Welcome to the optional presentation: Advanced Respiratory Assessment and Interventions. This presentation is not required, but there is review material within that may be on your ANCC exam. If you are not already very comfortable with respiratory assessment and mediations, you will find this presentation very beneficial.

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Our learning objective is to explore advanced nursing assessments and nursing interventions related to the respiratory system. It is my intention to do this by giving you review on the items that may appear on the exam. This is in no way a comprehensive review of the possible nursing responses to respiratory disease.

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We will reach this objective by exploring advanced methods of respiratory assessment, to include pulmonary testing and laboratory values. We will also review the etiologies of common pathologies. We will take a look at nursing interventions, focusing on reviewing pharmacological treatments that you may see on the exam.

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We are going to start by reviewing how lung function is measured. This will help you to understand disease guidelines and diagnosis, and will help you to evaluate treatment outcomes more effectively. A person has a normal resting breathing pattern, moving air in and out of the lungs, called ventilation. A person can increase the amount of air breathed in based on oxygen demand, by increasing the ventilation rate and taking in more air with each breath. What we see here is a chart depicting ventilation. The normal resting respiratory rate is seen here, also called tidal volume. With effort, a person can inhale a defined amount of air beyond resting volumes. This represents all of the air that can be breathed in at once, called inspiratory reserve volume. Similarly, a person can exhale a set amount of air beyond the resting volume expired, called expiratory reserve volume. A certain amount of air remains in the lungs even after max expiration, called residual volume. Residual volume keeps the lungs inflated. Atelectasis occurs when the lungs loose the residual volume. Total air that can be breathed in and exhaled is called vital capacity. This plus the residual volume is called total lung capacity. For our nursing purposes, we are concerned with how much air can be forcefully moved out of the lungs. A forced expiratory volume (usually over 1 second) is a common metric in lung functioning. With inflammation and bronchoconstriction, this volume is reduced. Remember also, that with certain diseases (emphysema/COPD), air is trapped even after forced exhalation. This causes increased pressure in the lungs and possibly on the circulation from the heart to the lungs. This may result in

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right sided heart failure (cor pulmonale). Learning lung function and how it is measured can help you understand the functional consequences on patients with lung pathologies.

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Lung diseases are classifies 2 ways: Obstructive versus Constrictive, and Acute vs. Chronic. Let’s explore both of these in more detail.

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Obstructive disease involves difficulty in air movement due to damage to the airways or lung tissue. Patients with obstructive disease have difficulty with exhaling due to the narrowed airways and damage to the alveoli. Lung volume is altered, causing the person to have to take shorter faster breaths to increase air volume. Asthma is a good example of obstructive disease. Constrictive disease is a result of changes to the lung tissue itself, in which the tissue is stiff and has increased resistance. Because of this, these patients have difficulty inhaling, due to the stiffness of the lung tissues. More force is needed to inhale, causing increased pressure in the lung tissues. This can eventually cause involvement of the pulmonary circulation all the way back to the heart. An example of this would be pulmonary fibrosis.

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I think that review of acute versus chronic seems pretty obvious on its face. However, it is important to understand that symptomology for various diseases can overlap, and so even though a person has a chronic condition, exacerbations of this chronic disease can quickly lead to the need for acute treatment.

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The reason that we reviewed the classifications of lung disease was that you have a good understanding of what is going on when the patient is experiencing symptoms. This leads to better intervention. For example, knowing that Constrictive disease symptomology is related to lung tissue stiffness, you can understand that typical medications to open the airway may not be effective in reducing symptomology. You may expect more pressure-type complications as well. Conversely, the obstructive disease symptomologies can help you understand that moving air may not be the only issue; moving air out is also a problem. Air trapping and even possible O2 poisoning or acid base problems may ensue from this pathology.

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Here is a list of some common respiratory conditions that affect older adults. Although I know you are at least familiar with each one, we will review by highlighting important considerations for each. I don’t want to read all of the slides to you, so I will pick out a few details that I want you to remember for each.

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Allergic rhinitis is a reaction of the nasal mucosa to a specific allergen. This one was deliberately chosen first, because there is a gerontological consideration that I want to point out. Although all populations get allergic rhinitis, true allergic rhinitis may mimic a phenomenon called geriatric rhinitis. Geriatric rhinitis develops because of the age related changes to the nasal mucosa and turbinates. Typical treatment of allergic rhinitis may actually exacerbate geriatric rhinitis. The etiology involves activation of the allergic response in the nasal mucosa leading to inflammation in the nasal passages. Your assessment includes looking for evidence of this response (sneezing, itching, drainage, etc.), and so your treatment will be supportive of reducing the allergic response and reducing inflammation, thus opening up the nasal passages. Since allergic rhinitis is caused by an allergen, teach your patients to identify and avoid the trigger. If reaction occurs, help the patient to correctly administer OTC or prescribed medications that halt the local allergic and inflammatory response.

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Asthma is a difficult diagnosis in older adults. Although asthma usually presents in younger adulthood, it can also present in the 60’s, 70’s, and even 80s! Asthma is characterized by hyperreactive airways (above and beyond the typical allergic response), and is often triggered by irritation by inhaled particulates. The defining characteristic is the rapid onset and severity of symptoms, particularly in older adults. Your assessment will reflect the hyper inflamed and constricted airways, and so treatment is to use rapid medications to reverse this immediate response, and longer acting medications to prevent acute reactions. Correct administration of inhaled medications is a key teaching point, as incorrect administration is one of the leading causes of medication failure. Be sure to pay particular attention to anxiety, which can exacerbate the constrictive response and increase O2 demand. Assisting patients to reduce anxiety during acute exacerbations is a key nursing interaction.

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COPD is a chronic obstructive condition that I am sure you have all been involved with at one time or another. This is the number one respiratory problem in older adults, and is almost always due to exposure to a noxious substance, most commonly smoking. COPD is different than other conditions because the obstruction is not able to be fully controlled. It is diagnosed by an FEV1 of < 0.7. This would be stage 1 and progresses to more severe as you approach stage IV. COPD can consist of mixed symptomologies of 2 distinct disorders: emphysema and chronic bronchitis. Emphysema is characterized by destruction of the alveoli leading to less surface area for perfusion, while chronic bronchitis is inflammation (excess mucous, coughing) and constriction of the bronchial tree for 3 months for 2 years straight. One interesting fact though is that not all COPD is caused by smoking. It has been discovered that a genetic defect can also cause this. If your patient does not have a history of smoking or other exposure, they might want to be tested for alpha antitrypsin deficiency. You can see that there is a gender difference in the consequences of the disease, so keep this in mind during care planning.

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Treatment involves supporting ventilation and perfusion. I want to add that nurses can help patients by teaching proper breathing techniques, such as pursed lip breathing and use of the diaphragm to move air. Use caution with oxygen, as too much oxygen with COPD patients can diminish the respiratory drive and cause oxygen poisoning.

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Take a look at this video for COPD. It is a very helpful visual. Click on the image to view.

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Pneumonia is an acute infection of the lung parenchyma. This can be deadly for older adults, who may lack the strength to clear the lungs enough for perfusion to occur. As mentioned in the respiratory presentation, pneumonia does not present in an older person like it does in a younger adult. Often this can get overlooked, particularly when there is no fever. Be vigilant with your physical assessment. One thing to point out in the slide is that pneumonia can be caused by inhalation of an infectious agent, by aspiration of infectious material from the nasal passages or the stomach, or can occur hematogenous, which means an infection is planted in the lung tissue by an infectious agent that traveled in the blood stream. This type is particularly dangerous. Treatment depends on the type of infectious agent at the root of the infection. Treatment also must include ventilation support.

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Lung cancer: we all know what cancer is, and by default understand what lung cancer is. I will pick out a few facts that you might see on your exam: first of all, understand that there are 2 types: small cell and non-small cell. Small cell is definitely the more progressive type. It is staged I-IV, with treatment based on type and stage. The hallmark symptom is a persistent cough often that is blood tinged. The nurse’s role, other than supporting ventilation, is to educate the patient on treatment procedures and to provide help in facilitating social supports. Anxiety and depression may also be a problem for these patients.

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Tuberculosis is more prevalent in older adults (particularly over 65), so it is worth mentioning here. Tb is an acute infection of the lung parenchyma by a mycobacterium. The immune cells have a hard time eradicating the organism, and so may form a scar or cyst around the infection site. Risk factors include having traveled out of the country, as well as decreased immune status. Living in close quarters can increase the chance of disease spread. Testing and precautions should be taken with older adults whose history may reveal risk factors that predispose them to Tb. The hallmark symptoms of active disease are cough, chest pain, bloody tinged sputum, and night sweats. Weight loss often occurs in older adults. Comorbid respiratory issues may mask the disease symptoms. Treatment involves extensive and regimented drug therapy that may be difficult for older adults to follow and/or tolerate. Patients receiving Tb therapy will require close follow up, not only for compliance, but for supportive care.

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As many of you are accepting more and more patients who have higher acuities, I want to mention pulmonary embolism. This is a clot that becomes lodged in the vasculature of the lung, potentially causing infarct. It is usually due to a DVT that breaks loose. Prevention of DVT formation can be instrumental in preventing PE. Immobile patients are at particular risk for this. The signs and symptoms can be the same as other respiratory exacerbations. Depending on the severity of the PE, you may or may not suspect it. People who have a PE usually have symptoms that may be quick in onset, they can have extreme pain, and can have sudden drops in O2 that is not reversible with O2 therapy. If you suspect PE, notify the MD pr provider immediately. A VQ scan will provide insight on if a PE is present (the V/Q scan checks ventilation/perfusion ratio) or a spiral CT scan can be used to detect PE. Pts. should be NPO for this test. Treatment will consist of antithrombolytic agents to prevent the clot from growing, and possibly clot buster meds if the clot is causing infarct. Be ready to provide education and support for the patient during these procedures.

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This slide briefly reviews some of the more common labs associated with respiratory conditions. This is by no means comprehensive, but it will give you a nice refresher on what the labs are telling you about the older client’s respiratory condition. Normal blood pH for an adult is 7.35-7.45. Older adults can range slightly skewed to the left. Watch pH closely though, as increases or decreases can mean acute changes in status and that the body is not compensating for reduced respiratory functioning. Respiratory alkalosis can result from hyperventilation/increased respiratory rate. Respiratory acidosis can occur when the lungs cannot expel carbon dioxide quickly enough. Your obstructive lung diseases can cause this. Your COPDers may actually live in chronic respiratory acidosis, as their kidneys balance the acidosis with bicarb production. Acute changes in pH can signify respiratory and or metabolic imbalance. It is well known that elevations in WBCs can signify infection. What is interesting here though, is that your CBC with WBC differential (CBC with diff) can give you clues as to the cause of respiratory problems. Your elevated leukocytes signify infection, while a decreased value could indicate sepsis. The neutrophils are present in bacterial type infections, while decreased values may indicate a virus. The eosinophils are elevated when there is an allergic reaction, or asthmatic reaction. The basophils are elevated by chronic inflammation and by an acute hypersensitivity reaction. Blood gas interpretation is an advanced skill. It can give you more accurate data on how the lungs are functioning metabolically, and is particularly important in caring for COPD patients.

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I am sure that you use respiratory medications every day in your clinical practice, but I am going to review these by class, and then try to highlight tips for use in the older adult population. The first we will look at are the inhaled bronchodilators. Generally, they work by blocking a reaction in the smooth muscle of the airway, which then causes the muscles to relax. Not all of these work in the same way through. Some are beta agonists, and some are anticholinergic. Basically they affect slightly different receptors that cause the same overall outcome in the airway. But, because they affect different receptors, watch for slightly different side effects. Research has shown that the anticholinergics may have better outcomes in older adults than the beta agonists. A third group is the theophyllines, taken orally. The meds may be short acting or long acting; knowing this can help you understand which to use during an exacerbation, and which will not be effective during this time. There are inhaled medications that contain both a bronchodilator and a different medication, such as a glucocorticoid.

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Next are the antiinflammatory medications. These medications reduce swelling by blocking the inflammatory cascade within the walls of the airways. They include the inhaled corticosteroids, the oral corticosteroids, and also the leukotriene modifiers can be considered antiinflammatory in nature. Also watch for combined formulations of these medications which may be combined with another type of respiratory med, such as the bronchodilators. The glucocorticoids taken orally can cause decreases in bone density, may increase risk for fracture, and may also exacerbate HTN and/or cause ulcers. Watch for these complications for patients on these medications.

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Although I don’t want you to concentrate deeply on this, sometimes the inflammation experienced in the lungs can be a result of some immune issue the patient may be experiencing. In this case, inflammation can be reduced using an autoimmune medication.

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This slide contains a list of very common medications that are prescribed to treat upper airway issues. Although you are probably familiar with each of these, take a moment to read over the information, as each class contains a tip to remember that directly pertains to administration to older adults.

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I hope that you now have a refreshed knowledge base of etiologies for common respiratory pathologies, labs, pulmonary function tests, and highlighted gerontological nursing interventions, with a focus on pharmacological treatments. This concludes our optional presentation on advanced respiratory assessment and intervention.

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