Nursing of AdultsWith

Medical & Surgical Conditions

Respiratory Disorders

(Lower Airway)

Acute Bronchitis

• Etiology/Pathophysiology– Inflammation of the trachea and bronchial tree– Retention of secretions causes high risk of

bacterial growth– Usually secondary to upper respiratory

infection– Exposure to inhale irritants

Acute Bronchitis

• Signs & Symptoms– Productive cough– Rhonchi/wheezes– Dyspnea– Chest pain– Lowgrade temperature– Malaise– Headache

Acute Bronchitis• Treatment

– Cough suppressants• Codeine

– Antitussives• Pertussin

– Antipyretics• Tylenol

– Bronchodilators

– Brethine

– Antibiotics

– Vaporizer

– Encourage fluids

Legionnaires’ Disease

• Etiology/Pathophysiology– Legionella pneumophila– First identified in 1976 at the American Legion

convention in Philadelphia– Thrives in water reservoirs

• Air conditioners and humidifiers

– Causes life-threatening pneumonia– Leads to respiratory failure, renal failure,

bacteremic shock, and ultimately death

Legionnaires’ Disease

• Signs & Symptoms– Elevated temperature

• 102 – 105 degrees

– Headache

– Nonproductive cough

– Difficult and rapid respirations

– Crackles or wheezes

– Tachycardia

– Signs of shock

– Hematuria

Legionnaires’ Disease

• Treatment– Oxygen– Mechanical ventilation, if necessary– IV therapy– Antibiotics

• Erythromycin

• Rifampin

– Antipyretics– Vasopressors

• For shock

Tuberculosis

• Etiology/Pathophysiology– Tubercle bacillus (Mycobacterium tuberculosis)– Chronic pulmonary and extrapulmonary infectious disease– Inhalation of droplet containing tubercle bacillus– Infection

• Presence of mycobacteria in the tissue of a person who has no s/s of TB

• Positive TB skin test• 10% will become active disease

– Active Disease• S/S of TB are present

– NOT easily transmitted• Most inhaled TB organisms are destroyed by the upper resp.

system

Tuberculosis

• Signs & Symptoms– Fever– Weight loss– Weakness– Productive cough– Chills– Night sweats– Hemoptysis

Tuberculosis• Diagnostic Tests

– Presumptive Diagnosis• Mantoux Tuberculin Skin Test

– Read 48 – 72 hours after given

– Enduration (raised hardened tissue)

– <5mm negative

– >5mm positive

• Chest X-ray• Acid-fast bacilli smear x 3

– Confirmed Diagnosis• Sputum culture

– Positive for TB bacilli

Tuberculosis

• Treatment– Tuberculosis Isolation (AFB)

• Isolation room• Negative air pressure• Particulate respiration masks

– Medications• 6-9 months• First Line:

– isoniazid (INH), rifampin, rifampin and isoniazid (Rifamate), pyrazinamide, ethambutol, streptomycin

• Second Line: – Ethionamide, para-aminosalicylate sodium (PAS), cycloserine,

capreomycin, kanamycin, amikacin

Pneumonia

• Etiology/Pathophysiology– Inflammatory process of the bronchioles and the

alveolar spaces due to infection– Bacteria, viruses, mycoplasma, fungi, and parasites– Aspiration– Retained secretions become infected– Inflammation of respiratory tract occurs– Decreased oxygen/carbon dioxide exchange

Pneumonia

• Signs & Symptoms– Productive cough

• Sputum depends on cause

– Severe chills– Elevated temperature– Increased heart rate– Increased respiratory rate– Dyspnea

Pneumonia• Treatment

– Oxygen– Chest percussion and postural drainage– Encourage to cough and deep breathe– Antibiotics

• Penicillin, erythromycin, cephalosporin, and tetramycin

– Analgesics• Tylenol or aspirin

– Expectorants– Bronchodilators– Humidifier or nebulizer

Pleurisy

• Etiology/Pathophysiology– Inflammation of the visceral and parietal pleura– Bacterial or viral

Pleurisy

• Signs & Symptoms– Sharp inspiratory pain

• Usually radiates to the shoulder or abdomen

– Dyspnea– Cough – Elevated temperature– Pleural friction rub

Pleurisy

• Treatment– Antibiotics– Analgesics

• Demerol or morphine

– Antipyritics• Tylenol

– Oxygen– Anesthetic block for intercostal nerves

Pleural Effusion/Empyema• Etiology/Pathophysiology

– Pleural Effusion– Accumulation of fluid in

the pleural space– Usually secondary– Empyema

• Fluid accumulation with pleural effusion becomes infected

Pleural Effusion/Empyema

• Signs & Symptoms– Dyspnea– Air hunger– Respiratory distress

• Nasal flaring

• Tachypnea

• Dyspnea

• Decreased breath sounds

– Fever

Pleural Effusion/Empyema• Treatment

– Thoracentesis– Chest tube with closed

water seal drainage system

• Glass bottle system• Pleur-evac• (Pg. 385 Box 9-6

Maintaining chest tubes and closed chest drainage bottles)

– Antibiotics– Cough and deep breath

                                                               

Atelectasis

• Etiology/Pathophysiology– Abnormal condition characterized by the collapse of

lung tissue– Due to occlusion of air to a portion of the lung– Postoperative complication– Secretions– Foreign body– Mucous plug– Emphysema, pneumothorax, tumor

Atelectasis

Atelectasis

• Signs & Symptoms– Dyspnea– Tachypnea– Pleural friction rub– Restlessness – Hypertension > hypotension– Elevated temperature– Decreased breath sounds– Crackles

Atelectasis• Treatment

– Cough and deep breath– Analgesia– Early ambulation– Incentive spirometery– Intermittent positive pressure breathing– Oxygen– Chest percussion and postural drainage– Bronchodilators

• Proventil

– Antibiotics– Mucolytic agents

• Mucomyst - Decrease viscosity of secretions

– Chest tube

Pneumothorax

• Etiology/Pathophysiology– A collection of air or gas in the pleural space,

causing the lung to collapse– Penetrating chest injury– Coughing– Ruptured bleb– Spontaneous

Pneuomothorax

Pneumothorax

• Signs & Symptoms– Decreased breath sounds– Sudden, sharp chest pain with dyspnea– Diaphoretic– Increased heart rate– Tachypnea– No chest movement on affected side– Sucking chest wound– Mediastinal shift

Pneumothorax

• Treatment– Chest tube to water seal drainage system– Oxygen– Analgesics– Encourage fluids

Chest Tube Placement

Chest Tube Drainage System

Lung Cancer

• Etiology/Pathophysiology– Primary tumor or metastasis– Small cell lung cancer– Non-small cell lung cancer– Squamous cell carcinoma– Large-cell carcinoma– 80% linked to smoking

Lung Cancer

• Signs & Symptoms– Hemoptysis– Dyspnea– Fever– Chills– Wheezing – Pleural effusion

Lung Cancer

• Treatment– Surgery– Most are not diagnosed early enough for curative

surgical intervention– Segmental resection– Lobectomy– Pneumonectomy– Radiation– Chemotherapy

Pulmonary Edema

• Etiology/Pathophysiology– Accumulation of serous fluid in interstitial

tissue and alveoli • Left ventricular failure

• Inhalation of irritating gases

• Rapid administration of IV fluids

• Barbiturate or opiate overdose

Pulmonary Edema• Signs & Symptoms

– Dyspnea– Tachypnea– Tachycardia – Cyanosis – Pink or blood tinged, frothy sputum– Restlessness– Agitation– Wheezing – Crackles– Sudden weight gain– Decreased urinary output

Pulmonary Edema• Treatment

– Oxygen– Mechanical ventilation, if necessary– Diuretics

• Lasix

– Narcotic analgesics• Morphine will help decrease resp rate

– Nipride• Vasodilator that improves myocardial contraction and

reduces pulmonary congestion

– Strict I&O; Daily weight– Low sodium diet

Pulmonary Embolus

• Etiology/Pathophysiology– Foreign substance in the pulmonary artery

• Blood clot, fat, air, or anmiotic fluid

– High risk• Prior thrombophlebitis

• Recent surgery, pregnancy, or given birth

• Taking contraceptives long-term

• Hx of CHF, obesity, or immobilization from fracture

Pulmonary Embolus

• Signs & Symptoms– Sudden, unexplained dyspnea– Rapid respiratory rate– Hemoptysis– Chest pain– Elevated temperature– Increased WBC

Pulmonary Embolus

• Treatment– Oxygen– HOB up 30 degrees– Anticoagulants

• Heparin (IV)– Gradually tapered

• Coumadin (oral)– Initiated as Heparin is tapered – Continued at home for up to 1 year

– Fibrinolytic agents

Adult Respiratory Distress Syndrome(ARDS)

• Etiology/Pathophysiology– Complication of other disease processes

– Direct or indirect pulmonary injury

– Viral or bacterial pneumonia, chest trauma, aspiration, shock, drug over doses, renal failure, pancreatitis, COPD, Guillain-Barre’ syndrome, and myasthenia gravis

• .increased permeability of capillary membrane

• .allows fluid to leak into interstitial spaces and alveoli

• .pulmonary edema and hypoxia

• .alveoli lose their elasticity and collapse

• .capillaries allow plasma and RBC’s to leak out, resulting in hemorrhage

Adult Respiratory Distress Syndrome(ARDS)

• Signs & Symptoms– Respiratory distress

• Dyspnea

• Restlessness

– Tachycardia– Hypotension– Decreased urinary output

Adult Respiratory Distress Syndrome(ARDS)

• Treatment– Treat cause– Oxygen– Corticosteroids– Diuretics– Morphine– Lanoxin– Antibiotics

Chronic Obstructive Pulmonary Disease

• Chronic airflow limitation

• Includes

• Emphysema

• Chronic Bronchitis

• Asthma

• Bronchiectasis

Emphysema

• Etiology/Pathophysiology– The bronchi, bronchioles and alveoli become

inflamed as a result of chronic irritation– Air becomes trapped in the alveoli during

expiration, causing alveolar distention, rupture, and scar tissue

– Cigarette smoking is primary irritant– Complication:

• Cor pulmonale– Right-sided congestive heart failure due to pulmonary

hypertension

Emphysema

Emphysema

• Signs & Symptoms– Dyspnea on exertion– Sputum

• Initially there is very little

• Eventually becomes copius

– Barrel chest• Increased anteroposterior diameter caused by

overinflation

– Chronic weight loss– Emaciation– Clubbing of fingers

Barrel-Chest

Emphysema• Treatment

– Oxygen (low-flow)• 1-2 liters per NC

– Chest physiotherapy

– Bronchodilators• Theophylline or aminophylline, Isuprel, Brethine, Alupent, Proventil,

Bronkosol

– Corticosteroids

– Antibiotics

– Diruretics

– Humidifier

– Pursed-lip breathing

– High-protein, high-calorie diet• Encourage fluids between meals rather than with meals

Chronic Bronchitis

• Etiology/Pathophysiology– Hypertrophy of mucous gland causes

hypersecretion and alters cilia function– Increases suseptibility to infection causing

airway scaring– Increased airway resistance causes

bronchospasm– Most common cause is cigarette smoking

Chronic Bronchitis

• Signs & Symptoms– Productive cough

• Especially in the mornings

– Dyspnea– Use of accessory muscles to breath– Wheezing

Chronic Bronchitis• Treatment

– Bronchodilators• Theophylline, aminophylline, etc

– Mucolytics• Mucomyst

– Antibiotics• Erythromycin

– Oxygen (low-flow)• 1-2 liters per NC

– Pursed-lip breathing

Asthma• Etiology/Pathophysiology

– Narrowing of the airways due to various stimuli– Extrinsic

• External factors– Pollens, dust, feathers, animal dander, foods

– Intrinsic• Internal causes

– Respiratory infection

– Influenced by secondary factors• Mental or physical fatigue and emotional factors

– Antigen-antibody reaction

Asthma• Signs & Symptoms

– Mild Asthma• Dyspnea on exertion• Wheezing

– Acute Asthma Attack• Usually at night• Tachypnea• Expiratory wheezing• Use of accessory muscles• Nasal flaring• Cyanosis• Productive cough

– Status asthmaticus• Severe, unrelenting attack that fails to respond to usual treatment• Leads to exhaustion and respiratory failure

Asthma• Treatment

– Maintenance Therapy• Serevent inhalant, prophylactic• Corticosteroid inhalant

– Floevent

• Avoid allergens

– Acute or Rescue Therapy• Proventil inhalant• Corticosteriod and epinephrine oral or sq• Aminophylline IV• Oxygen

– Monitor by pulse oximetry

Bronchiectasis

• Etiology/Pathophysiology– Gradual, irreversible process that involves

chronic dilation of bronchi resulting in loss of elaticity

– Repeated pulmonary infections– Secondary causes may be cystic fibrosis,

foreign body, or tumor

Bronchiectasis

Bronchiectasis• Signs & Symptoms

– Dyspnea– Cyanosis– Clubbing of fingers– Coughing

• Esp in the morning and when lying down

• Copious amounts of foul-smelling sputum

– Fatigue– Weakness– Loss of appetite– Wheezes and crackles

Bronchiectasis• Treatment

– Oxygen (low-flow)• 1-2 liters per NC

– Chest physiotherapy– Hydration– Mucolytic agents

• Mucomyst

– Antibiotics– Bronchdilators

• Theophylline

– Cool mist vaporizer– Surgery

• Lobectomy