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The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Respiratory

An Ambulatory Nurses' Guide to Assist Older Adults Through Cancer Treatment

R=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)

R=Respiratory

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

References

Adachi, M., Ishihara, K., Abe, S., Okuda, K. (2007). Professional oral health care by dental hygienists reduced respiratory infections in elderly persons requiring nursing care. International Journal of Dental Hygiene 5(2), 69–74.
Akinbami, L., Moorman, J.E., Liu, X. (2011). Asthma Prevalence, Health Care Use, and Mortality: United States, 2005-2009. National Health Statistics Reports, 32 Retrieved from http://www.cdc.gov/nchs/data/nhsr/nhsr032.pdf.
Campbell, E. (2008). Aging of the Respiratory System. In A. Fishman & J. Elias (Eds.), Pulmonary diseases and disorders (4th ed., Vol. 1, pp. 263-278). New York: McGraw-Hill.
Celli, B. (2012). Pulmonary Rehabilitation in COPD. Retrieved April 4, 2012 from http://www.uptodate.com/contents/pulmonary-rehabilitation-in-copd​.
COPD International. (2012). COPD Statistics.
Downs, C. A. (2011). Functional Assessment of Chronic Pulmonary Disease. Journal of  American Academy of  Nurse Practitioners 23(4), 161-167.
Eldridge, L. (2012). Lung Cancer Statistics. Retrieved from http://lungcancer.about.com/od/whatislungcancer/a/lungcancerstats.htm.
Gorina, Y. & Lentzner, H. (2008). Multiple Causes of Death in Old Age. Trends in Health and Aging 9, 1-9. Retrieved from http://www.cdc.gov/nchs/data/ahcd/agingtrends/09causes.pdf.
Horn, L., Pao, W. & Johnson, D.H. (2012). Neoplasms of the Lung. In D.L. Longo, D.L. Kasper, J.L. Jameson, A.S. Fauci, S.L. Hauser, & J. Loscalzo (Eds.), Harrison's Principles of Internal Medicine (18th ed.). New York: McGraw-Hill.​
Leader, D. (2011). 6-Minute Walk Test. Retrieved from http://copd.about.com/od/copdtreatment/a/sixminutewalktest.htm.
Murphy, S.L., Xu, J., Kochanek, K.D. (2012). Deaths: Preliminary Data for 2010. National Vital Statistics Reports 60(4), 1-51.
Nguyen, H. Q., Burr, R.L., Gill, D.P, Coleman, K. (2011). Validation of the StepWatch device for measurement of free-living ambulatory activity in patients with chronic obstructive pulmonary disease. Journal of Nursing Measurement 19(2), 76-90.
Rycroft, C.E., Heyes, A., Lanza, L., Becker, K. (2012). Epidemiology of chronic obstructive pulmonary disease: a literature review. International Journal of Chronic Obstructive Pulmonary Disease 7, 457-494.
Tzortzaki, E. G., A. Proklou, Siafakas, N.M. (2011). Asthma in the Elderly: Can We Distinguish It from COPD? Journal of Allergy, 1-7.
World Health Organization. (2008). COPD predicted to be third leading cause of death in 2030. Retrieved from http://www.who.int/respiratory/copd/World_Health_Statistics_2008/en.