The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Respiratory

Related Issues:

Smoking status, anxiety, oxygen therapy, air quality, chronic pulmonary diseases

Why Respiration is Important:

• Chronic Obstructive Pulmonary Diseases (COPD) is a major health problem in the elderly with a prevalence of approximately 210 million patients worldwide; the World Health Organization predicts that it will become the third or fourth leading cause of death by 2030 (WHO 2008)
• Lung cancer is the leading cause of death in both women and men, with 2/3 of those diagnosed age 65 years and older
• Older adults are at increased risk for pulmonary complications post-operatively

Normal Age-Related Changes:

• ↑Stiffness of the chest wall
• Decrease in respiratory muscle strength
• Changes in shape and fine structures of the lung
• A loss of elastic recoil properties of the lung
• ↓ cough reflex (Campbell, 2008)

Older adults are at increased risk if they have any of the following:

Conditions

Pulmonary Cancers and Diseases

• COPD, Emphysema, Asthma, Bronchiectasis, Pulmonary Edema
• Pneumonia, Bronchitis, Pleural effusion
• Pulmonary fibrosis, Pneumothorax

Neuromuscular (brain, spinal cord)

• Sarcoidosis, scoliosis

Bone Diseases

• Osteoporosis

Gastrointestinal

• Swallowing deficits, aspiration

Cardiovascular Diseases

• Pulmonary hypertension, congestive heart failure

Thoracic Surgery Complications

• PE, DVT

Medication-Related Risk Factors

• Opioids (can cause respiratory depression)
• Incorrect usage of prescribed medications (noncompliance or over usage)
• Ace inhibitors (can cause cough)

Behavioral Risk Factors

• Positive smoking history
• Exposure to secondhand smoke, occupational and environmental pollutants
• Sedentary lifestyle

Chemotherapy-Related Risk Factors

• Bleomycin, mitomycin, busulfan, Carmustine (BCNU), lomustine (CCNU), methotrexate, gemcitabine

Surgery-Related Risk Factors

• Thoracic surgery
• Head and neck surgery
• Any surgical procedure with general anesthesia
• Neurosurgery (brain, brainstem, upper spinal surgeries)
• Post-op atelectasis

Radiation Risk Factors

• Radiation to lung, or adjacent organs

Cancer Diagnoses

• Lung carcinoma
• Mesothelioma
• Metastatic disease to the chest-wall, or lung structures

Assessment:

1. Screening Questions

• Have you noticed any changes in your breathing?
• Do you have a cough (productive and/or nonproductive)? Is this new?
• Do you have any special breathing medications or equipment that you need to use on a daily basis?
  (Downs, 2011)

2. Observations

• Evaluation of breathing patterns: use of accessory muscles?
• Use of pursed lip breathing?
• Dyspnea at rest or exertion?
• Patient coloring: are their lips or nailbed cyanotic?
• Any finger clubbing?
  (Downs, 2011; Campbell, 2008)

3. Screening Tools and Measurements

• Pulmonary function tests with Spirometry
• Pulse oximetry at rest and with exercise
• Peak flow readings
• Ability to perform ADL’s
• Six Minute Walk Test

Preparing for the Test (Leader, 2011)
On the day of the test, be sure to:

• Dress in comfortable clothing
• Wear comfortable shoes, preferably designed for walking
• Use walking aids if you normally need them, such as a cane or walker
• Eat a light meal before early morning or afternoon tests
• Avoid vigorous exercise within 2 hours prior to the test

Reasons for Stopping the Test
Your technician should stop the test if you experience any of the following:

• Chest pain
• Intolerable dyspnea
• Leg cramps
• Staggering
• Excessive sweating
• If you become pale or ashen in appearance

Helpful Tips
During the test:

• You will be permitted to slow down, stop and rest as needed
• You may lean against the wall when resting, but should remain standing
• If you do stop to rest, keep in mind the timer will not stop when you do and you should start up again when you are ready
• Your technician will be watching you carefully, periodically reporting how many minutes have elapsed
• Advise your technician of any concerns, both prior to and during the test
• Cardiopulmonary Exercise Testing (CPET)
• Modified Borg Scale: patient self report

4. Physical Assessment: standard physical examination with focus on respiratory status and lung auscultation (Campbell, 2008)

Nursing Intervention:

• Determine underlying etiology of altered respiratory status and correct if possible
• Review respiratory health history/medication compliance
• Initiate and coordinate referrals as appropriate:
• Pulmonary consults
• Pulmonary rehabilitation
• Smoking cessation programs
• Referrals for emotional and spiritual well-being
• Respiratory therapy, oxygen therapy       
• Referrals for home care to assess safety of the home
• Referrals to physical therapy
• Occupational therapy for assistive devices
• Arrange caregiver assistant (HHA), if applicable
• Educate patient about energy conservation techniques, balancing rest with exercise
• For patients for surgery:
• Pre-op teaching/conditioning
• Post-op use of deep breathing exercises, use of incentive spirometry, need for ambulation
• Provide education to patient and caregivers about:
• Disease process
• Treatment/management plan
• Medications: proper use and care of inhalers, spacers, acapella or flutter valve
• Good dental hygiene (Adachi, 2007)
• Procedures
• Palliative care
• Hospice care

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