1

PHYSIOLOGICAL BASIS OF THE CARE OF THE ELDERLY

CLIENTRespiratory System

2

Patient Scenario

D.A. is a 78 year old male who states he cannot get rid of his “cold”

He has a productive cough Sputum is white to grey He has a 31 pack year smoking history He uses Albuterol inhaler up to 6 times

per day

3

Informal evaluation

What additional information do you need?

Subjective information Objective information Psychosocial information

4

Anatomy of the lungs

5

Performance of respiration

Controlled by respiratory muscles of the thorax Diaphragm Intercostal muscles

Coordinated by respiratory centers of the brain and carotid arteries

Respiratory centers respond to changes in: Blood levels of oxygen Carbon dioxide Blood pH

6

Age related changes of the respiratory system

Stiffening of connective tissue of lungs Alteration in alveolar shape → increased

alveolar diameter Decreased alveolar

surface area Increased chest

wall stiffness Stiffening of the

diaphragm

7

Consequences of age-related changes

Increased residual volume Decreased vital capacity Premature airway closure → air trapping

in lower airways

8

9

Abnormal breath sounds

Crackles—intermittent, nonmusical, caused by fluid filled alveoli popping open

Wheezes—high pitched, occur when air flow is blocked

Rhonchi—low pitched, snoring, rattling, occur when fluid partially blocks large airways

10

Measurement of oxygenation

11

Lung volumes and capacities

12

PFT results are based on predicted values

13

Arterial blood gases

14

Overlapping symptoms

Pulmonary embolism? GERD? Obstruction? ACEi cough? Vocal cord dysfunction?

Asthma

Chronic bronchitisCOPD

15

Commonalities within lung diseases

Symptom Asthma Chronic bronchitis

COPD Heart Failure

Wheezing

Chest tightness

Chronic productive cough

Maybe

Nocturnal dyspnea

Smoking history Maybe

16

Asthma

Airway inflammation Increased mucous secretion production Increased airway

responsiveness/sensitivity Reversible airflow obstruction (usually) Eventually causes irreversible

damage and scarring Often overlooked in the

older client

17

The asthmatic lung

18

Symptoms of asthma

Coughing Wheezing Shortness of breath Chest tightness Nocturnal dyspnea between 0400-0600

CHF nocturnal dyspnea occurs 1-2 hours after retiring

19

Classifications of asthma

Mild Intermittent

Mild Persistent

Moderate Persistent

Severe Persistent

□ Sx ≤ 2 days per week

□ Sx ≤ 2 nights per week

□ Sx > 1 times per week but < once per day

□ Nighttime sx > twice per month

□ Symptoms daily

□ Nighttime sx > one night per week

□ Continuous daily symptoms

□ Frequent nighttime symptoms

20

Goals of asthma therapy

Prevent symptoms that interfere with quality of life

Prevent exacerbations of asthma Minimize need for emergency

department visits Maintain normal activity levels Maintain (nearly) normal pulmonary

function Minimize use of “rescue” medication Minimize adverse effects of medication

21

Stepwise approach to managing asthma

Intermittent asthma Step 1

Preferred: short acting β-agonist (SABA) prn Example: Albuterol

Persistent asthma with daily medication Step 2

Preferred: low dose inhaled corticosteroids (ICS)

Example: Beclomethasone

22

Stepwise approach to managing asthma

Step 3 Preferred: Low dose ICS + LABA or medium

dose ICS Example LABA: Advair

Step 4 Preferred: Medium dose ICS + LABA

23

Stepwise approach to managing asthma

Step 5 Preferred: High dose ICS + LABA And consider Omalizumab for patients who

have allergies Step 6

Preferred: High dose ICS + LABA + oral corticosteroid

And consider Omalizumab for patients who have allergies

24

Stepwise approach to managing asthma

At each step…

Patient education Environmental control Step up if needed Step down if possible and

if asthma is well controlled for at least 3 months

25

Use of inhalers

Refer to video link in syllabus Spacers are useful for

the elderly who have difficulty with coordination and timing (refer to link)

Encourage to rinse with warm water and expectorate (“swish and spit ”) to minimize candidiasis, gum disease, tooth decay

26

Use of nebulizers

Provides misted form of medication Easy to use at home Machine requires regular cleaning Breathe slowly, deeply Hold each breath 1-2 seconds before breathing out Important to continue until dose is complete

27

Use of peak flow meter

Measures movement of air out of lungs Helps patient antici- pate asthmatic episode Patient finds best peak flow number

Every day for 2 weeks On waking and between 1200-1400 Before inhaled β-agonist

28

Potentially harmful medications for the patient with asthma

Β-blockers—can induce bronchospasm NSAIDs—bronchospasm Diuretics—hypokalemia Antihistamines—prolonged QT interval ACEi—cough Antidepressants—symptoms of

depression can be worsened by corticosteroids

29

Chronic obstructive pulmonary disease

COPD

Chronic bronchitis

Emphysema

30

Criteria for chronic bronchitis

Cough and sputum production on most days

Minimum of 3 months for at least 2 successive years, or,

For 6 months during 1 year

31

A note on acute bronchitis…

Acute inflammation of the bronchi Usually self-limiting Viral Similar to pneumonia: productive cough,

chills, lethargy, low grade fever Negative chest xray Treatment: rest, humidification, cough

suppressants, acetaminophen

32

Criteria for emphysema

Permanent destruction of the alveoli Collapse/narrowing of

bronchioles Usually in older adults with long smoking history

33

Chronic bronchitis Emphysema

34

Blue bloater

COPD with chronic bronchitis Increased mucous production Normal to decreased lung capacity Increased residual lung volume with air

trapping Cyanosis and right heart failure Body responds by decreasing ventilation

and increasing cardiac output

35

Blue bloater

36

Pink puffer

COPD with severe emphysema Pink complexion Dyspnea Increased residual lung capacity Decreased elastic recoil High tidal volume Destruction of capillary bed Body compensates for destruction of

pulmonary capillary bed by hyperventilation Retractions

37

Pink puffer

38

Effect of smoking and smoking cessation

39

Management of COPD

Assessment, monitoring treatment of disease

Reduce risk factors Prevent disease progression Assess, manage anxiety and depression Mucolytic therapy (e.g., Mucomyst) Rehabilitation Manage exacerbations

40

Medications for COPD

Bronchodilators Inhaled corticosteroids Antibiotics Flu vaccine annually Pneumococcal vaccine at age 65 Exercise training Mucolytics and expectorants (e.g.,

Mucomyst, Guaifenesin)

41

Treatment of end-stage COPD

Continuous oxygen administration—low flow

Postural drainage Chest percussion Controlled coughing Tracheal suctioning

42

Low flow oxygen in COPD

Normal stimulus to breathe is rise in CO2 level

In COPD, stimulus to breathe is a decrease in O2 level

Oxygen flow that is too high will minimize or eliminate the stimulus to breathe in a COPD patient CO2

O2

43

Tuberculosis in the elderly Elderly the most vulnerable Drug resistant forms prevalent Vulnerability enhanced by multiple risk

factors: Living in an institution, homeless Exposure to drug-resistant form Previous infection Diabetes Use of immunosuppresive drugs (including

corticosteroids) Malnutrition Renal failure

44

Treatment of tuberculosis

Isoniazid—prevent active disease once infected

Rifampin Side effects can be significant Interrupting treatment can create drug

resistant form

45

Lung cancer in the elderly

More common in the young-old Initial symptoms are vague and mimic

other pulmonary illnesses Chest xray initial diagnostic test Older, debilitated patients may not be

surgical candidates Chemotherapy Radiation Palliative care

46

Respiratory infections: risk factors

History nosocomial pneumonia COPD Recent hospitalization, insitutionalization Smoking Hyperglycemia Use of immunosuppressants and/or

antibiotics and/or oxygen therapy Recent antibiotic use Eating dependency

47

Pneumonia symptoms in the elderly

Cough Fever Sputum production Prodromal headache, myalgia, lethargy Changes in behavior and mental

status New onset tachycardia and tachypnea Change in function

48

Pneumonia

49

Pulmonary embolism risk factors

Clotting disorders Immobility Dehydration Recent surgery Atrial fibrillation Obesity

50

Symptoms of pulmonary embolism

Sudden onset Tachypnea Dyspnea Chest pain Hypoxia Hypotension Possible shock

51

Recommended vaccinations

Flu vaccination every year Pneumonia vaccination once if given after

the age of 65 Revaccinate in 5 years once only if first

vaccination given before the age of 65

52

Formal evaluation

What is your nursing diagnosis for RB?

What is your desired outcome?

What are appropriate interventions pertinent to your desired outcome?