Nursing diagnoses are chosen, and then described using related to statements. Diagnoses lead to the establishment of wellness outcomes, which are achieved through nursing intervention. The focus of this presentation is on general respiratory wellness outcomes. Take a few minutes to review this diagram.

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After this presentation is over, be sure to check out the additional resources section materials. Also be sure to review the optional presentation on Advanced Respiratory Assessment and Interventions, which provides more detail on medications used and interventions related to specific diseases and conditions.

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You should now have a better understanding of the age-related respiratory changes in the older adult, the functional consequences of these, and general interventions for encountered respiratory risks. Although acute conditions and nursing responses are not addressed here, the major take away points are to appreciate the cumulative effects of risk exposure, the effect of normal age-related changes, and to promote high level respiratory wellness to minimize effects of pathological invasion. For acute situations, prioritize actions based on degree of change from patient baseline, and the level of compensatory reserve the client has during assessment. Emergent action is always needed if the airway is no longer patent, if ventilation is not effective, if perfusion is altered, or if gas exchange in ineffective. Clarify standing orders with the provider if you assess for potential risk of respiratory decline. This is the end of this presentation on Respiratory Function. Thanks so much for your attention!

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