Nurses Notes on COPD [Emphysema & Bronchitis]

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

 DEFINITION: Is a disease state in which airflow is obstructed by emphysema, chronic bronchitis or both. The airflow obstruction is usually progressive, irreversible, and associated with airway hyperactivity, resulting in narrowing of peripheral airways, airflow limitation and changes in the pulmonary vasculature.

 RISK FACTORS: cigarette smoking, air pollution and occupational exposure(coal, cotton and grain)

CLINICAL MANIFESTATIONS:

·          Dyspnea, cough and increased work of breathing

·          Dyspnea  on mild exertion advancing to dyspnea at rest

·          Weight loss

·          Symptoms are specific to disease: Bronchitis and Emphysema

 SYMPTOMS:

    BRONCHITIS-

·          Chronic cough and production of copious purulent sputum which has a quality of layering out into three layers on stranding, a frothy top layer, a middle clear layer and  a dense particular layer,

·          hemoptysis, clubbing of the fingers and

·          repeated episodes of pulmonary infection.

     EMPHYSEMA-

·          Dyspnea with insidious onset progressing to severe dyspnea with slight exertion.

·          Chronic cough, wheezing, dyspnea, fatigue, and tachypnea

·          On inspection “barrel chest” due to air traping, muscle wasting and pursed lip breathing

·          On auscultation, diminished breath sounds with crackles, wheezes, rhonchi and prolonged expiration

·          Hyperresonance with percussion and a decrease in fremitus

·          Anorexia, weight loss, weakness and inactivity

·          Hypoxemia and Hypercapnia, morning headache in advance stages

·          Inflammatory reactions and infections from pooled secretions.

 COMPLICATIONS:

·          Respiratory insufficiency or failure

·          Atelectasis

·          Pneumonia

·          Pneumothorax

·          Pulmonary HPN

 Medical management:

·          Bronchodilators

·          Oxygen Therapy including nighttime oxygen

·          Varied treatment specific to disease

 NURSING MANAGEMENT:

    I.ASSESSMENT

 ·          Assess risk factors

·          Obtain health history such as duration of respiratory difficulty, dyspnea, shortness of breath, wheezing, exercise, tolerance, fatigue, effects on eating and sleeping habits

·          Perform physical examination to obtain baseline data:

-       Pulse, RR, and rhythm

-       Contraction of abdominal muscles during inspiration

-       Use of accessory muscles to breathe, prolonged expiration

-       Cyanosis, neck vein engorgement

-       Peripheral edema

-       Cough, color, amount and consistency of sputum

-       Status of sensorium, increasing stupor, apprehension

 II.             NURSING DIAGNOSIS

·          Impaired gas exchange related to ventilation perfusion inequality

·          Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough and bronchopulmonary infection.

·          Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstiction and airway irritants

·          Self- care deficit related to fatigue secondary to increased work of breathing and insufficient ventilation and oxygenation.

·          Activity intolerance due to fatigue, hypoxemia and ineffective breathing pattern

·          Ineffective coping related to less socialization, anxiety, depression, lower activity level and inability to work

·          Deficient knowledge related to risk of smoking as evidenced by continuing at risk behaviors

III.            PLANNING

·          Improved gas exchange

·          Smoking cessation

·          Improved breathing pattern

·          Maximal self- management

·          Improved activity tolerance

·          Achievement of airway clearance

·          Impaired coping ability

·          Improved health related quality of life

·          Adherence to the therapeutic programs and home care

IV NURSING INTERVENTIONS:

   Improving Gas Exchange

·          Monitor Dyspnea and Hypoxia

·          Administer Medications and be alert  for potential side effects

·          Assess relief of bronchospasm through patient report of less dyspnea

·          Monitor prescribed oxygen effectiveness with pulse oximetry or arterial blood gas (ABG ) analysis

Achieving Airway Clearance

·          Encourage high fluid intake to liquefy secretions

·          Instruct patient in directed or controlled coughing

·          Provide chest physiotherapy with potential drainage and intermittent passive pressure (IPPB) when ordered

·          Instruct patient in effective breathing techniques

·          Measure expiratory flow rates

 Preventing Bronchopulmonary Infections

 ·          Instruct patient to report signs of infection and report any worsening of symptoms

·          Advise patient to avoid outdoor exposure during high pollen counts or significant air pollution because there may increase bronchospasm

·          Encourage immunization against hemophilus Influenzae and streptococcus pneumonia and pneumococcal vaccine every 5 to 7 yrs.

 IV.            EVALUATION:

 Expected patient outcomes:

·          Demonstrates improved gas exchange

·          Achieves maximal airway clearance

·          Improves breathing pattern

·          Maintains maximal level of self-care and physical functioning

·          Achieves activity tolerance and exercises and performs activities with less shortness of breath

·          Develops effective coping mechanisms and participates in a pulmonary rehabilitation program

·          Adheres to the therapeutic program

Nurses Notes Rheumatic Heart Disease

RHEUMATIC HEART DISEASE

DEFINITION: Endocarditis associated with rheumatic fever caused by group A beta-hemolytic streptococcal infection.

CLINICAL MANIFESTATIONS

·          Heart murmurs characteristic of valvular stenosis, egurgitation or both become audible on auscultation

·          Cardiac symptoms defend on which side of the heart is involved. Severity of symptoms depends on size and location of the lesion

·          The mitral valve is mostly affected, producing symptoms of left sided heart failure, shortness of breath, crackles and wheezes

DIAGNOSTIC PROCEDURES

·          Throat culture for accurate diagnosis of streptococcal infection of the throat

MEDICAL MANAGEMENT

·          Eradication of causative organism and prevention of additional complications such as thromboembolitic event

·          Long term antibiotic therapy-Penicillin

NURSING MANAGEMENT

·          Teaching patient about the disease its treatme nt and the steps needed to avoid complications

·          Educate patient and community regarding recognition of streptococcal infections and the need to treat them

·          Teach susceptible patients that may require long term oral antibiotic therapy and may be required to take prophylactic antibiotics

·          Emphasize that less common diagnostic procedures such as cystoscopy, also require prophylactic antibiotic therapy

Nurses Notes on Hypertension

HYPERTENSION

 Definition:   a systolic blood pressure above 140 mmhg or a diastolic pressure above 90 mmhg based on two or more measurements.

Classification:

1.     Optimal- systolic 120 mmhg diastolic 80 mmhg (120/80)

2.     Normal- systolic 130 mmhg diastolic 85 mmhg (130/85)

3.     High normal- systolic 130 to 139 mmhg diastolic 85 to 89 mmhg (130

4.     Stage 1- systolic 140 to 159 mmhg diastolic 90 to 99 mmhg

5.     Stage 2- systolic 160 to 179 mmhg diastolic 100 to 109 mmhg

6.     Stage 3- systolic 180 mmhg or higher diastolic 110 mmhg or higher

Hypertension is a major RISK FACTOR for atherosclerotic cardiovascular disease, heart failure, stroke and kidney failure

I.              ESSENTIAL (PRIMARY) HYPERTENSION

·          It accounts to 90-95% in the adult population have essential HPN

·          Affects more women than men, African- American men

         Pathophysiology:

There is increased in peripheral resistance and or cardiac output secondary to increased sympathetic stimulation, increased renal sodium reabsorption, increased rennin angiotensin aldosterone system activity, decreased vasodilation of the arterioles or resistance to insulin action.

         RISK FACTORS:

Obesity, excessive alcohol intake, overstimulation with coffee, smoking and drug intake.

II.             SECONDARY HYPERTENSION

·          Characterized by elevation in BP with a specific cause such as arterial disease, renal disease, certain medications, tumors and pregnancy hypertension.

DIAGNOSTIC PROCEDURE:

- History and physical examination

- Retinal examination

- Laboratory studies:urinalysis, blood chemistry (sodium, potassium, creatinine, FBS, total and high density lipoprotein), ECG and echocardiography to assess left ventricular hypertrophy

- Special studies: intravenous pyelography, renal arteriography, split renal function studies, rennin levels, 24 hour urine protein, creatinine clearance.

COMPLICATIONS:

·          Renal Hemorrhage

·          Heart failure

·          Renal insufficiency and Failure

·          Cardiovascular Accident (CVA)

·          Transient Ischemic Attack (TIA)

·          Myocardial Infarction (MI)

·          Left Ventricular Hypertrophy

Medical management:

Goal- to prevent death and complications by achieving and maintaining an arterial BP below 140/90 mmhg (130/85 mmhg for people with DM or proteinuria> 1 g/24 hrs. whenever possible.

NURSING MANAGEMENT:

I.              ASSESSMENT

·          Assess BP at frequent intervals , know baseline and note changes in pressure

·          Note the apical and peripheral pulse rate , rhythm and character

·          Assess symptoms such as nose bleeds, angina pain, shortness of breath, alterations in vision, speech or balance (vertigo), headache or nocturia

·          Assess extent to which HPN has affected patient personally, socially and financially

II.             NURSING DIAGNOSIS

1.     Deficient knowledge regarding the relationship between the treatment regimen and control of the disease process

2.     Noncompliance related to side effects of prescribed therapy

III.            PLANNING AND GOALS

·          The major goal of the patient include understanding the disease process and its treatment, compliance with the self care program and absence of complications.

IV.            INTERVENTIONS

1.     Increasing Knowledge

·          Emphasize the concept of controlling HPN ( with lifestyle changes and medications) rather than curing it

·          Arrange a consultation with a dietitian to help patient plan a weight loss

·          Obtain patient education materials

·          Advise patient to limit alcohol intake and avoid use of tobacco (smoking)

2.     Monitoring and Managing Complications

·          Assess all body systems when patient returns for follow up care

·          Question patient about blurred vision, spots or diminished visual acuity

·          Report any significant findings promptly to determine whether additional studies or changes in medications are required.

V. EVALUATION

Expected Patient outcomes:

·          Maintains adequate tissue perfusion

·          Complies with self-care program

·          Experiences no complications

Drug Study: Pyrantel

DRUG NAME	CLASSIFICATION	DOSE	MECHANISM OF ACTION	CONTRAINDICATIONS	SIDE EFFECTS	NURSING RESPONSIBILITIES
Generic Name: Pyrantel Pamoate Brand Name: Helmintox	Classification:  anti-nematodal thiophene Indication: used as a deworming agent in the treatment of hookworms (all species) and roundworms	Dose: 5 mL Route: PO Frequency: Once	Pyrantel pamoate acts as a depolarizing neuromuscular blocking agent, thereby causing sudden contraction, followed by paralysis, of the helminths. This has the result of causing the worm to "lose its grip" on the intestinal wall and be passed out of the system by natural process. Since Pyrantel is poorly absorbed by the host's intestine, the host is unaffected by the small dosage of medication used. Spastic (tetanic) paralyzing agents, in particular pyrantel pamoate, may induce complete intestinal obstruction in a heavy worm load	· Pregnancy— Use of pyrantel during pregnancy is not recommended. · Pyrantel is poorly and incompletely absorbed from the gastrointestinal tract and resulting maternal serum concentrations are low (0.05 to 0.13 mcg/mL). Therefore, it is unlikely that significant amounts of pyrantel would be excreted in breast milk. Problems in humans have not been documented.	·     Nausea, vomiting, diarrhea, stomach/abdominal cramps,headache, drowsiness, dizziness, trouble sleeping, or loss of appetite may occur. ·     For immediate medical attention if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.	·                   Pyrantel comes as a capsule and a liquid to take by mouth. It usually is taken as a single dose for pinworm and roundworm infections. The dose usually is repeated after 2 weeks for pinworm infections.. ·                   Pyrantel may be taken with food, juice, or milk or on an empty stomach. ·                   Shake the liquid well to mix the medication evenly. Pyrantel may be mixed with milk or fruit juice. ·                   Perianal examinations    (cellophane tape swabs of the perianal area to detect the presence of ova may be required prior to and starting 1 week following treatment with pyrantel) ·                   Stool examinations    (may be required prior to and approximately 2 weeks following treatment with pyrantel to determine efficacy or provide proof of cure; because of colonic mixing, ova may persist in the stool for up to 1 week following cure)

Drug Study: Meropenem

DRUG NAME	CLASSIFICATION	DOSE	ACTION	CONTRAINDICATIONS	SIDE EFFECTS	NURSING RESPONSIBILITIES
Generic Name: Meropenem Brand Name: Meronem	Classification: Beta- Lactam Antibiotic Indication: The spectrum of action includes many gram-positive and gram-negative bacteria (including Pseudomonas) and anaerobic bacteria. More active against Enterobacteriaceae and less active against gram-positive bacteria. It is also very resistant to extended-spectrum beta lactamases but may be more susceptible to metallo-beta-lactamases.[1] Meropenem is frequently given in the treatment of febrile neutropenia. This condition frequently occurs in patients with hematological malignancies and cancer patients receiving anticancer drugs that cause bone marrow suppression..	Dose: 300 mg Route: TIV Frequency: Once	Meropenem is bactericidal except against Listeria monocytogenes where it is bacteriostatic. It inhibits bacterial wall synthesis like other beta-lactam antibiotics. In contrast to other beta-lactams, it is highly resistant to degradation by beta-lactamases or cephalosporinases. Resistance generally arises due to mutations in penicillin binding proteins, production of metallo-beta-lactamases, or resistance to diffusion across the bacterial outer membrane..	· Allergy to penicillins or cephalosporins; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. · Kidney function declines as you grow older. This medication is removed by the kidneys. Therefore, elderly people may be at greater risk for side effects while using this drug. · Pregnancy. It is not known whether this drug passes into breast milk. Consult your doctor before breast-feeding.	· The most common adverse effects are diarrhea (4.8%), nausea and vomiting (3.6%), injection-site inflammation (2.4%), headache (2.3%), rash (1.9%), and thrombophlebitis (0.9%). ·  Many of these adverse effects were observed in the setting of severely ill individuals who were already taking many medications. Meropenem also has a reduced potential for causing seizures in comparison withimipenem. ·  Several cases of severe hypokalemia have been reported.	·                   Meropenem must be administered intravenously. It is supplied as a white crystalline powder to be dissolved in 5% monobasic potassium phosphate solution. Dosing must be adjusted for altered kidney function and for haemofiltration. ·                   Before you administer meropenem, look at the solution closely. It should be clear and free of floating material. Gently squeeze the bag or observe the solution container to make sure there are no leaks. Do not use the solution if it is discolored, if it contains particles, or if the bag or container leaks.