ASTHMA A chronic inflammatory disease of the airways causing hyper responsiveness, mucosal edema and mucous production.

PATHOPHYSIOLOGY: BRONCHOCONSTRICTION: During an asthma episode, inflamed airways react to environmental triggers such as smoke, dust, or pollen. The airways narrow and produce excess mucus, making it difficult to breathe. In essence, asthma is the result of an immune response in the bronchial airways The airways of asthmatics are "hypersensitive" to certain triggers, also known as stimuli (see below). In response to exposure to these triggers, the bronchi (large airways) contract into spasm (an "asthma attack"). Inflammation soon follows, leading to a further narrowing of the airways and excessive mucus production, which leads to coughing and other breathing difficulties

CLINICAL MANIFESTATIONS: a. b. c. d. e. Cough with or without mucous productions dyspnea sneezing exacerbation asthma attack ofeten occurs at night or early morning because of circardian variations that influence airway receptor thresholds.

f. Asthma exacerbations may begin abruptly but most frequently is preceeded by increasing symptoms over the previous days. g. Generalized wheezing h. Generalized chest tightness i. Expiration requires effort and becomes prolonged. j. Diaphoresis, tachycardia, widened pulse pressure k. Hypoxemia- secondary to ventilation-perfusion mismatch l. Central cyanosis- late sign of poor oxygenation. ASSESSMENT AND DIAGNOSTIC FINDINGS a. Assess for patients family history b. Assess for environmental factors: - seasonal changes - high pollen counts - mold - pet dander - climate changes - air pollution c. Assess for occupation-related chemical compounds - Metal wood and vege dusts - Medications (aspirin, antibiotics, piperazine, cimetadine) - Industrial chemicals and plastics - Laundry detergents - Animal insect dusts - Sera - Secretion d. Assess for comorbid conditions that accompany asthma - GER - Diagnostic induced asthma - Allergic bronchopulmonary asthma aspergillosis LABORATORY FINDINGS: a. b. c. d. e. sputum and blood tests elevated level of eosinophils elevated level of immunoglobulin E Arterial Blood Gas Analysis and pulse oximetry reveals hypoxemia Normal PaCo2 value may signal impending respiratory failure

PREVENTION

Patients with asthma must undergo tests to identify substances that precipitate the symptoms. COMPLICATIONS Status Asthmaticus Respiratory failure Pneumonia Atelectasis

MANAGEMENT A. Pharmacologic Therapy 2 General classes of Asthma medications: a. Long Actin Medications *CORTICOSTEROIDS- most potent and effective anti-inflammatory medication. When the patient uses inhaled corticosteroids with spacer, they should rinse his/her mouth after administration to prevent thrush. *CROMOLYN Na (Intal) *NEDOCROMIL (Tilade) -moderate anti-inflammatory agents used in children. b. Long Actin Beta2-adregernic agonists- used with anti-inflammatory medications to control asthma symptoms. *THROPHYLIINE- for relief of nighttime asthma. *LEUKOTRINE MODIFIERS/ INHIBITORS- potent bronchoconstrictors that dilate blood vessels and alter permeability. QUICK RELIEF MEDICATIONS: Short-acting Beta2-adrenergic agonists- are the medication of choice for relief of acute symptoms and prevention of exercise-induced asthma. B. MANAGEMENT OF EXACERBATIONS a. Asthma Exacerbations are best managed by early treatment and education. b. Quick acting beta2-adrenergic agonist medications are fast used prompt relief of airflow obstruction. c. Systematic corticosteroids to decrease airway inflammation in patients who fail to respond to inhaled beta-adrenergic medications. d. Oxygen supplementation maybe required to relieved hypoxemia. e. Antibiotic Therapy Treatment for patients with acute asthma exacerbations with comorbid conditions. (e.g fever, purulent sputum) f. Peak flow monitoring:

Peak flow meters the highest airflow during a forced expiarion. It also helps measure asthma severity and indicates current degree of asthma control. NURSING MANAGEMENT Nursing management depends on the severity of symptoms. a. Nurses must use a calm approach, which is an important aspect of nursing care. b. Assess the patients respiratory status by: -monitoring the severity of symptoms - breath sounds - peak flow - pulse oximetry - vital signs c. Aminister medications as prescribed and monitor patients response to the medications. c. Administer fluid if the patient is dehydrated.

STATUS ASTHMATICUS a severe and persistent asthma that does not respond to conventional therapy. Attacks can occur with little or no warning and can progress rapidly to asphyxiation.

SIGNS AND SYMPTOMS: - Labored breathing - Prolonged exhalation - Engorged neck veins - Wheezing ASSESSMENT AND DIAGNOSTIC FINDINGS Pulmonary Function- most accurate means of assessing acute airway obstruction

MEDICAL MANGEMENT a. close monitoring of the patient b. treatment of Beta2- adrenergic agonist c. corticosteroids- used to decrease the intense airway inflammation and swelling d. short-acting inhaled Beta2- adrenergic agonists provide most rapid relief from bronchospasm. e. Oxygen Therapy to trear dyspnea, central cyanosis, and hypoxemia. -high flow supplemental Oxygen is best delivered using a partial or complete nonrebreather mask f. Magnesium Sulfate-calcium antagonist, administred to induced smooth muscle relaxation causing bronchodilation. g. Sedative Medications are contraindicated. NURSING MANAGEMENT main focus is to actively assess the airway and patients response to treatment. Constantly monitor the patient for the first 12-24 hours until Status Ashtmaticus is controlled. Assess patients skin turgor for signs of dehydration. Administer IV Fluids as prescribed. BP, Cardiac rhytm should be monitored. Provide a quiet room free from irritants to conserve patients energy.

PULMONARY EMBOLISM - an obstruction of the pulmonary artery or one of its branches by a thrombus that originates somewhere in the venous system or in the right side of the heart. MANIFESTATIONS: a. b. c. d. Dyspnea- most common Tachypnea-most frequent Chest pain usually sudden and pleuritic Deep Venous Thrombosis- sudden onset of pain or swelling and warmth of the proximal or distal extremity, skin discoloration and superficial vein distention.

ASSESSMENT AND DIAGNOSTIC FINDINGS a. Chest X-rays b. ECG- shows sinus tachycardia, PR- interval depression, non- specific T-wave changes c. Peripheral Vascular Studies d. Arterial Blood Gas Analysis- shows hypoxemia and hypocapnia e. V/Q Scan- an invasive procedure, evaluating the different regions of the lung and allows comparison of the percentage of ventilation and perfusion in each area. f. Spiral Computed CT Scan of the Lung g. D-dimer Assay: blood test for evidence of blood clots h. Pulmonary Angiography- best nethod to diagnose Pulmonary Embolism. Allows for direct visualization under fluoroscopy of the arterial obstruction and accurate assessment of the perfusion deficit. PREVENTION a. Prevent deep venous thrombosis by: - active Leg exercise - early ambulation - use of elastic compression stockings b. Anticoagulant Therapy for patients older than 40 years old. c. Low doses of Heparin before surgery to reduce risk of postoperative Deep Venous thrombosis and Pulmonary embolism d. Sequential Compression devices are oten used to prevent Venous stasis through compression and relaxation of the calf muscles.

MANAGEMENT

*Emergency Management is the primary concern, to stabilize the Cardiopulmonary system. a. b. c. d. e. f. g. Administer Nasal Oxygen immediately to relieve hypoxemia IV infusion lines inserted to establish routes of medications Perfusion Scan Hypotension is treated by a slow infusion of dobutamine Administer digitalis glycosides, IV diuretics, and anti-arrhythmic agents Indwelling urinary catheter for massive embolism to monitor urine output. Small doses of IV Morphine or sedatives to relieve patient anxiety.

*General Management: a. OxygenTherapy- to correct hypoxemia, relieve pulmonary vascular vasoconstriction. b. Use of elastic compression stockings c. Elevating Leg (above heart level) also increases venous flow. *Pharmacologic Therapy A. Anti Coagulation Therapy (heparin, Warfarin Na)- primary method for managing acute deep vein thrombosis and pulmonary Embolism Heparin- to prevent occurrence of emboli B. Thrombolytic Therapy- used in treatment for patients who are severly compromised. - resolves the thrombi or emboli more quickly and restores more normal hemodynamic functioning of the pulmonary circulation. - Side effects: BLEEDING -Contraindications: a. CVA within past 2 months b. active bleeding c. surgery within 10 days of the thrombotic event d. recent labor and delivery e. trauma f. severe hypertension *Surgical Management: a. Surgical Embolectomy: for patients with massive Pulmonary Embolism or hemodynamic instability. The removal of actual clot. b. Transvenous catheter embolectomy- technique in which a vacuum- cupped catheter is introduced transvenously into the affected pulmonary artery.

c. Interrupting the Inferior Vena Cava- is another surgical technique used when Pulmonary Embolism recurs or when patient does not tolerate anticoagulant therapy. *Nursing Management a. minimize risk of Pulmonary Embolism b. Preventing thrombus formation by encouraging ambulation and active and passive leg exercise to prevent venous stasis in patients prescribed at bed rest. c. Assessing potential for Pulmonary Embolism d. Maintaining oxygen therapy e. Relieving anxiety f. Monitor for complications g. Provide postoperative nursing care

POISONING POISON- is any substance, when ingested, inhaled, absorbed, applied to the skin or produced within the body injures the body by its chemical action. A. Swallowed Poisons- maybe corrosive. It includes alkalines and acid agents that can cause tissue destruction after coming into contact with mucous membranes. Includes: a. Lye b. Drain cleaners c. Toilet bowl cleaners d. Bleach e. Non phosphate detergents f. Oven cleaners g. Button batteries

B. Carbon Monoxide Poisoning- may result of industrial or household incidents or attempted suicides. It exerts its toxic effects by binding to circulating hemoglobin and there by reducing the oxygen carrying capacity of blood. CARBOXYHEMOGLOBIN- carbon monoxide bound to hemoglobin. It does not transport oxygen. MANIFESTATIONS - appear intoxicated (from cerebral hypoxia) - headache - muscular weakness - palpitation - dizziness - confusion progressing rapidly to coma - skin color: from pink or cherry red to cyanotic and pale. Management: The goal of management is to reverse cerebral and myocardial hypoxia. General measures to apply: a. carry patient to fresh air immediately. Open all doors and windows b. loosen all tight clothing c. initiate CPR. Administer 100% oxygen. d. prevent chilling. Wrap patient in blankets. e. keep patient as quiet as possible. f. do not give alcohol in any form or permit the patient to smoke. C. Skin Contamination Poisoning (Chemical Burns) Severity of chemical burns are determined by the mechanism of action,

penetrating strength and concentration, amount and duration of exposure of the skin to the chemical. MANAGEMENT: a. skin should be drenched immediately with running water from shower, hose or faucet, except in case of lye and white phosporus. b. Patients clothing should be removed. c. Prolonged lavage with generous amounts of tepid water is important. Food poisoning A sudden illness that occurs after ingestion of contaminated food or drink. BOTULISM- serious form of Food poisoning. ASSESSMENT AND DIAGNOSTIC FINDINGS: - food, gastric contents, vomitus, serum and feces are collected for examination. - fluids and electrolytes should be assessed. - Assess for: a. lethargy b. rapid pulse rate c. fever d. oliguria e. anuria f. hypotension g. delirium MANAGEMENT: a. monitor patients respiration, BP, level of conciousness, CVP and muscular activity. b. Measures to control nausea are important to prevent vomiting. c. An anti-emetic medication is administered parenterally or prescribed if the patient cannot tolerate fluids or medications by mouth. d. For mild nausea, patient is encouraged to take sips of weak tea, carbonated drinks or tap water. e. Clear liquids are prescribed for 12-24 hours and diet is gradually progressed to low residue, bland diet.