Chapter 32 Homework Have the students answer these questions prior to covering

Introduction to Medical-Surgical Nursing, 6th ed.

32

Lesson Plans for

Chronic Disorders of the Lower Respiratory

Tract

CHAPTER LESSON PLANS & OBJECTIVES

Lesson 32.1:

2. For selected chronic respiratory disorders, describe the pathophysiology, signs and symptoms,

complications, diagnostic measures, and medical treatment.

4. Explain the relationship between cigarette smoking and chronic respiratory disorders.

CHAPTER TEACHING FOCUS

• In this chapter, the student will be introduced to chronic respiratory disorders and their associated risks,

preventive interventions, and treatment.

• Examples of inflammatory, obstructive, and restrictive pulmonary diseases will be discussed, and

cigarette smoking will be emphasized as a major risk for these disorders.

CONCEPTS

The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).

Concepts for nursing practice. St. Louis: Elsevier. The specific exemplars chosen and listed below for

each concept have been tailored specifically to correspond to the Linton textbook.

THEME: Oxygenation and Hemostasis

• Concept: Gas Exchange

• Exemplar: Asthma, p. 598

• Cultural Considerations: What Does Culture Have to Do with Asthma? p. 598

• Figure 32-1: Comparison of terminal bronchioles, respiratory bronchioles, and alveoli in a normal

lung (A) and in the lung of a person with bronchial asthma (B), p. 599

• Pharmacology Capsule, p. 600

THEME: Protection and Movement

• Concept: Inflammation

• Exemplar: Chronic Bronchitis, p. 603

• Figure 32-3: Chronic bronchitis, p. 603

• Put on Your Thinking Cap! p. 604

• Figure 32-4: Types of Emphysema, p. 604

2 Chapter 32Chronic Disorders of the Lower Respiratory Tract _______________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

THEME: Attributes and Resources

• Concept: Development

• Exemplar: Cystic Fibrosis, p. 612

THEME: Homeostasis and Regulation

• Concept: Cellular Regulation

______________________________________ Chapter 32Chronic Disorders of the Lower Respiratory Tract 3

Introduction to Medical-Surgical Nursing, 6th ed.

CHAPTER PRETEST

Have the students answer these questions prior to covering this chapter to understand where they stand

in relation to the content.

1) Chronic obstructive pulmonary disease (COPD) is characterized by varying combinations of asthma,

chronic bronchitis, and __________.

a) pneumonia

b) cor pulmonale

c) pneumonitis

d) emphysema

2) Airway dynamics refers to __________.

a) the study of airways

b) a patient’s ability to inhale or exhale by force

c) the study of bronchoconstriction

d) acute asthmatic episodes

3) The early phase of an acute asthmatic episode is characterized by triggers that cause __________.

a) activation of the inflammatory process

b) red and white blood cells infiltrating swollen tissues of the airway

c) pronounced airway inflammation

d) hyperreactive airways

4) How long after the early phase of an asthma attack does the late phase begin?

a) 30 minutes

b) 60 minutes

c) 5 to 6 hours

d) 10 hours

5) Severe, persistent bronchospasm is called __________.

a) sarcoidosis

b) cystic fibrosis

c) status epilepticus

d) status asthmaticus

6) “Blue bloaters” most often suffer from what condition?

a) Asthma

b) Chronic bronchitis

c) Pneumonia

d) Emphysema

7) “Pink puffers” most often suffer from what condition?

a) Emphysema

b) Chronic bronchitis

c) Pneumonia

d) Asthma

8) Cor pulmonale is the term used to describe __________.

a) enlargement of the airways

b) mucus obstruction

c) right-sided heart failure

d) breakdown of respiratory walls

9) Tuberculosis is spread through __________.

a) the placenta

b) airborne droplets

c) unprotected sex

d) contaminated blood

10) Which of the following surgical procedures performed for lung cancer patients involves the removal of

an entire lung?

a) Wedge resection

b) Pneumonectomy

c) Lobectomy

d) Segmental resection

4 Chapter 32Chronic Disorders of the Lower Respiratory Tract _______________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

Chapter Pretest Answers

CHAPTER BACKGROUND ASSESSMENT

Discuss these questions with your students prior to covering this chapter to understand where they stand

in relation to the content.

Question: How does the routine use of a peak expiratory flow rate (PEFR) meter benefit an asthma

patient?

Question: What is a common medical treatment plan for tuberculosis, and why is it important for the

nurse to know?

______________________________________ Chapter 32Chronic Disorders of the Lower Respiratory Tract 5

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 32.1

Textbook Objectives Covered

1. Identify examples of chronic inflammatory, obstructive, and restrictive pulmonary diseases.

3. Assist in developing a nursing care plan for the patient who has a chronic respiratory disorder.

4. Explain the relationship between cigarette smoking and chronic respiratory disorders.

Lesson Preparation Checklist

• Prepare lecture from TEACH lecture slides available on Evolve.

• Guest speaker: primary care nurse practitioner

• Student performance evaluation of all entry-level skills required for student comprehension of

principles underlying chronic respiratory disorders, including:

Materials and Supplies

• computer and PowerPoint

projector

• drug references

Key Terms

• asbestosis (p. 617)

• bronchitis (p. 603)

• granuloma (p. 616)

6 Chapter 32Chronic Disorders of the Lower Respiratory Tract _______________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 32.1

Student Preparation

Assignments 2 hours

1

READ – Textbook (pp. 598-619)

ANSWER – Text

• Review Questions for the NCLEX Examination: 1 (p. 620)

ANSWER – Study Guide

• Part IA: 1-7, 9, 10 (p. 193)

• Part IE: 5 (p. 195)

• Part IIF: 1 (p. 195)

2

• Part IIF: 2-14, 16, 19-27 (pp. 195-196)

READ – Textbook (pp. 598-619)

REVIEW

• Figure 32-1: Bronchioles and alveoli in normal lung; lung of person with asthma (p. 599)

ANSWER – Text

• Review Questions for the NCLEX Examination: 4, 9 (pp. 620-621)

ANSWER – Study Guide

• Part IA: 8 (p. 193)

• Part IB: 8, 9, 10 (p. 194)

3

READ – Textbook (pp. 598-619)

REVIEW

• Figure 32-6: Sitting on edge of bed to allows more effective respiratory function (p. 609)

• Figure 32-8: Normal adult chest and chest deformities (p. 619)

ANSWER – Text

• Review Questions for the NCLEX Examination: 2, 3, 5, 6, 7, 8 (pp. 620-621)

ANSWER – Study Guide

• Part IB: 1-7 (p. 194)

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Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 32.1

4

READ – Textbook (pp. 610-619)

REVIEW

• Box 32-1: Facts about Smoking (p. 610)

• Box 32-2: Aids to Smoking Cessation (p. 610)

ANSWER – Text

• Review Questions for the NCLEX Examination: 10 (p. 621)

ANSWER – Study Guide

• Part IE: 4 (p. 194)

Lecture Outline 20 minutes

Slide 1

Chapter 32

Chronic Disorders of the Lower Respiratory Tract

1,

2,

&

3

Slide 2

Asthma

• Pathophysiology: potentially reversible obstructive airway disorder: airway inflammation

and hyperresponsiveness

TALKING POINTS:

• The incidence of asthma has been increasing.

Slide 3

Pathophysiology: Acute Episode

• Begins when “triggers” activate the inflammatory process

• Airways constrict and become edematous

• Mucous secretion increases, forming plugs in the airways, and tenacious sputum is

produced

Slide 4

Pathophysiology

• Late phase

• Begins 4-8 hours after the early phase response

• Red and white blood cells infiltrate swollen tissues of the airways

• During this phase, which lasts several hours or days, the airways are hyperreactive

(very sensitive)

• Risk for another episode until phase subsides

• When no specific trigger can be identified, the patient may be said to have “intrinsic”

asthma

• Asthma with known triggers: “extrinsic” asthma

8 Chapter 32Chronic Disorders of the Lower Respiratory Tract _______________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 32.1

Slide 5

Complications

• Status asthmaticus: severe, persistent bronchospasm

• Can lead to right-sided heart failure, pneumothorax, worsening hypoxemia, and

respiratory or cardiac arrest

• Over time, repeated episodes can cause permanent changes

Slide 6

• What findings may suggest the respiratory arrest is imminent?

Signs and Symptoms

• Dyspnea, productive cough, use of accessory muscles of respiration, audible expiratory

wheezing, tachycardia, and tachypnea

TALKING POINTS:

Slide 7

Medical Diagnosis

• Health history, the physical examination, spirometry, and the pulmonary function test

results

TALKING POINTS:

• What will the results of a pulmonary function test typically reveal?

Slide 8

NIH 2007 Guidelines for Diagnosis and Management of Asthma

• Assessing and monitoring asthma severity and control

• Peak flow monitoring, periodic spirometry, sputum eosinophils

• Education for a partnership in care

TALKING POINTS:

• What can be changed in a patient’s environment?

• What are some comorbid conditions that can interfere with asthma management?

Slide 9

Medical Treatment

• Bronchodilators

• Antiinflammatory drugs

TALKING POINTS:

• What is the primary goal of medical therapy for asthma?

• People with mild asthma may have to use inhaled bronchodilators only when they have

Slide 10

Assessment

• Essential information (medications, allergies, known cardiac disease, sleep disruption);

immediately take steps to relieve symptoms

• Health history

• Frequency and severity of attacks, the factors known to trigger attacks, effect of

condition on patient’s life, strategies used to manage the condition, sources of stress

and support, and patient’s knowledge about asthma and its treatment

______________________________________ Chapter 32Chronic Disorders of the Lower Respiratory Tract 9

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 32.1

Slide 11

Assessment (cont.)

• Physical examination

• Measurement of vital signs and auscultation of lung sounds

• Assess skin color and respiratory effort

3

&

4

Slide 12

Patient Teaching

• Long-term control medications

• Triggers

• Reduce environmental triggers

• Avoid tobacco, have infections treated promptly, manage stress

1,

2,

&

3

Slide 13

Interventions

• Ineffective breathing pattern

• Impaired gas exchange

• Anxiety

TALKING POINTS:

• Monitor the patient’s respiratory rate, pattern, and effort.

• Monitor for signs and symptoms of impending respiratory failure.

Pathophysiology

• Chronic bronchitis

• Bronchial inflammation; increased production of mucus and chronic cough that persist

1

–

4

Slide 15

Pathophysiology (cont.)

• Emphysema

• Degenerative, nonreversible disease: enlargement of the airways beyond the terminal

bronchioles

• Centrilobular emphysema

• Associated with cigarette smoking; affects mainly the respiratory bronchioles

• Panacinar emphysema

• Affects the respiratory bronchioles and the alveoli

10 Chapter 32Chronic Disorders of the Lower Respiratory Tract _______________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 32.1

1,

2,

Complications

• Respiratory failure

Factors: infection, air pollution, continued smoking, left ventricular failure, myocardial

TALKING POINTS:

• Respiratory failure is marked by hypoventilation and ventilation-perfusion mismatch with

rising arterial carbon dioxide pressure (PaCO2), declining arterial oxygen pressure (PaO2),

and respiratory acidosis.

Slide 17

Signs and Symptoms

• Chronic bronchitis

• Productive cough, exertional dyspnea, and wheezing

• Emphysema

TALKING POINTS:

• What does the term blue bloater mean? Pink puffer?

Slide 18

Medical Diagnosis

• Patient’s health history and physical examination

• Pulmonary function tests

• Computed tomography (CT) scan

Slide 19

dysrhythmias.

Medical Treatment

• Drug therapy

• Goals: improved ventilation and removal of secretions

• Bronchodilators

• Corticosteroids

TALKING POINTS:

• What are examples of bronchodilators?

______________________________________ Chapter 32Chronic Disorders of the Lower Respiratory Tract 11

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 32.1

Slide 20

Medical Treatment (cont.)

• Oxygen therapy

• Initial is usually 1 to 3 L/minute

• Chest physiotherapy

• Exercise

• Nutrition

• Supplementary feedings may be needed

• Good hydration

TALKING POINTS:

• What is the goal of oxygen therapy?

• High levels of oxygen are not administered because patients with COPD may rely on

hypoxic drive to breathe.

• The patient may be referred to a rehabilitation program that includes exercise

reconditioning.

Surgical Treatment

• Lung volume reduction surgery (LVRS)

• Up to 30% of hyperinflated lung tissue excised to improve mechanics of breathing,

3

Slide 22

Assessment

• Describe the presenting symptoms—often dyspnea, cough, chest pain, or a combination

of these

• Obtain a complete medical history

Slide 23

Assessment (cont.)

• Physical examination

• Posture, color, respiratory effort, and use of accessory muscles of respiration;

measure vital signs. Note pursed-lip breathing

• Hypoxemia: restlessness, confusion, and lethargy

12 Chapter 32Chronic Disorders of the Lower Respiratory Tract _______________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 32.1

Slide 24

Interventions

• Impaired gas exchange

• Ineffective airway clearance

• Anxiety

• Imbalanced nutrition: Less than body requirements

Slide 25

Bronchiectasis

• Abnormal dilation/distortion of bronchi and bronchioles; usually confined to one lung lobe

or segment

• Follows recurrent inflammatory conditions, infections, or obstructions but is sometimes

congenital

Slide 26

Cystic Fibrosis

• Hereditary disorder characterized by dysfunction of the exocrine glands and production of

thick, tenacious mucus

• Cough is the first pulmonary symptom

TALKING POINTS:

• What occurs with the absence of pancreatic enzymes?

• Most patients do not develop diabetes because the endocrine function of the pancreas is

still adequate.

Slide 27

Cystic Fibrosis (cont.)

• Stools become bulky and foul-smelling

• Lose more salt in sweat than normal; at risk for salt depletion, especially in hot

environments

______________________________________ Chapter 32Chronic Disorders of the Lower Respiratory Tract 13

LESSON 32.1

Slide 28

Cystic Fibrosis (cont.)

• Treatment

• Pancreatic enzyme replacement, chest physiotherapy, and aerosol and nebulizer

treatments to reduce mucus viscosity

TALKING POINTS:

• Alternatives to manual chest physiotherapy include the ﬂutter mucus clearance device, a

handheld tool that vibrates to loosen secretions and promotes movement of secretions out

of the lungs.

• What issues may arise with the treatment of infections?

Slide 29

Cystic Fibrosis (cont.)

• Nursing care

• To clear airway: administer prescribed medications, maintain hydration, and perform

chest physiotherapy

• Prevent infection with medical asepsis and protect patient from others with infections

TALKING POINTS:

• What are the goals of nursing care with cystic fibrosis?

• Allow the patient to maintain as much control as possible and try to maintain the patient’s

usual routines during hospitalization.

Tuberculosis

• Cause and risk factors

• An infection caused by Mycobacterium tuberculosis, an acid-fast aerobic bacterium

TALKING POINTS:

• Tuberculosis was a leading cause of death in the United States until effective drugs

Pathophysiology

• Most people do not acquire active (symptomatic, progressive) tuberculosis