1 NCLEX RN Preparation Program Respiratory Disorders Module 5, Part 3 of 3.
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Transcript of 1 NCLEX RN Preparation Program Respiratory Disorders Module 5, Part 3 of 3.
2
Chronic Airflow Limitation
Emphysema
+
Chronic Bronchitis
=
COPD
Chronic Obstructive Pulmonary Disease
Photo Source: National Heart, Lung and Blood Institute (NHLBI http://www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd_WhatIs.html
3
Emphysema
Loss of lung elasticity
Hyperinflation
Air trapped in lungs
Alveoli over-stretched bullae
4
Chronic Bronchitis
Recurrent inflammation Vasodilation, Congestion, Edema, Spasm
Excessive thick mucus blocks air flow Hypoxemia, CO2 retained
5
Causes of COPD
Smoking Alpha1-Antitrypsin
Deficiency Air pollution
Secondary smoke
Photo Source: National Cancer Society, http://visualsonline.cancer.gov/details.cfm?imageid=1997 and http://visualsonline.cancer.gov/details.cfm?imageid=2740
7
Assess
* LOC* Airway status and breathing* Pulses* RR, depth* BP, Heart Rate* SpO 2 level on room air* Color, temperature & capillary refill
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Diagnostic Tests
Arterial Blood Gases Oxygen Saturation Chest x-ray Labs Pulmonary Function Tests (PFTs)
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Teach Effective Breathing Diaphragm Pursed-lips Controlled cough Orthopneic position
http://emphysemafoundation.org/pulhthex.jsp
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Inflammation Infection
Inhaled steroids Systemic steroids Prevent pneumonia Influenza vaccination yearly Pneumovax q 5 years
15
Mealtime Strategies
Rest 4-6 small meals Bronchodilator ac Easy chewing Supplements Avoid gas-producing foods
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Stepped Therapy
1. Combivent (ipratropium + albuterol)
2. Add beta2 agonist (Albuterol)
3. Add theophyllin
4. Add Prednisone
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Pneumonia
Photo Source: Centers for Disease Control, Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Pneumonia_x_ray.jpg
20
Categories
Viral Fungal Bacterial Aspiration
Photo Source: USDS, http://www.ars.usda.gov/is/graphics/photos/sep01/k9606-20.htm]
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Classification
Causative agent (Streptococcus pneumoniae)
Anatomic location of the infection (lobar pneumonia)
By where it was acquired (community vs. hospital/nosocomial)
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Major Organisms
Community-acquired: Streptococcus pneumoniae (gram +) Staphylococcus aureus (gram +)
Nosocomial: Staphylococcus aureus (gram +) MRSA
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Who is at greatest risk?
Photo Source: National Camcer Society, http://visualsonline.cancer.gov/details.cfm?imageid=1994 and http://visualsonline.cancer.gov/details.cfm?imageid=2193
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Community Prevention
PneumovaxWash handsDon’t smokeWear mask: dusty, moldy areasAvoid crowdsEat healthy dietExercise
25
Nosocomial Prevention
Prevent aspiration - How? Prevent cross-contamination Vaccinate inpatients Education Mouth care??
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Signs & Symptoms
Fever, chills Dyspnea, RR, shallow breathing Coughing, crackles, wheezing Pleuritic pain Anorexia Hypoxemia Sputum: purulent, blood-tinged, rusty
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Goal: Improve Gas Exchange
Oxygen Antibiotics Rest Incentive spirometry Raise head of bed No smoking
31
Pulmonary Tuberculosis
Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Mantoux_tuberculin_skin_test.jpg and http://commons.wikimedia.org/wiki/Image:TB_CXR.jpg
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Tuberculosis: What is it?
Mycobacterium tuberculosis causes inflammation in upper lungs
Bacillus colonies form a lesion (tubercle) When the colonies die, they cause
necrosis & scar tissue (consumption of tissue)
Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Mycobacterium_tuberculosis_8438_lores.jpg
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How do I know I have it?
Cough that will not go away Feeling tired all the time Weight loss Loss of appetite Fever Coughing up blood Night sweats
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Skin Testing
Mantoux 0.1 ml PPD
48-72 hours induration
False-positive False-negative
Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Mantoux_tuberculin_skin_test.jpg
37
Sputum Testing
First morning specimen 3 days Acid-fast Bacilli Tb C & S
Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:TB_Culture.jpg
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How is it treated?
Initial Therapy may include: Isoniazid (INH) Rifampin Pyrazinamide (PZA) Ethambutol or Streptomycin
After two months: Isoniazid Rifampin
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Isoniazid
Precautions: Take on empty stomach, avoid antacids LFTs if liver disease
Warnings: Increases Dilantin & Tegretol levels
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Rifampin
Precautions Body secretions turn orange May ruin contact lenses
Warnings Reduces contraceptive, methadone
effect May interact with anti-retrovirals
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Rifapentine
Precautions Probably discolors body secretions
Warnings Decreased potency diabetes meds,
barbs, antibiotics, contraceptives
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Ethambutol Precautions
Decreased visual acuity Decreased red-green color discrimination
Warnings Optic toxicity is dose related Increased toxicity with renal insufficiency
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Pyrazinamide
Precautions Hepatotoxicity Nausea/vomiting Polyarthralgias Hyper-uricemia Transient rash Photo-sensitive dermatitis
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Hospitalization
Isolate all patients with active pulmonary TB in negative-pressure rooms with high-volume air replacement and circulation
Continue isolation until combined drug treatment has been administered for 2 weeks, and three consecutive sputum smears have tested negative.
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Transplant Recipients
Immune suppressed Donor organ with latent TB Reactivate pt’s latent infection Diagnosis difficult
Decreased PPD reaction
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HIV positive
Increased risk: Why? Interactions with protease inhibitors Decreased CD4 cell count anergy
(impaired or absent ability to react to common antigens administered through skin) PPD testing early in HIV infection Use control to rule out anergy
?? INH prophylaxis
47
Drug Toxicity
Hx of liver disease Consuming alcohol daily Baseline + repeat LFTs Watch!
Dark urine Light stools Fatigue
50
Patient/Family Teaching
Prevention Phone contact Test entire family Use precautions Follow-up sputum cultures Diet
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Acute Respiratory Failure
Dyspnea, tachycardia Progressive respiratory distress Breath sounds Mental status
53
Diagnostic Tests
pO2 < 60 mmHg
pCO2 > 50 mmHg
O2 saturation < 90% Chest x-ray – increasing
infiltrates to “white out”
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Collaborative Management
Oxygen Mechanical ventilation
Photo Source: Wikimedia Commons / Public Domain image, http://commons.wikimedia.org/wiki/Image:CPR_Dummy-Air_Force.JPG
55
Intubation
Intubation tray Patient position Bed position Suction Oxygen flow meter Verify ETT placement Secure ETT
Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Intubation.jpg
59
Acidosis
Low pH = acidosis (normal 7.35-7.45) Low pH + low HCO3 = metabolic
acidosis (normal 21-26) Low pH + high CO2 = respiratory
acidosis (normal 35-45)
60
Alkalosis
High pH = alkalosis High pH + high HCO3 = metabolic
alkalosis High pH + low CO2 = respiratory
alkalosis
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Ventilator Alarms
High pressure Low inspiratory pressure High respiratory rate Low exhaled volume
62
Monitor Physiological Response
Breath sounds Breathing pattern Skin color Secretions Oxygen saturation ABGs, daily chest x-ray
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Manage the Ventilator
Correct settings? Alarms on? Maintain humidity Monitor inline temperature ETT placement, cuff Tubing adjustments
65
Prevent Complications
Barotrauma Stress ulcers Infection: Ventilator-assisted
pneumonia (VAP) Ventilator dependence Pressure necrosis
66
Weaning from Ventilator
Awake, rested Muscle strength Heart rhythm Breath sounds ABGs Pulmonary function tests
68
Extubation
Explain procedure Prepare: nasal cannula, towel, Chux Hyper-oxygenate Suction Deflate pilot balloon Suction Pull tube No talking!
69
Pneumothorax
Signs and Symptoms Pleuritic chest pain SOB Tachypnea Tachycardia Asymmetrical chest wall
movement Decreased breath sounds Cyanosis Photo Source: Colorado State University,
http://www.cvmbs.colostate.edu/clinsci/wing/trauma/tension.htm
70
Tension Pneumothorax
Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp
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Tension Pneumothorax
Signs and Symptoms Tracheal deviation Distended neck veins Hypotension Compensatory tachycardia
& tachypnea Decreased cardiac outputMust be treated promptly
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Hemothorax
Signs and Symptoms In addition to those seen with
pneumothorax: Subcutaneous Emphysema
(crepitus) Percussion dullness over
area of hemothorax
Photo Source: http://www.chgranby.qc.ca/trauma_formation_drain.htm
73
Nursing Care of the Chest Tube
Maintain closed system Assess, kinks, water seal, drainage
Maintain patency occlusive dressing, tubing, suction
Photo Source: Wikimedia Commons, GNU license, http://commons.wikimedia.org/wiki/Image:Chest_drain_-_bedside_with_fluids.jpg
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Nursing Care of the Patient
Oxygen Vital signs Chest wall movement, trachea, neck
veins Position Watch for distress
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Pulmonary Embolus
DVT Air Fat Catheter
Photo Source: National Heart, Lung and Blood Institute (NHLBI),
76
Signs/Symptoms
Classic triad Common: dyspnea, tachypnea,
pleuritic pain Pleuritic chest pain + dyspnea +
predisposing factor
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Diagnosis
ABGs Chest x-ray V/Q scan Spiral CT Pulmonary angiogram
Photo Source: CDC/Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Pneumonia_x-ray.jpg
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Prevention
Early ambulation Hydration Anti-embolic stockings Sequential pumps Avoid lower extremity punctures Aspirate clotted IVs SQ heparin or LMWH
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Collaborative Management
Continue oxygen Bed rest Heparin drip Coumadin Thrombolytics? Embolectomy, umbrella filter