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Transcript of Respiratory
ALTERATIONS IN THE RESPIRATORY SYSTEM
Carol Bowdoin RN, MSNFall 2010
OBJECTIVES1. Compare & contrast various pulmonary infections,
the:a) Incidence, b) Physiologic alteration (pathophysiology), c) Clinical manifestations, & d) Prognosis (Includes complications).
2. Use the nursing process & critical thinking skills to structure an approach (Plan of Care)in caring for an adult client with an acute respiratory disturbance.
a) Would include Nursing Diagnosis, Nursing Interventions, Expected Outcomes & Collaborative Treatment
3. Describe the health teaching needs of client with or at risk for respiratory disturbance.
4. Compare & contrast methods for monitoring clients with alterations in respiratory system
OBJECTIVES5. Identify needs of clients with respiratory
disturbances & provide discharge planning & community-based care.
6. Discuss effects of smoking & air pollution on development of alterations in respiratory function
7. Apply lecture content in developing a comprehensive plan of care for adult clients with respiratory disturbances
RESPIRATORY ASSESSMENT REVIEW SEE SELF STUDY -
VISTA Review
A&PAssessment TechniquesConcepts of:
Oxygenation Hypoxia
Read: Chap 21 Assessment of Respiratory Function
DIAGNOSTIC STUDIES OF THE RESPIRATORY SYSTEM – SEE SELF STUDY - VISTA
Blood studies ABGs
Oximetry Sputum studies Skin tests Pulmonary Function Tests Radiologic Studies
X-rays CT Scans MRI PET Pulmonary Angiography V/Q Scan
Endoscopic Exams Bronchoscope Mediastinoscopy
Thoracentesis Lung Biopsy Exercise testing
Read: Chap 25 Respiratory Modalities & Diagnostic Test
Copyright 2008 by Pearson Education, Inc.
FACTORS THAT INFLUENCE RESPIRATORY FUNCTION Age
Review Chart 21-2 p. 495 Text Structural Changes Functional Changes History & Physical Findings
Environment Exposure to second-hand smoke Allergens & environmental pollutants
Lifestyle Smoking Recreational & occupational exposure
Health status Personal or family Hx of lung disease
Medications Affect respiratory function, gas exchange, acid-base
balance Stress
Chart 21-7 p. 498
MANIFESTATIONS OF POSSIBLE RESPIRATORY DISORDER
Age-related Changes Decrease in elastic recoil of the lungLoss of skeletal muscle strength in thorax and diaphragmFibrosis in the alveoliFewer functional capillariesLess effective coughDecrease in PO2
Normal breath sounds Table 21-5 : vesicular, bronchovesicular, bronchialAbnormal (Adventitious) breath sounds Table 21-6: crackles, wheeze, friction rubs
MANIFESTATIONS OF POSSIBLE RESPIRATORY DISORDER
Nasal Assessment Asymmetry, Redness, swelling, Septum abnormalities, Purulent drainage, Changes in ability to smell
Frontal or Maxillary Sinus Assessment Tenderness
Thoracic Assessment Markedly increased or decreased respiratory rate, Abnormal AP diameter, Intercostal retraction or bulging, Asymmetric chest expansion, Malposition of the trachea, Changes in tactile fremitus, dullness or
hyperresonance on percussion or Asymmetric diaphragmatic excursion
Breath Sound Assessment [Table 21-6] Adventitious sounds, Absence of breath sounds, or Malposition of normal quality breath sounds
Important!
RISK FACTORS FOR RESPIRATORY DISEASE Smoking – single most important
contributor Exposure to second-hand smoke Personal or family history of lung disease Genetic make-up Allergens & environmental pollutant Recreational & occupational exposure
Copyright 2008 by Pearson Education, Inc.
COMMON MANIFESTATIONS OF IMPAIRED RESPIRATORY FUNCTIONHypoxia (Altered gas exchange)
Altered breathing patternsObstructed or partially obstructed airway
UPPER AIRWAY INFECTIONS – SELF STUDY
Infections Rhinitis
Non-allergic Allergic Viral Rhinitis (common cold)
Sinusitis Acute Chronic
Read Chap 22 p. 517 -548 Upper Airway Infections
UPPER RESPIRATORY CONDITIONS – INFLUENZA
INFLUENZA “FLU” Highly contagious viral respiratory disease Transmitted by airborne droplet & direct contact Incubation period: 18 – 72 Hours Usually occurs in epidemics or pandemics Droplet Precautions Seasonal Flu Influenza A
H1N2, H3N2• Influenza B Flu Variants
H1N1 – Swine Flu H5N1 - Avian influenza
Possible pandemics: Seasonal Flu H1N1 – Swine Flu H5N1 - Avian influenza
2010 Flu vaccine includes these 3 strains
FLU PATHO
INFLUENZA “FLU” Acute/Seasonal Flu
Type A Influenza Usually self-limiting febrile illness associated
with URI & LRI Clinical Manifestations:
Sudden onset Fever Headache Non-productive Coughing Sore throat Nasal congestion &/or Rhinorrhea Body aches Chills or rigors Fatigue Malaise
Clients at Risk: Immunocompromised** Elderly* COPD* Alcoholism* Diabetes*
Complication: Hospital acquired Pneumonia* Viral Pneumonia**
This chest film shows diffuse pulmonary infiltration due to acute pulmonary histoplasmosis caused by H. capsulatum.
Photomicrograph of Haemophilus influenzae as seen using a Gram-stain technique.
During the flu outbreak of 1918 H. influenzae was termed Pfeiffer's Bacillus, where it was found in the sputum of many influenza patients, and thought to be the cause of influenza.
INFLUENZA “FLU” Acute/Seasonal Flu
Medications Vaccination Recommendations: People older than 50 years of age, Children 6 to 23 months of age, Pregnant women, residents of extended care facilities, Those with chronic medical diseases or disabilities. Health care providers Household members of high risk groups Prophylaxis Flu vaccine
Ages < 5 & > 50 & high risk individuals – injection (inactivated virus) Flu Mist
Healthy individuals ages 5 – 49(live attenuated virus) Treatment to reduce severity Amantadine Rimantadine Zanamivir Oseltamivir Ribavirin Symptom relief also includes: ASA Acetaminophen NSAIDs Antitussives Antibiotics are not indicated
http://www.cdc.gov/vaccines/pubs/vis/default.htm#flu
2010 Recommendations:
• Every person 6 mons & older•Peak time Jan-Feb – Get now
SWINE FLU – H1N1 Risk
Babies, children, & teens Pre-existing health conditions:
Heart, lung (asthma), kidney Diabetes Weak immune system Pregnancy Long-term care facilities, residential facilities 70% hospitalized pts have 1 or more Med
Dx Clinical Manifestations
Season flu S&S + vomiting & diarrhea
TX Antivirals – 1 course per person diagnosed
Complications Acute bronchitis Secondary Bacterial Chest infection -
Antibiotics Encephalitis
Influenza Infection Control Measures
CLIENT EDUCATION Prevention
Universal precautions Avoid close contact Hand Hygiene Cover mouth when coughing Contain secretions Get Flu Vaccine
INFLUENZA
Nursing DX: Knowledge deficit RT:
Teach health promotion measures Immunization education
FLU VACCINE IMPORTANCE– Risk Reduction activities
– Reduce transmission via hand washing– Avoid crowds– Avoid those who are ill
INFLUENZA
TEACH CLIENT: EMERGENCY WARNING SIGNS - IF YOU BECOME ILL AND EXPERIENCE ANY OF THE FOLLOWING WARNING SIGNS, SEEK EMERGENCY MEDICAL CARE.
Emergency warning signs in children:
Emergency warning signs in adults:
• Fast breathing or trouble breathing
• Bluish or gray skin color • Not drinking enough fluids• Severe or persistent vomiting • Not waking up or not interacting• Being so irritable that the child
does not want to be held • Flu-like symptoms improve but
then return with fever and worse cough
• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness • Confusion • Severe or persistent vomiting • Flu-like symptoms improve but
then return with fever and worse cough
INFLUENZA COMPLICATIONS This is an inferior view of a
brain infected with Gram-negative Haemophilus influenzae bacteria.
In the U.S. and other industrialized countries, More than 50% of H.
influenzae serotype b cases present as meningitis with fever, headache, and stiff neck.
3%-6% of cases are fatal; up to 20% of surviving patients have permanent hearing loss.
Gross pathology of subacute bacterial endocarditis involving mitral valve. Left ventricle of heart has been opened to show mitral valve fibrin vegetations due to infection with Haemophilus
parainfluenzae. Autopsy
Meningitis, Haemophilus
SBE
INFLUENZA COMPLICATIONSPneumonia
This chest film shows diffuse pulmonary infiltration due to acute
pulmonary histoplasmosis caused by H. capsulatum.
May be viral or bacterial (more common)
Main cause of death from flu infection May be fatal for
elderly
Bilateral interstitial infiltrates in a 31-year-old patient with atypical influenza pneumonia
REVIEW: WHAT IS THE DIFFERENCE BETWEEN A COLD & THE FLU?
Symptoms Cold FluFever Rare to low grade Temp of 100°F or higher for up to 4
days; present in 80% casesCoughing Hacking, productive Non-productive “dry cough”
Aches Slight body aches & pains Severe aches & pains; “hair hurts”
Stuffy Nose Common & typically resolves within a week
Not common
Chills Uncommon 60% have chills
Tiredness/ Fatigue
Mild Moderate to Severe
Sneezing Common Not Common
Sudden Symptoms
Develop over a few days Rapid onset within 3-6 hrs. Hits hard & includes high fever, aches & pains
Headache Uncommon unless develop sinusitis
80% have headache
Sore Throat Common Not common
Chest Discomfort
Mild to moderate Severe
OBSTRUCTION AND TRAUMATIC DISORDERS OF THE UPPER AIRWAY:
* OBSTRUCTIVE SLEEP APNEA (OSA)* EPISTAXIS
SLEEP APNEA Obstructive sleep apnea
Intermittent absence of airflow through mouth & nose during sleep Partial indicated by low-pitched snoring during inhalation Complete indicated by extreme Inspiratory effort with no
chest movement Obstruction of airflow can occur hundreds of times/night Serious & potentially life-threatening disorder Increases risk for heart disease, HTN, & heart
failure
Risk Factors: Morbid Obesity Large neck Circumference ETOH Abuse CNS Depressants Smoking
SLEEP APNEA Pathophysiology
Periods of asphyxia due to: Loss of normal pharyngeal muscle tone Pharynx to collapse during inspiration Tongue is pulled against posterior pharyngeal
wall Obstruction causes O2 sat, PO2, and
pH to fall, and PCO2 to rise Hypoxemia Acidosis Hypercapnia
Asphyxia causes brief arousal from sleep Restores airway patency and airflow
Episodes may occur hundreds of times a night
SLEEP APNEA Clinical manifestations
Loud snoring during sleep Apnea lasting 15 – 120 sec. Gasping or choking Restlessness/Thrashing during sleep Daytime fatigue Excessive daytime drowsiness Headache Depression Impotence HTN
Diagnostic studies Polysomnography (overnight sleep study)
Nursing and collaborative management: Nursing Diagnoses:
Disturbed Sleep Pattern Fatigue Ineffective Breathing Impaired Gas Exchange Decreased cardiac output related to dysrhythmias
secondary nocturnal hypoxemia Risk for Injury Risk for Sexual Dysfunction
Teach Measures to reduce airway dryness Adequate fluid intake General teaching about process and treatments
CPAP/BiPAP Education Effects are immediate Must wear nightly to achieve adequate sleep Amount of BiPAP pressure prescribed is adjusted to keep
airways open when breathing in & out without tiring patient
SLEEP APNEA
Treatments CPAP BiPAP
Surgical Intervention:o Tonsillectomyo Adenoidectomyo Uvulopalatopharyngoplasty (UPPP)o Tracheotomy
SLEEP APNEA
BIPAP – BI-LEVEL POSITIVE AIRWAY PRESSURE
Developed in the 1980’s Provides more normal
respiratatory ventialtion Provides enough continuous
airway pressure to keep airways open but decreases on exhalation
Synchronizes with patient’s respritations
Best for patients with CHF, certain neuromuscular disorders atlectasis, & lung disorders with CO2 retention
REVIEW QUESTION
Tell whether the following statement is true or false.Cigarette smoking and obesity are potential risk
factors for obstructive sleep apnea.
ANSWER
True.Rationale: •Sleep apnea is more prevalent in men, especially those who are older and overweight. •Cigarette smoking has also been identified as another possible risk factor
EPISTAXIS Aka: Nose bleed May indicate:
Dry environment Allergic rhinitis, colds, or sinusitis Nasal fracture/ trauma Bleeding disorder HTN
Risk factors See Chart 22-5 p 605
Location Anterior Septum - the midline, vertical
cartilage separating nasal chambers Lined with fragile blood vessels Usually not serious & easy to stop Seek medical help if:
Bleeding persists > 15-20 Nose bleeds recur Blood persistently drains down back of
throat Neck or serious head injury suspected This can be a serious problem resulting in
significant blood loss or airway compromise.
NURSING CARE OF PATIENTS WITH EPISTAXIS Assessment of bleeding Monitor airway and breathing Vital signs Reduce anxiety Patient teaching
Avoid nasal trauma, nose picking, and forceful nose blowing
Air humidification First Aid:
Sit & lean forward Pinch nostrils to stop bleeding. If bleeding does not stop in 15
minutes, seek medical attention.
EPISTAXIS
Medications Topical vasoconstrictors
Adrenaline Cocaine Phenylephrine
Chemical agents for cauterization Topical anesthetics if packing is required Prophylactic antibiotic therapy
Procedures Immediate first aid action Packing/ balloon tamponade Chemical or surgical cautery to sclerose
involved vessels Ligation or embolization of internal
maxillary artery
QUESTIONTopical adrenaline is used to reduce blood flow
in the patient with epistaxis. True of False?
AnswerTrue.Rationale: Topical vasoconstrictors, such as
adrenaline (1:1000), cocaine (0.5%), and phenylephrine, may be prescribed.
LOWER AIRWAY OBSTRUCTIONS
RISK FACTORS Smoking Environmental exposure Age related changes
STRUCTURAL /OBSTRUCTIVE DISORDERS - ATELETASIS Collapse of alveoli and lobules in the lung.
Caused by bronchial obstruction by secretions due to: Impaired cough mechanism Conditions that restrict normal lung expansion on
inspiration The affected portion collapses and shrinks The remainder of the lung over expands Results in the loss of the ability of air sacs at the
furthest reaches of the lungs to expand Secondary to obstruction of a bronchus related to:
Pleural effusion, Pneumothorax Cardiomegaly (Enlarged heart), Pericardial effusion, tumor
ATELECTASIS Etiology
Obstruction of the bronchus PneumothoraxPleural effusionTumorLoss of pulmonary surfactant
Risk FactorsCOPDSmokers undergoing surgeryProlonged bedrestMechanical ventilation
Figure 11. 78-year-old man with right middle lobe Atelectasis. Anteroposterior radiograph shows right middle lobe Atelectasis in the tipped up position. The Atelectasis lobe swings forward and lies horizontally. This appearance is similar to the configuration of right middle lobe Atelectasis on the apical lordotic view (Figure 6c).
ATELECTASIS Interdisciplinary Care
Prevention Reversing underlying cause
BiPAP Bronchoscopy Antibiotic therapy
Diagnosis Chest x-ray
ATELECTASIS Nursing Care :
Directed toward airway clearance Treat signs & symptoms Provide bronchial hygiene
*(aggressive pulmonary toileting) Prevention:
TCDB q 2h Promote proper chest expansion (HOB 45-90 degrees,
Orthopnea position) Respiratory Assessment: monitor more often when
administering opioids & sedatives- narcotic antidote: Narcan IV Incentive spirometry q2h Early ambulation Suction if ineffective cough
LOWER RESPIRATORY INFECTIONSACUTE TRACHEOBRONCHITIS ACUTE BRONCHITIS
o Definitiono Inflammation of the bronchi o Viral or bacterialo May be a precursor to developing Pneumonia
o Causeso Impaired immune defenses and smoking
o Clinical Manifestations– Non-productive cough
• Later becomes productive– Cough is paroxysmal (spasmodic) “barking cough”– Cough aggravated by cold, dry, or dusty air – Chest pain– Moderate fever– General malaise–Patient Education - key
PATHOPHYSIOLOGY – TRACHEO “BRONCHITIS”Host Factors Antimicrobals/
other medsSurgery/ invasive devices
Contaminated hands, gloves, devices, water,
solutins
Aaerodigestive colonization
Aspiration
Tracheal colonization/ inoculation
Inoculation /inhalation
Mechanical, cellualr, humoral lung defenses overwhelmed
Inflammation &Tissue Damage
Cap Dilation & edema of mucosa
Exudate & mucosa impaired Cilia irritation
Dry Cough
Tracheobroncitis
Bacteremia Complication:
• PneumoniaTransslocation
from GI
Rhinovirus, Parainfluenza virus, RSV, M. pnuemoniae, C. pneumoniae
Irritation & swelling of trachea & bronchial airways
Risk factors:Lung disease,
smoke, malnourished,
immunocomprised
Low grade temp
(<101F)
Burning chest pain
behind sterum
Dyspnea
Dx : CXR,
decreased PaO2 & Spo2
TRACHEO “BRONCHITIS” NSG DX & CARESecondary to lung disease
Host Factors Antimicrobals/ other meds
Surgery/ invasive devices
Contaminated hands, gloves, devices, water,
solutins
Aaerodigestive colonization
Aspiration
Tracheal colonization/ inoculation
Inoculation /inhalation
Mechanical, cellualr, humoral lung defenses overwhelmed
Inflammation &Tissue Damage
Cap Dilation & edema of mucosa
Exudate & mucosa impaired Cilia irritation
Dry Cough
Tracheobroncitis
Bacteremia Complication
:• Pneumonia
Transslocation from GI
Rhinovirus, Parainfluenza virus, RSV, M. pnuemoniae, C. pneumoniae
Irritation & swelling of trachea & bronchial airways
Risk factors:Lung disease,
smoke, malnourished, immunocompri
sed
Low grade temp
(<101F)
Burning chest pain
behind sterum
Dyspnea
Home Care
•Nsg Interventions (all types)• Monitor resp & O2 status•TEACH:• Cause•Monitor for chgs in resp & O2 status•Take all of meds•Contact MD if: •Persistent cough> 3-4 days or can’t stop coughing•Rash, itching, swelling stomach pain•Lips or nailbeds blue
Nursing DX:Alteration breathing pattern
Hospital Care
•Nsg Interventions:• Monitor resp & O2 status•Bedrest•Pulse Ox•ABGs•CBC•Telemetry•IV/INT•Antibiotics•Bronchodilators•Steroids•Breathing Tx•Postural Drainage•TEACH:• Cause• Prevention
Nursing DX:Impaired gas exchange
•Persistent cough> 3-4 days or can’t stop coughing•Rash, itching, swelling stomach pain•Lips or nailbeds blue
LOWER RESPIRATORY INFECTIONS - PNEUMONIAPNEUMONIA Description:
Acute inflammation of lung parenchyma (alveloi & respiratory bronchioles)
Classes: Viral Bacterial
Types: Community-acquired
Streptococcus pneumonae Klebsiella pneumonae Psudomonas aeruginosa Escherichia coli Haemophilus pneumonae Other influenza viruses
Hospital-acquired Streptococcus pneumonae
Atypical “Walking Pneumonia” Severe Acute Respitatory Sydronme (SARs)
Immunocompromised related Pneumocystis - HIV
Aspirationo Causative Agents:
o Infectious – bacteria, viruses, fungi & other microbeso Non-infectious – aspirated or inhaled substances
Pneumonia - Pathophysiology50% of Community Acquired areStreptococcus Pneumonia
• Pathogens enter the lungs:• Aspiration of
Oropharyngeal secretions
• Inhalation of contaminated air or water
• Through the bloodstream
• Inflammation of lung parenchyma• Fluid accumulates in
alveoli• Edema forms as
alveolar capillaries dilate & allows fluid to leak into interstitial tissues
Aspiration of S. pneumoniae
Release of bacterial endotoxin
Inflammatory response initiated:Attraction of neutrophils; release of inflammatory mediators
Alveolar edema
Exudate formation
Red hepatization & consoldiation of lung
parenchyma
Leukocyte infiltration(neutrophils & macrophages)
Gray hepatization & deposition of fibrin on
pleural surfaces; phagocytosis in
alveoli
Alveoli & respiratory bronchioles fill with serous exudate, red blood cells, fibrin, & bacteria
Resolution of InfectionMacrophages in alveoli ingest
& remove degenerated neutrophils, fibrin & bacteria
Risk factors:Past lung disease (CA,
COPD), Diabetes, Debilitating illnesses,
Malnutrition, immunocomprised
Risk factors:•Prolonged bed rest•Dyspnea•Nasal congestion•Pain with breathing• Table 23-2 pp 635
Pneumonia – Clinical Manifestations
Aspiration of S. pneumoniae
Release of bacterial endotoxin
Inflammatory response initiated:Attraction of neutrophils; release of inflammatory mediators
Alveolar edema
Exudate formation
Red hepatization & consoldiation of lung
parenchyma
Leukocyte infiltration(neutrophils & macrophages)
Gray hepatization & deposition of fibrin on
pleural surfaces; phagocytosis in
alveoli
Alveoli & respiratory bronchioles fill with serous exudate, red blood cells, fibrin, & bacteria
Resolution of InfectionMacrophages in alveoli ingest
& remove degenerated neutrophils, fibrin & bacteria
Fever, chills, headache, myalgias,
restlessness; asymmentric
chest movements
Productive cough,
dyspnea,Sore throat
Decreased PO2Splinting affected areaUse of accessory muscles; Chg in mental status
Crackles,Green or yelow sputumTachycardia
CBC Leukocytsois
CXR•Lobar inflitrate (streptococcal)• Interstitual inflitrates (myocplasmic)• Patchy inflitraes, small pleural effusion (viral)• Single inflitrate & poss. Pleural effusion (Chlamydia)l• Bronchopneumonia unit or bilateral, lobar consoldiation (Legionnaire’s)
Bld culturesBacteremia
Diagnosis: History and clinical presentation CXR to rule out Pneumonia:
Bronchopneumonia Patchy infiltrates
Lobar pneumonia One or more lobes involved
Aspiration pneumonia Caused by aspiration
Leukocytosis Abnormal ABGs Pleural effusion Pneumothorax on x-ray
LOWER RESPIRATORY INFECTIONS - PNEUMONIA
Pneumonia – Nsg Dx & Care
Aspiration of S. pneumoniae
Release of bacterial endotoxin
Inflammatory response initiated:Attraction of neutrophils; release of inflammatory mediators
Alveolar edema
Exudate formation
Red hepatization & consoldiation of lung
parenchyma
Leukocyte infiltration(neutrophils & macrophages)
Gray hepatization & deposition of fibrin on
pleural surfaces; phagocytosis in
alveoli
Alveoli & respiratory bronchioles fill with serous exudate, red blood cells, fibrin, & bacteria
Resolution of InfectionMacrophages in alveoli ingest
& remove degenerated neutrophils, fibrin & bacteria
Fever, chills, headache, myalgias,
restlessness; asymmentric
chest movements
Productive cough,
dyspnea,Sore throat
Decreased PO2Splinting affected areaUse of accessory muscles; Chg in mental status
Crackles,Green or yelow sputumTachycardia
CBC Leukocytsois
Bld cultures Bacteremia
Nursing DX:• Impaired gas exchange •Ineffective breathing pattern
Nursing DX:• Ineffect airway clearance •Hyperthermia•Activity intolerance
Nursing DX:• Inbalanced nutrition less than body requirements
Fatique, anorexia, wt loss
Nursing DX:• Pain•Anxiety
Collaborative TX:•Symptoms •Chart 23-1 pp 630 -633
•Nsg Interventions•Promote rest, hydration•TCDB q 2h•Early moblization•Incentive spirometer•Administer meds & monitor effect•Monitor O2 & resp status q2h•Manage fever•Administer meds/ antibiotics forbacterial)
•Nsg Interventions•Provide nutrtion & hydration•Dietary consult
•Nsg Interventions•Maintain airway•Supplemental O2 PRN•TEACH: meds, activity limits, avoid irritants ie smoke, pollen•DC planningPrevention – immunization for high risk clients•Sx to report toMD after DC
•Nsg Interventions•Administer analgesics•Comfort measures
Expected Outcomes•Clear breath sounds•Normal breathing patterns\•No S&S hypoxia•CXR – WNL•No complications RT pneumonia
Primary Atypical Pneumonia – mycoplasma pneumoniae –
“Walking Pneumonia”• Class:
• Infectious• Young adults, military and college students
• Manifestations: pharyngitis/bronchitis– Highly contagious– Fever– Headache– Myalgias– Arthralgias– Dry, hacking, nonproductive cough
Viral Pneumonia: Older adults and chronic conditions
Causes: Airborne virsuses
Influenza Respiratory syncytial virsus (RSV) Herpes or varicella viruses Rarely common cold virsuses
Manifestations Flu-like symptoms Headache Fever Fatigue Malaise Muscle aches
Complication SARS
Pneumocystis Pneumonia: Aids patients and immunocompromised *****
Class:Opportunistic
Manifestations Abrupt onset Fever Tachypnea Shortness of breath Dry, nonproductive cough Respiratory distress can be significant
Intercostal retractions Cyanosis
Aspiration Pneumonia: Older surgery patients at high risk**
Gastric contents aspirated into lungs causing a chemical pneumonitis
Bacterial pathogens (anaerobic) add to inflammation Emergency surgeries OB Depressed cough/gag reflex Impaired swallowing Enteral nutrition/NG/feeding tubes Silent regurgitation
Class Noninfectious
Clinical manifestations:
Legionnaires’ Disease (Bronchopneumonia): Legionella pneumophilia. Found in sitting water
Risk: Smokers, older adults, chronic diseases, impaired
immune system. Clinical Manifestations
Dry cough General malaise Chills & Fever Headache Confusion Anorexia Diarrhea Myalgia Arthralgias
PNEUMONIA - COMPLICATIONS Atelectasis
Usually clears with cough and deep breathing Bacteremia
Bacterial infection in the blood Lung abscess
Seen when caused by S. aureus and gram-negative pneumonias Empyema
Requires antibiotics and drainage of exudate Pericarditis
Spread of microorganism to heart Meningitis
Patient who is disoriented, confused, or somnolent should have lumbar puncture
Endocarditis Microorganisms attack endocardium and heart
valves Manifestations similar to bacterial endocarditis
Respiratory Failure The level of oxygen in the blood becomes too low or
the level of carbon dioxide in the blood becomes too high.
ACUTE RESPIRATORY FAILURE (ARF)Start here
CLASSIFICATION OF RESPIRATORY FAILURE
Fig. 68-2ARF will be discussed more in Med-surg II
PO2CO2
SEVERE ACUTE RESPIRATORY SYNDROME A serious form of atypical
pneumonia, caused by a virus isolated in 2003Aka “Hong Kong Flu”
Coronavirus (cold virus) - mutated
Transmited by droplets to mucous membranes (mouth, nose, eyes) of a near-by person
S&S occur 2-10 days after contact
Causes acute respiratory distress
Can lead to death
SARS S&S Hallmark symptoms
Fever greater than 100.4 degrees F (38.0 degrees C) Dry Cough Overall discomfort/body aches Difficulty breathing or other respiratory symptoms.
Symptoms in the order of how commonly they have appeared included:
Fever Chills and shaking Muscle aches & joint pain Cough Headache Less common symptoms include (also in order): Dizziness Productive cough (sputum) Low white cell count Sore throat Runny nose Nausea and vomiting Diarrhea Dyspnea due to pneumonia Hypoxia
Contagious during symptoms/2nd week S&S appear 3-7 days after exposure Stay home until 10 days after fever & resp
S&S subside Nursing diagnoses
Impaired gas exchange Risk for infection
SEVERE ACUTE RESPIRATORY SYNDROME
If hospitalized – placed on droplet isolation & in negative pressure room
TESTS & DIAGNOSIS Nasopharyngeal wash & swabs Sputum C&S Blood clotting tests Blood chemistries
ALT and CPK are sometimes elevated. LDH levels are often elevated. Sodium and potassium are sometimes
low. Chest x-ray or chest CT scan Complete blood count (CBC)
White blood cell (WBC) count may be low.
Lymphocyte count may be low. Platelet count may be low.
Bronchoalveloar lavage Tracheal aspirate Pleural fluid tap Stool C&S
SARS TREATMENT Persons suspected of having SARS should
be evaluated immediately by a health care provider
Hospitalized under negative pressure isolation if they meet the definition of a suspected or probable case. PPE Droplet isolation
Treatment same as for CAP May include:
Antibiotics to treat bacterial causes of atypical pneumonia
Antiviral medications High doses of steroids to reduce lung inflammation Oxygen, breathing support (mechanical
ventilation), or chest physiotherapy In some serious cases, blood serum from people
who have already recovered from SARS has been given. There is no strong evidence that these treatments work well.
LUNG ABSCESS Most common etiology:
Aspiration of oral anaerobes Bacterial pneumonia (S. aureus,
Klebsiella) Mechanical or functional bronchial
obstruction At risk population
Decreased level of consciousness Anesthesia Injury Disease of the central nervous system Seizure Excessive sedation Alcohol abuse Swallowing disorders Dental caries Debilitation
LUNG ABSCESS Clinical Manifestations
Insidious onset Productive cough Chills and fever Pleuritic chest pain Malaise Anorexia Temperature elevation Foul-smelling, purulent, blood-streaked
sputum Leukocytosis Dyspnea Weakness Anorexia &weight loss Decreased or absent breath sounds or
crackles Pleural friction rub
Treat with antibiotics such as Flagyl
ASPIRATION Oropharyngeal contents
contaminated lungs with bacteria - cause bacteria pneumonia
Chemical burn from aspiration of acidic gastric contents & acute inflammatory response – cause of atelectasis, pneumonitis & resp failure
Risk factorsSee Chart 23-10
After tube feeding
ASPIRATION Prevention is key:
Elevate HOB. Turn patient to the side when vomiting. Prevention of stimulation of gag reflex
with suctioning or other procedures Assessment and proper administration
of tube feeding Rehabilitation therapy for swallowing Compensate for absent gag reflex or
swallowing difficulty Assess NG/feeding tube placement
Check residual every 4 hrs Promote gastric emptying Manage effects of prolonged intubation
or tracheostomies
PLEURAL CONDITIONS
PLEURAL CONDITIONS Pleurisy:
An inflammation of both layers of the pleurae Pleural Effusion
Accumulation of fluid in the pleural space Empyema:
Accumulation of thick, purulent fluid in the pleural space Pulmonary Edema:
Abnormal accumulation of fluid in the lung tissue, alveolar space or both. Severe & life-threatening
PLEURISY Inflammation of both the
parietal and visceral layers of the pleura
Inflamed surfaces rub together with respirations and cause sharp pain that is intensified with inspiration
Usually accompanies URI
PLEURISY Clinical Manifestations
Severe “knife-like” pain, aggravated by deep breathing, coughing & movement Fever, malaise, Rapid respirations Shallow breathing chest splinting Limited chest wall movement on affected side Diminished breath sounds Pleural friction rub
Treat cause & symptoms Analgesics Topical application of heat or cold Indocin Intercostal nerve block
Teach comfort measures Turn to affected side to splint area & decrease
pain Use hands or pillow to splint rib cage when
coughing
PLEURISY MEDICATIONS NSAIDS
Indocin Bronchodilators
Theodur (PO & IV) Slo-bid (PO) Theophylline (PO) Ventolin or Albuterol (PO & inhaler) Aminophylline (IV or PO)
Monitor Aminophylline level Normal level: 10-20
Corticosterioids Beconase or Beclovent or Vancenase (oral or nasal inhaler) Prednisone (PO) Solu-medrol (IV)
Antibiotics Penicillin G - pneumococcal Erythromycin - mycoplasma, Legionnaires Tetracycline - mycoplasma Cephalosporins - klebsiella Bactrium – pneumocystis
Antitussives Codeine preparations Robitussin DM Guaifenesin or Robitussin
Expectorants Nursing Alert: Water is BEST!---- Force Fluids Guaifenesin or Robitussin Organidin
Antipyretics ASA Acetaminophen Motrin
PLEURAL EFFUSION Definition
AKA “Water on the Lung” Accumulation of fluid in the
pleural space Indicates underlying
pulmonary disease/abnormality A form of restrictive lung disease
Large effusions impair lung expansion and cause dyspnea.
Secondary to other conditions, such as: CHF Pulmonary Embolism Post CABG Pneumonia, Pulmonary infections, Nephrotic syndrome, Inflammatory disease Tumors, Cancer TB Autoimmune disease Chest Trauma
PLEURAL EFFUSION - PATHOPHYSIOLOGYGenetic/ Family
HxEnvironmental Life Style*Secondary to
lung disease
Transudative Pleural
Effusion** Exudative Pleural
Effusion** Empyema** Chylothorax*
*
Increased hydrostatic pressure Ex: CHF*,
Pul Embolus
Pleural fluid contains small amounts protein (CHON)
Decreased oncotic pressure caused by inadequate albumin level Ex: Chronic kidney* & liver
disease* Forces watery pleural fluid from capillaries into pleural space
Pleural fluid contains large amounts protein (CHON)
Inflammatory response causes increases capillary permeability Ex: Pulmonary Infections (Pneumonia), tumors, emboli; Pancreatitis* , Ruptured
esophagusForces thick pleural fluid from capillaries into pleural
space
Pleural fluid contains pus
Forms a pocket (loculates) or abscess between pleura & fissures
Impairs lung expansion
Worsening
Dyspnea
** Dx confirmed by CXR if > 250 ml,
thoracentesis cytology exam, & physical exam
Decreased chest
movement
Decreased breath sounds
Chest dull to
percussion
Pleural friction
rub
Egophony
Disruption of pulmonary lymph vessels due to trauma or surgery
Abnormal accumulation of lymph fluid in pleural space
Produces fat malabsorption in GI tract
Weight loss;
malnutrition
Decreased immunity
Dyspnea,
orthopnea
Fever, persistent cough,
night sweats
Pleuritic chest pain
PLEURAL EFFUSION – NURSING DXGenetic/ Family
HxEnvironmental Life Style*Secondary to
lung disease
Transudative Pleural
Effusion
Exudative Pleural
Effusion Empyema Chylothorax
Increased hydrostatic pressure Ex: CHF*,
Pul Embolus
Pleural fluid contains small amounts protein (CHON)
Decreased oncotic pressure caused by inadequate albumin level Ex: Chronic kidney* & liver
disease* Forces watery pleural fluid from capillaries into pleural space
Pleural fluid contains large amounts protein (CHON)
Inflammatory response causes increases capillary permeability Ex: Pulmonary Infections (Pneumonia), cancer, tumors, emboli; Pancreatitis* , Ruptured
esophagusForces thick pleural fluid from capillaries into pleural
space
Pleural fluid contains pus
Forms a pocket (loculates) or abscess between pleura & fissures
Impairs lung expansion
Worsening
Dyspnea
Decreased chest
movement
Decreased breath sounds
Chest dull to
percussion
Pleural friction
rub
Egophony
Disruption of pulmonary lymph vessels due to trauma or surgery
Abnormal accumulation of lymph fluid in pleural space
Produces fat malabsorption in GI tract
Weight loss;
malnutrition
Decreased immunity
Dyspnea, orthopne
a
Nursing DX:• Ineffective breathing pattern
Nursing DX:•Pain/ Discomfort RT irritation/ inflammation
Nursing DX:• Risk for Infection
Nursing DX:Impaired gas exchange
Fever, persistent
cough, night sweats
Nursing DX:• Imbalance nutrition
Pleuritic chest pain
PLEURAL EFFUSION – NURSING & COLLABORATIVE TX
Genetic/ Family Hx
Environmental Life Style*Secondary to lung disease
Transudative Pleural
Effusion*** Exudative Pleural
Effusion*** Empyema*** Chylothorax
Increased hydrostatic pressure Ex: CHF*,
Pul Embolus
Pleural fluid contains small amounts protein (CHON)
Decreased oncotic pressure caused by inadequate albumin level Ex: Chronic kidney* & liver
disease* Forces watery pleural fluid from capillaries into pleural space
Pleural fluid contains large amounts protein (CHON)
Inflammatory response causes increases capillary permeability Ex: Pulmonary Infections (Pneumonia), tumors, emboli; Pancreatitis* , Ruptured
esophagusForces thick pleural fluid from capillaries into pleural
space
Pleural fluid contains pus
Forms a pocket (loculates) or abscess between pleura & fissures
Impairs lung expansion
Worsening
Dyspnea
Decreased chest
movement
Decreased breath sounds
Chest dull to
percussion
Pleural friction
rub
Egophony
Disruption of pulmonary lymph vessels due to trauma or surgery
Abnormal accumulation of lymph fluid in pleural space
Produces fat malabsorption in GI tract
Weight loss;
malnutrition
Decreased immunity
Dyspnea, orthopnea
Nursing DX:• Ineffective breathing pattern
Nursing DX:•Pain/ Discomfort RT irritation/ inflammation
Nursing DX:• Risk for Infection
Nursing DX:Impaired gas exchange Fever
Nursing DX:• Imbalance nutrition
Pleuritic chest pain
•Nsg Interventions (all types)• Monitor resp & O2 status• Assist with thoracentesis & monitor post for complications• Administer antibiotics, antipyretics, TPN/lipids & monitor effects•Provide supplemental O2•Provide adequate nutrition•TEACH:• Cause•Monitor for chgs in resp & O2 status•Purpose & procedure for thoracentesis
TX:• TPN & IV lipids• Pleurodesis• Med: Octreotide
TX***:• Underlying cause•Thoracentesis: drain pleural fluid•Antibiotic Therapy•Surgery – separate pleural membranes
Expected Outcomes (all) • Resolution or reduction of PF•Afebrile•Control chest wall pain•Adeq CHON intake• RR 12 -24 BPM
MANAGEMENT OF PLEURAL EFFUSION - THORACENTESIS
Thoracentesis or chest tube insertion with drainage of fluid may be needed: Rationale:
Drain accumulated PE > 250 mL Promote lung expansion & gas exchange
Pre-procedure care Verification of signed informed consent Assessing knowledge and understanding of the procedure and its purpose Medication administration as required Positioning the client leaning over an anchored overbed table Teaching about the level of discomfort to expect
Post procedure Relieve discomfort Monitor for complications
Fluid balance S&S hypovolemic shock
PULMONARY EDEMA Definition
Abnormal accumulation of fluid in lung tissue, alveoli or both
Severe, life-threatening condition
PULMONARY EDEMA PATHOPHYSIOLOGYGenetic/ Family Hx: CV Disease,
recent MI, mitral regurgitation
Increased microvascular venous pressure
Abnormal LV cardiac function (heart failure)
Blood backs up into pulmonary vasculature
Fluid leaks into interstitual spaces & alveoli
HypervolemiaSudden increase in intravascular pressure in lung
Pnueomectomy
Cardiac output shifts to remaining lung
Flash pulmonary edema
SOB, air hungerCough, AnxietyGurgling when breathing, Orthopnea, Wheezing, nasal flaring, crackles, cyanosis, pink frothy sputum, paroxysmal nocturnal dyspnea
Excessive sweating,Pale skinRestlessnessDecreased LOC, inability to speak in full sentences
Interruption of gas exchange leads to hypoxemia
Severe Infection Toxic exposure
Fluid overload; liver or kidney failure
CBC, Chemistries, Creatinine, Liver Enz, ABGs, Pulse Ox, C-reactive protein, PT/APTT, BNP, CXR, EKG, Ultrasound heart
Respiratory failure
Untreated: Coma & death
Complication:
• Hypoxia
Nocturia, Pitting ankle edema,
Lung Disease
Inflammation
Thickening of alveolar membrane
Hypoxemia
Nursing DX:• Alteration in fluid balance
Nursing DX:• Ineffective breathing pattern
Nursing DX:Impaired gas exchange
PULMONARY EDEMAMedical /Collaborative Care Concept Map
QUESTIONS?!!