REVIEWER OXYGENATION PROBLEMS 5.

Paroxysmal nocturnal dyspnea (PND)

 SOB with sudden onset
General nursing assessment
 Occurs during sleep or at night
 Health history  Awakens patient with feeling of suffocation
 Physical assessment  Relieved by sitting up
 Laboratory/diagnostic examinations  Heart failure
 Medications

Health History
Reasons for seeking health care
1. Dyspnea
2. Cough
3. Sputum production
4. Chest pain
5. Wheezing
6. Hemoptysis
7. Cyanosis What to Assess…
8. Clubbing of fingers  Acute or chronic
 Sudden or gradual
 Progressive recurrent or proximal
Risk Factors
 Relieved by any interventions
 Smoking
 Worse when upset
 Personal/Family history
 Associated with cough, fever chills or night
 Occupational exposure
sweats
 Allergens & environmental pollutants
 Any changes in body weight
 Activities
 At rest or with exertion
 Age-related changes
 Related to activities

Dyspnea Cough
 Severe or changing cough (bronchogenic
carcinoma)
 Dry, irritative cough (viral respi. Tract infection)
 Cough at night (LSHF or Asthma)
 Morning cough with sputum production
(Bronchitis)
 Cough of recent onset (acute infection)
 Cough that worsens when in supine position
(Sinusitis)
TYPES OF DYSPNEA
1. Exertional dyspnea Sputum production
 Most common occurs with physical exertion and  Increased production, profuse or small in amount
relieved by rest  Purulent, rusty, bloody, frothy or mucoid thick
 Occurs when the boy uses more oxygen and (tenacious) or thin
makes more carbon dioxide- during exercise or  Offensive odor/foul – smelling
physical activities.
2. Sudden dyspnea Bacterial infection
 Pneumothorax airway obstruction, ARF, ARDS or  Profuse purulent thick ( yellowish, greenish or
pulmonary embolism. rusty – colored)
3. Orthopnea
 SOB when in reclining lying position Viral bronchitis
 Relieved by sitting up  Thin, mucoid
 Heart disease or COPD
4. Dyspnea associated with wheezes Lung tumor
 Asthma or COPD  Pink-tinged mucoid
 Due to bronchoconstriction

Pulmonary edema
 Profuse, frothy, pink
Lung abscess or bronchiectasis Percussion
 Foul smelling Resonance in normal lungs & simple chronic
bronchitis
Chest pain Dullness lobar pneumonia
 Intermittent or persistent Flatness pleural effusion
 Localized or radiating Hyper resonance emphysema
 Sharp, doll, stabbing or aching
 Intensity
 Relieved by any interventions Auscultation
 Effects on respiration Normal Breath sounds:
 Past medical history Vesicular (entire lung field) low pitched
 Smoking history & environmental exposure Bronchial (over the High pitched
trachea)
Bronchovesicular (over the medium pitched
Wheezing main bronchus)
 High-pitched, musical sound heard mainly on AbN diminished or absent in
expiration common in patient with atelectasis, & pleural
bronchoconstriction or airway narrowing effusion

CLUBBING OF FINGERS Adventitious Breath Sounds

Clubbing develops in 5 steps Crackles (Rales) Inflammation or congestion as in
1. Fluctuation and softening of the nail be pneumonia, bronchitis, CHF,
(increased ballot ability) bronchiectasis & pulmonary Fibrosis
2. Loss of the normal <165 angle (lovibond angle) Wheezes Bronchoconstriction due to increased
between the nail bed and the fold (cuticula). secretions or edema as in asthma, CB,
3. Increased convexity of the nail fold Bronchiectasis
4. Thickening of the whole distal (end part of the Friction Rubs Pleurisy or pleuritis
finger resembling a drumstick)
5. Shiny aspect and striation of the nail and skin. Nursing diagnosis
Ineffective airway clearance r/t
Hemoptysis  Bronchoconstriction
 Bright red of frothy  Increased mucus production
 URT, GIT or LRT  Ineffective cough
 Amount  Possible bronchopulmonary infection
 Salty taste, burning or bubbling sensation before Ineffective breathing pattern r/t
bleeding  Shortness of breath
 Associated with certain circumstances or  Mucus production
activities  Bronchoconstriction
 History of chest trauma  Airway irritants
 Sudden, intermittent or continuous  Chronic airflow limitation
Impaired gas exchange r/t
Cyanosis (central or peripheral)  Chronic pulmonary obstruction
 Due to inadequate amount of oxygen in the  Ventilation- perfusion inequality due to
blood destruction of alveolar capillary membrane
 Appears when Hgb level = 5g/dl Activity Intolerance r/t
 Compromise pulmonary function, resulting in
Palpation SOB & fatigue
 Painful areas or masses
 Chest & diaphragmatic excursion Nursing Interventions
 Tactile fremitus
Promoting smoking cessation
 Symmetrical chest excursion
1. Explain the risk of smoking
 AbN: decreased in chronic fibrotic disease;
2. Provide a strong warning and establish a definite
asymmetrical in pleurisy, chest trauma, bronchial
“quit date”
obstruction
3. Refer to smoking cessation program
 Fremitus: normally louder near the large bronchi
4. Continue reinforcement and analyze relapses.
 AbN: absent (emphysema); increased
(pneumonia)
Improving airway clearance  Albuterol (ventolin)
 Eliminate or minimize exposure to all pulmonary  Terbutaline (bricanyl)
irritants
1. Beta-adrenergic agonist
 Increased fluid intake within cardiac reserve
 Diaphragmatic breathing and coughing  Relax smooth muscles of all airways
techniques  Best administer as INHALANTS
 Perform CPT: postural drainage, chest  S/E: tremor, tachycardia, palpitations
clapping/percussion or vibration & suctioning as 2. Anti-cholinergic
indicated  Bind to acetylcholine receptors and result in
 Assist in administering nebulizer and bronchodilation (mostly larger airways)
bronchodilators  Reduces sputum production
 Inhaled route is preferred
Improving breathing pattern  S/E: palpitations
1. diaphragmatic breathing & pursed-lip breathing  Atroven (ipratropium bromide)
exercises
2. encourage alternating activity with rest periods Xanthine- derivatives
3. assume position of comfort - Aminophylline
4. relaxation techniques - Epinephrine
- Theophylline
Improving gas exchange  Weak bronchodilator
1. diaphragmatic breathing & coughing techniques  delays respiratory muscle fatigue
2. administer bronchodilators as prescribed  reduces trapped lung gas
3. administer low-flow oxygen (1-2 lpm or based on  improves respiratory muscle mechanics
ABG results)
Theophylline
Increasing activity tolerance  relax and open airways
1. graded physical exercises: walking, stationary  improve the diaphragm’s ability to contract
bicycling, swimming  increase the clearance of mucus
2. regular exercise program  S/E: nervousness, tremors, or nausea
3. energy conservation techniques  Check the blood level from time to time to
 control your breathing ensure that you are getting the correct
 eliminate unnecessary activities dose (therapeutic range: 10-20 mcg/ml,
 get assistance toxic range 80-100 mcg/ml)
 organize your time  Signs of toxicity: vomiting, agitation, apical
 organize your methods pulse of 200 bpm
 organize your space
 pace yourself Aminophylline (Theophylline)
 maintain a good posture  Best taken in AM on an empty stomach, because
 avoid lifting it can cause INSOMIA
 choose a work height  Check HR – can cause tachycardia
 relax  Maintain adequate urine output
 use proper equipment  Avoid caffeine containing foods
 Stop smoking
Medications (Common Respiratory Tract Agents)
Common pulmonary medications Corticosteroids
1. Bronchodilators  Reduce airway inflammation
 Sympathomimetics  Efficacy and role in stable COPD uncertain
 Xanthine derivatives
2. Corticosteroids Anti-inflammatory drugs (steroids)
3. Mucolytics, expectorant & antitussive Can be given in several forms
1. Inhaled form
Bronchodilators 2. Pill form
 Open narrowed airways or dilate the bronchus 3. Intravenous form

Prednisone
Sympathomimetics
  Best given after meals
 S/E: weight gain and increased appetite
 Check serum K level – can cause hyperkalemia

Mucolytic
 Loosen secretions in respiratory tract by altering
the viscosity of sputum
 Example: mucomyst (acetylcysteine)
Antitussives
 Drugs that block or suppress the cough reflex
 Used for respiratory disorders non- productive,
irritating cough
 Examples: codeine, dextromethorphan,
benzonatate
Expectorants
 Rugs that liquefy secretions or decrease viscosity
of secretions
 Often in combination with antihistamines and
decongestants
 Example: guafenesin
Antihistamines
 Relieve allergy symptoms
 H1 Blockers = block histamine
 Example: diphenhydramine HCI