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1 NCLEX RN Preparation Program Respiratory Disorders Module 5, Part 3 of 3.

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Presentation on theme: "1 NCLEX RN Preparation Program Respiratory Disorders Module 5, Part 3 of 3."— Presentation transcript:

1 1 NCLEX RN Preparation Program Respiratory Disorders Module 5, Part 3 of 3

2 2 Chronic Airflow Limitation Emphysema + Chronic Bronchitis = COPD Chronic Obstructive Pulmonary Disease Photo Source: National Heart, Lung and Blood Institute (NHLBI

3 3 Emphysema  Loss of lung elasticity  Hyperinflation  Air trapped in lungs  Alveoli over-stretched  bullae

4 4 Chronic Bronchitis  Recurrent inflammation  Vasodilation, Congestion, Edema, Spasm  Excessive thick mucus blocks air flow  Hypoxemia, CO 2 retained

5 5 Causes of COPD  Smoking  Alpha 1 -Antitrypsin Deficiency  Air pollution Secondary smoke Photo Source: National Cancer Society, and

6 6 Signs of COPD  General  Breathing  Sputum  Sounds  Skin  Finger tips

7 7 Assess * LOC * Airway status and breathing * Pulses * RR, depth * BP, Heart Rate * SpO 2 level on room air * Color, temperature & capillary refill

8 8 Is this an emergency?  Dyspnea scale 0-10  Oxygen saturation < 90%  Peak flow < 300 ml

9 9 Diagnostic Tests  Arterial Blood Gases  Oxygen Saturation  Chest x-ray  Labs  Pulmonary Function Tests (PFTs)

10 10 Goal: Patent Airway  Position  Secretions  Mucolytics  Expectoration  Hydration  Humidifier

11 11 Teach Effective Breathing  Diaphragm  Pursed-lips  Controlled cough  Orthopneic position

12 12 Bronchospasm  Bronchodilators  Cholinergic antagonists  Theophyllins

13 13 Inflammation Infection  Inhaled steroids  Systemic steroids  Prevent pneumonia  Influenza vaccination yearly  Pneumovax q 5 years

14 14 Conserve Energy  Schedule activities  Don’t rush  Supplemental oxygen  Avoid arm raises

15 15 Mealtime Strategies  Rest  4-6 small meals  Bronchodilator ac  Easy chewing  Supplements  Avoid gas-producing foods

16 16 Stepped Therapy 1. Combivent (ipratropium + albuterol) 2. Add beta 2 agonist (Albuterol) 3. Add theophyllin 4. Add Prednisone

17 17 Control Anxiety = Dyspnea  Develop a plan  Develop support network  Join support group

18 18 Complementary/Alternatives  Ask about non-prescribed methods used  Teach relaxation techniques

19 19 Pneumonia Photo Source: Centers for Disease Control, Wikimedia Commons,

20 20 Categories  Viral  Fungal  Bacterial  Aspiration Photo Source: USDS, 20.htm]

21 21 Classification  Causative agent (Streptococcus pneumoniae)  Anatomic location of the infection (lobar pneumonia)  By where it was acquired (community vs. hospital/nosocomial)

22 22 Major Organisms  Community-acquired: Streptococcus pneumoniae (gram +) Staphylococcus aureus (gram +)  Nosocomial: Staphylococcus aureus (gram +) MRSA

23 23 Who is at greatest risk? Photo Source: National Camcer Society, and

24 24 Community Prevention Pneumovax Wash hands Don’t smoke Wear mask: dusty, moldy areas Avoid crowds Eat healthy diet Exercise

25 25 Nosocomial Prevention  Prevent aspiration - How?  Prevent cross-contamination  Vaccinate inpatients  Education  Mouth care??

26 26 Signs & Symptoms  Fever, chills  Dyspnea,  RR, shallow breathing  Coughing, crackles, wheezing  Pleuritic pain  Anorexia  Hypoxemia  Sputum: purulent, blood-tinged, rusty

27 27 Diagnosis  Sputum C&S  Leukocytosis  ABG’s  Blood C&S  Chest x-ray  Oxygen saturation

28 28 Goal: Improve Gas Exchange  Oxygen  Antibiotics  Rest  Incentive spirometry  Raise head of bed  No smoking

29 29 Goal: Clear Airway  Enhance cough strength  Bronchodilators  Rest  Mucolytics  Corticosteroids

30 30 Goal: Control Pain and Fever  Pain  Fever control  Adequate volume

31 31 Pulmonary Tuberculosis Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons, and

32 32 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,

33 33 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

34 34 Diagnosis  Initial Screening – skin test Positive if >10mm induration  Chest x-ray  Sputum for AFB

35 35 Skin Testing  Mantoux 0.1 ml PPD  hours induration  False-positive  False-negative Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons,

36 36 Chest X-ray  To confirm positive PPD  When PPD cannot be done  Cavitation  Caseation

37 37 Sputum Testing  First morning specimen  3 days  Acid-fast Bacilli  Tb C & S Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons,

38 38 How is it treated?  Initial Therapy may include: Isoniazid (INH) Rifampin Pyrazinamide (PZA) Ethambutol or Streptomycin  After two months: Isoniazid Rifampin

39 39 Isoniazid  Precautions: Take on empty stomach, avoid antacids LFTs if liver disease  Warnings: Increases Dilantin & Tegretol levels

40 40 Rifampin  Precautions Body secretions turn orange May ruin contact lenses  Warnings Reduces contraceptive, methadone effect May interact with anti-retrovirals

41 41 Rifapentine  Precautions Probably discolors body secretions  Warnings Decreased potency diabetes meds, barbs, antibiotics, contraceptives

42 42 Ethambutol  Precautions Decreased visual acuity Decreased red-green color discrimination  Warnings Optic toxicity is dose related Increased toxicity with renal insufficiency

43 43 Pyrazinamide  Precautions Hepatotoxicity Nausea/vomiting Polyarthralgias Hyper-uricemia Transient rash Photo-sensitive dermatitis

44 44 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.

45 45 Transplant Recipients  Immune suppressed  Donor organ with latent TB  Reactivate pt’s latent infection  Diagnosis difficult Decreased PPD reaction

46 46 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 47 Drug Toxicity  Hx of liver disease  Consuming alcohol daily  Baseline + repeat LFTs  Watch! Dark urine Light stools Fatigue

48 48 Drug Resistance  Multi-drug resistant TB (MDRTB)  Second-line drugs  Increased time of treatment

49 49 Non-compliance  Failure of treatment  Resistant bacilli  Intermittent dosing?  Arrest the patient?

50 50 Patient/Family Teaching  Prevention  Phone contact  Test entire family  Use precautions  Follow-up sputum cultures  Diet

51 51 Acute Respiratory Failure  Dyspnea, tachycardia  Progressive respiratory distress  Breath sounds  Mental status

52 52 ARDS  Aspiration  Sepsis  Drowning  Trauma

53 53 Diagnostic Tests  pO 2 < 60 mmHg  pCO 2 > 50 mmHg  O 2 saturation < 90%  Chest x-ray – increasing infiltrates to “white out”

54 54 Collaborative Management  Oxygen  Mechanical ventilation Photo Source: Wikimedia Commons / Public Domain image,

55 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,

56 56 Mechanical Ventilation  FiO 2 100%  Tidal volume (V t ) 6-7 ml/kg  Rate 20-28/minute

57 57 Ventilators  Negative pressure  Pressure cycled  Time cycled  Volume cycled

58 58 Modes of Ventilation  CMV  SIMV  PSV  PEEP  CPAP

59 59 Acidosis  Low pH = acidosis (normal )  Low pH + low HCO3 = metabolic acidosis (normal 21-26)  Low pH + high CO2 = respiratory acidosis (normal 35-45)

60 60 Alkalosis  High pH = alkalosis  High pH + high HCO3 = metabolic alkalosis  High pH + low CO2 = respiratory alkalosis

61 61 Ventilator Alarms  High pressure  Low inspiratory pressure  High respiratory rate  Low exhaled volume

62 62 Monitor Physiological Response  Breath sounds  Breathing pattern  Skin color  Secretions  Oxygen saturation  ABGs, daily chest x-ray

63 63 Monitor Psychological Response  Anxiety  Communication  Anticipate questions/needs

64 64 Manage the Ventilator  Correct settings?  Alarms on?  Maintain humidity  Monitor inline temperature  ETT placement, cuff  Tubing adjustments

65 65 Prevent Complications  Barotrauma  Stress ulcers  Infection: Ventilator- assisted pneumonia (VAP)  Ventilator dependence  Pressure necrosis

66 66 Weaning from Ventilator  Awake, rested  Muscle strength  Heart rhythm  Breath sounds  ABGs  Pulmonary function tests

67 67 Weaning Methods  SIMV  CPAP  Pressure Support

68 68 Extubation  Explain procedure  Prepare: nasal cannula, towel, Chux  Hyper-oxygenate  Suction  Deflate pilot balloon  Suction  Pull tube  No talking!

69 69 Pneumothorax Signs and Symptoms  Pleuritic chest pain  SOB  Tachypnea  Tachycardia  Asymmetrical chest wall movement  Decreased breath sounds  Cyanosis Photo Source: Colorado State University,

70 70 Tension Pneumothorax Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank,

71 71 Tension Pneumothorax Signs and Symptoms  Tracheal deviation  Distended neck veins  Hypotension  Compensatory tachycardia & tachypnea  Decreased cardiac output Must be treated promptly

72 72 Hemothorax Signs and Symptoms  In addition to those seen with pneumothorax:  Subcutaneous Emphysema (crepitus)  Percussion dullness over area of hemothorax Photo Source:

73 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, _bedside_with_fluids.jpg _bedside_with_fluids.jpg

74 74 Nursing Care of the Patient  Oxygen  Vital signs  Chest wall movement, trachea, neck veins  Position  Watch for distress

75 75 Pulmonary Embolus  DVT  Air  Fat  Catheter Photo Source: National Heart, Lung and Blood Institute (NHLBI),

76 76 Signs/Symptoms  Classic triad  Common: dyspnea, tachypnea, pleuritic pain  Pleuritic chest pain + dyspnea + predisposing factor

77 77 Diagnosis  ABGs  Chest x-ray  V/Q scan  Spiral CT  Pulmonary angiogram Photo Source: CDC/Wikimedia Commons,

78 78 Prevention  Early ambulation  Hydration  Anti-embolic stockings  Sequential pumps  Avoid lower extremity punctures  Aspirate clotted IVs  SQ heparin or LMWH

79 79 Emergency Measures  Oxygen  HOB up  Support  Stat ABGs, chest x-ray  Prepare for code blue

80 80 Collaborative Management  Continue oxygen  Bed rest  Heparin drip  Coumadin  Thrombolytics?  Embolectomy, umbrella filter

81 81 Teach  Bleeding precautions  Avoid immobility  Avoid dehydration  Avoid aspirin products

82 82 Photo Acknowledgement: Unless noted otherwise, all photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.


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