NCLEX RN Preparation Program

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

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

Emphysema Alveoli over-stretched  bullae Loss of lung elasticity
Hyperinflation Air trapped in lungs Alveoli over-stretched  bullae The changes that cause disability with this disease are loss of lung elasticity and hyperinflation of the lungs. As a result, air that should have been exhaled is trapped in the lungs and the alveoli are over-stretched and break down into large air-filled spaces called bullae. There is now less surface area for gas exchange The hyper-inflated lungs flatten the diaphragm and weaken it. What does the diaphragm do? Gas exchange is adversely affected by the increased work of breathing in emphysema. The patient compensates by breathing faster, but eventually carbon dioxide is retained causing chronic respiratory acidosis. In later stages, the patient cannot keep up the respiratory rate needed for oxygenation and has a decreased functional residual volume and decreased lung capacity. These cause a low arterial oxygen level.

Chronic Bronchitis Recurrent inflammation  Vasodilation, Congestion, Edema, Spasm Excessive thick mucus blocks air flow Hypoxemia, CO2 retained This is an inflammation of the bronchi and bronchioles that is recurrent. The lungs are irritated and become inflamed, vasodilated, congested, edematous and spasm. Excessive thick mucus is produced and the bronchial walls thicken – these block airflow, especially in the smaller bronchioles. As a result, gas exchange is decreased causing hypoxemia and carbon dioxide retention and respiratory acidosis. Chronic bronchitis and pulmonary emphysema often co-exist. They both cause bronchospasm and dyspnea.

Causes of COPD Smoking Alpha1-Antitrypsin Deficiency Air pollution
Secondary smoke Alpha1-Antitrypsin Deficiency Familial emphysema, or alpha1-antitrypsin (AAT) deficiency-related emphysema, is caused by the hereditary deficiency of a protein called alpha1-antitrypsin. This deficiency leads to uncontrolled destruction of the alveoli and emphysema. Air Pollution Air pollution can contribute to COPD in the smoker Photo Source: National Cancer Society, and

Signs of COPD General Breathing Sputum Sounds Skin Finger tips
General: The patient has decreased muscle mass, slow moving, stooped, with a barrel chest (Anterior-poster diameter is increased) Breathing: Respiratory rate rapid, shallow, uses accessory muscles to breathe (intercostals, neck muscles); abdominal paradox, respiratory alternans, asynchronous breathing Sputum: Excessive, thick Sounds: Wheezing, crackles Skin: dusky appearance, delayed capillary refill, clubbing of fingers

Assess LOC Airway status and breathing Pulses RR, depth BP, Heart Rate
SpO 2 level on room air Color, temperature & capillary refill Quick assessments and interventions Follow your facility's protocol to quickly assess your patient and intervene. Fear worsens dyspnea, so try to reassure the patient. Acknowledge his fears and stay calm as you coach him in breathing techniques, such as pursed-lip breathing, to ease his distress. Perform these immediate measures: * Assess level of consciousness. * Assess airway status and breathing. * Assess central and peripheral pulses. * Measure respiratory rate and depth. * Assess blood pressure and heart rate. * Measure SpO 2 level on room air. * Elevate the head of the bed. * Auscultate breath sounds. * Assess skin color, temperature, and capillary refill to evaluate perfusion.

Is this an emergency? Dyspnea scale 0-10 Oxygen saturation < 90%
Peak flow < 300 ml To gauge the severity of your patient's dyspnea, you can rely on numeric ratings and clinical tests: To get a numeric rating , ask your patient to rate his breathlessness from 0 to 10, with 0 indicating not breathless at all and 10 being the worst imaginable breathlessness. A visual analogue scale, like similar tools used to evaluate pain, is a numeric tool for rating dyspnea. The scale consists of a line with “Not breathless at all” and “0” at one end and “Worst imaginable breathlessness” and “10” at the other, with numbers between. Have the patient use the scale to rate his dyspnea, then record the numeric value. This tool is sensitive enough that repeat measurements can indicate even minor changes in his condition. It isn't useful, however, for someone with impaired visual or cognitive function. Pulse oximetry is a noninvasive way to indirectly gauge arterial hemoglobin oxygen saturation (SpO 2 ) through a sensor placed on the patient's finger, toe, or earlobe. However, in someone with severe dyspnea, it doesn't eliminate the need to obtain ABGs to evaluate pH, PaCO 2 , and HCO3 - levels. Keep in mind that equipment problems such as malfunctioning or improperly positioned sensors can interfere with accuracy. Patient factors that can affect readings include low hemoglobin level and conditions that cause vasoconstriction, such as peripheral vascular disease, hypothermia, and shock. Measurement of peak expiratory flow (PEF) is a simple, noninvasive way to assess the speed at which air is forced out of the lungs after deep inhalation. Some patients with chronic respiratory conditions, such as asthma and COPD, use this test daily at home to monitor their condition. Because changes in PEF values can warn of deterioration in the patient's condition even before symptoms develop, the National Asthma Education and Prevention Program considers it a viable monitor of disease status. (Review the technique in Taking a Peek at Peak Flow Rate .) However, this test may be too demanding for someone with severe dyspnea.

Diagnostic Tests Arterial Blood Gases Oxygen Saturation Chest x-ray
Labs Pulmonary Function Tests (PFTs) Arterial Blood Gases Usually, patients show hypoxemia (pO2 < 80 mmHg) and hypercarbia (pCO2 > 45 mmHg). However, not all retain CO2 since it diffuses out the capillaries faster than oxygen is absorbed. Late in the disease, patients will retain CO2 and will develop respiratory acidosis as a result. Oxygen Saturation Oxygen saturation is decreased in COPD, often 89-91%. It is important to know each patient’s baseline before initiating therapeutic oxygen. Chest x-ray: The chest x-ray cannot diagnose COPD, but will show the classic signs of hyperinflation and a flattened diaphragm. Laboratory Testing Polycythemia results from chronic hypoxemia. The bone marrow will be stimulated to produce more red blood cells to carry more total oxygen. An Alpha1-Antitrypsin may be drawn if this deficiency is suspected. Pulmonary Function Tests COPD is classified by pulmonary function testing: peak flow Peak flow rate Vital capacity (VC) Forced expiratory volume in one second (FEV1) Forced vital capacity (FVC) Residual volume (RV) Total lung capacity (TLC) These tests are done twice: before and after the patient inhales a bronchodilator. They measure the patient’s ability to move air in and out of his lungs. How forcefully and how completely he does this indicates the severity of his COPD.

Goal: Patent Airway Position Secretions Mucolytics Expectoration
Hydration Humidifier 1. Maintain a patent airway: Position patient to maximize ventilation Remove secretions via suction, percussion & postural drainage Give mucolytics to break down secretions (Mucomyst, Pulmozyme) Facilitate expectoration with guaifenesin (Organidin, Robitussin) Hydration unless contra-indicated: drink 2-3 L/day Humidifiers may help in a dry climate (clean daily to prevent mold)

Teach Effective Breathing
Diaphragm Pursed-lips Controlled cough Orthopneic position 2. Teach effective breathing: The National Emphysema Foundation has a web site that teaches these exercises and others: Diaphragmatic breathing Pursed-lip exhalation Controlled coughing

Bronchospasm Bronchodilators Cholinergic antagonists Theophyllins
Prevent/treat bronchospasm: Iggy, Chart 33-5, pp : Beta adrenergic bronchodilators: Albuterol, Maxair: short acting; monitor heart rate; use at least 5 min before other inhalers Serevent: long acting, shake well before using, not for acute symptoms. Do not exhale into device if using powder type (powder will clump) Cholinergic antagonists Atrovent: Shake well (separates easily); short acting; watch for side effects; check pulse before & after using Theophyllins Theo-dur, Elixophyllin: po tablets; avoid caffeine – these cause tachycardia; monitor drug levels (10-20 is therapeutic); take with meals (irritates stomach) Iggy, Charts & teach how to use inhaler & dry powder inhaler correctly; know how to do these + how to use a spacer.

Inflammation Infection
Inhaled steroids Systemic steroids Prevent pneumonia Influenza vaccination yearly Pneumovax q 5 years 4. Prevent/treat inflammation & infections: Inhaled corticosteroids (Flovent, Pulmicort, Vanceril, Azmacort, Aerobid) Systemic corticosteroids (Prednisone): watch for GI side effects; will increase BS, irritability Pneumonia is a constant risk: teach patient to call health care provider for increase in sputum, change in sputum color Get yearly flu shot and Pneumovax every 5 years

Conserve Energy Schedule activities Don’t rush Supplemental oxygen
Avoid arm raises 5. Conserve energy: Schedule activities to allow rest periods Teach not to rush any activity – this causes dyspnea May need supplemental oxygen during activity Avoid working with arms raised (accessory muscles of breathing are used to stabilize shoulders)

Mealtime Strategies Rest 4-6 small meals Bronchodilator ac
Easy chewing Supplements Avoid gas-producing foods 6. Mealtime strategies: Rest before meals Eat 4-6 small meals per day Use bronchodilator 30 minutes before eating Select easy-to-chew foods Take dietary supplements (Pulmocare provides nutrition with decreased CO2 production)

Stepped Therapy Combivent (ipratropium + albuterol)
Add beta2 agonist (Albuterol) Add theophyllin Add Prednisone Combivent 3-6 puffs 4 times daily MDI with spacer; add Albuterol or Maxair for rescue prn Add Albuterol 2-6 puffs q 3-6 h by MDI with spacer; consider adding long-acting (Serevent) once daily Add long-acting theophylline mg po bid; if too much tachycardia, stop & go to next step Add prednisone 40mg po daily; taper when improves to lowest dose that manages symptoms. When at lowest dose, consider inhaled steroids.

Control Anxiety = Dyspnea
Develop a plan Develop support network Join support group 8. Control anxiety Help patient develop a plan for dyspnea episodes (i.e. breathing exercises) Develop support network of family & friends Join a support group (good also for the significant other)

Complementary/Alternatives
Ask about non-prescribed methods used Teach relaxation techniques 9. Complementary & alternative therapies Always consider the patient may already be using non-prescribed methods of dealing with this disability Other relaxation techniques: progressive relaxation, hypnosis, biofeedback

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

Categories Viral Fungal Bacterial Aspiration
Photo Source: USDS,

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

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

Who is at greatest risk? The common risk factors for community-acquired pneumonia include: Older adults No history of pneumococcal vaccination No history of influenza vaccine in the previous year Chronic or other co-existing conditions Recent history of or exposure to viral or influenza infections History of tobacco or alcohol use Photo Source: National Camcer Society, and

Community Prevention Pneumovax Wash hands Don’t smoke
Wear mask: dusty, moldy areas Avoid crowds Eat healthy diet Exercise Prevention Pneumococcal vaccine (Pneumovax): usually given once Influenza vaccination is also recommended since pneumonia often occurs as a complication of the flu Strict handwashing, especially around sick people: TEACH: Wash hands frequently especially after blowing your nose, going to the bathroom, or diapering, and before eating or preparing foods Don't smoke. Tobacco damages lung's ability to ward off infection Wear a mask when cleaning out very dusty or moldy areas Avoid crowds and sick people, especially those with colds or influenza Eat a balanced diet & get plenty of exercise

Nosocomial Prevention
Prevent aspiration - How? Prevent cross-contamination Vaccinate inpatients Education Mouth care?? Prevention of nosocomial pneumonia Decrease aspiration by the patient Prevent cross-contamination or colonization via hands of personnel Disinfect or sterilize respiratory-therapy devices Give vaccines to protect against particular infections Educate hospital staff and patients New measures being investigated involve reducing oropharyngeal and gastric colonization by pathogenic microorganisms Put pneumonia patients in respiratory isolation when admitted and for at least 48 hours after antibiotic therapy is started Regular mouth care of patients on mechanical ventilation using chlorhexidine (Peridex)

Signs & Symptoms Fever, chills Dyspnea,  RR, shallow breathing
Coughing, crackles, wheezing Pleuritic pain Anorexia Hypoxemia Sputum: purulent, blood-tinged, rusty Clinical Manifestations of Bacterial Pneumonia Physical assessment of the patient with pneumonia will show one or more of these: Fever and chills Dyspnea with increased shallow respiratory rate Coughing, crackles & wheezing Pleuritic pain, especially on inspiration Anorexia Hypoxemia Purulent, blood-tinged or rust colored sputum may be present The onset of bacterial pneumonia can vary from gradual to sudden. In most severe cases, the patient may experience shaking/chills, chattering teeth, severe chest pains, sweats, cough that produces rust colored or greenish mucus, increased breathing and pulse rate, and bluish colored lips or nails due to lack of oxygen.

Diagnosis Sputum C&S Leukocytosis ABG’s Blood C&S Chest x-ray
Oxygen saturation Diagnostic Tests Sputum cultures are only able to detect the organism about 50% of the time. Many patients do not produce sputum early in the infectious process or have a poor cough effort later in the process. The white blood cell count (WBC) will be elevated, especially the neutrophils Arterial blood gas will vary. Early in the pneumonia, the patient is hyperventilating, trying to get oxygen through the purulence in the alveoli. He will exhale a lot of CO2 and therefore be alkalotic. Later, as the patient gets tired, he will retain CO2 and become acidotic. It is important for the nurse to recognize these stages. Blood cultures: to see if septicemia exists Chest x-ray: consolidation or congestion in the areas infected Pulse oximetry: decreased oxygen saturation indicating hypoxemia

Goal: Improve Gas Exchange
Oxygen Antibiotics Rest Incentive spirometry Raise head of bed No smoking Collaborative Management Oxygen: Depending on the patient’s oxygen saturation, the nurse will give as little as 2 L via nasal cannula up to 100% non-rebreather mask or even intubation and mechanical ventilation. This patient will need humidified oxygen to keep the airway clear of secretions. Antibiotics: the nurse is responsible for checking that the patient’s organism is sensitive to the prescribed drug Nursing Management Monitor intake and output, but realize that fever and tachypnea will cause insensitive fluid loss that cannot be measured. Rest: the patient needs to decrease his oxygen demand Incentive spirometry. This exercise will reverse and prevent development of atelectasis. Also encourage deep breathing. Raise the head of the bed to at least 30 degrees to prevent orthopnea. No smoking by the patient or visitors!

Goal: Clear Airway Enhance cough strength Bronchodilators Rest
Mucolytics Corticosteroids Enhance the cough strength: an expectorant may be prescribed such as guaifenesin (Humibid, Humibid LA, Robitussin, Organidin NR, Fenesin). It is important to encourage an effective cough and to minimize non-productive coughing. A non-productive cough will exhaust the patient. Guaifenesin is an expectorant, that is, a medication that promotes elimination of mucus from the lungs. The expectorant effects of guaifenesin promote elimination of mucous by thinning the mucous and lubricating the irritated respiratory tract. Why wouldn’t the nurse want to give this patient codeine? Give nebulized bronchodilators (Albuterol, Atrovent): These “treatments” should be given at least every 4 hours, more often if the patient is wheezing or laboring to breathe. Make sure the patient gets enough rest Give nebulized mucolytics (Mucomyst) to loosen secretions Corticosteroids may decrease airway inflammation

Goal: Control Pain and Fever
Fever control Adequate volume Pain management Pleuritic pain is tiring as well as uncomfortable. It is important to relieve the pain but not suppress the patient’s cough strength. Oral pain medication will be less potent but will give longer relief without over-sedating the patient. Fever control Fever increases oxygen demand, so it’s important to keep the patient’s fever down. Curing the pneumonia will eventually lower the patient’s temperature, but the nurse will take measures to decrease the fever by: Medication: Tylenol Lowering the room temperature and removing blankets External measures: cooling blanket, ice packs, tepid bath Providing adequate volume Dehydration should be avoided, but overhydration is not necessary. Adequate hydration will help thin secretions and make them easier to remove. The patient will probably required IV fluids since he will be too short of breath to drink enough fluids. Monitor intake and output, but realize that fever and tachypnea will cause insensitive fluid loss that cannot be measured.

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

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) It used to be called “consumption”! Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons,

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 Early diagnosis is difficult because the disease develops slowly. Consider Tb for anyone with: High risk history Persistent cough Weight loss Anorexia Night sweats Hemoptysis Shortness of breath Fever or chills

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

Skin Testing Mantoux 48-72 hours False-positive False-negative
0.1 ml PPD 48-72 hours induration False-positive False-negative Induration: The basis of reading the skin test is the presence or absence of induration, which is a hard, dense, raised formation. This is the area that is measured. Sometimes the site has erythema, a reddening of the skin that can also have swelling. The erythema should NOT be measured. Whatever induration is present at 48 to 72 hours should be measured and recorded. Only the part of the reaction that can be felt, which is the induration, is measured, even if there is soft swelling or redness at the site. Keep in mind there might not be an induration. In order to feel the induration properly, keep your fingernails short enough so that they don't protrude beyond the finger. The induration is not always visible, so you must rely on palpation with your fingertips to discover if there's induration at the site. With your fingers together, touch the area lightly with the pads of your fingertips. Using a light, gentle motion, sweep the fingertips over the surface of the forearm in a 2-inch diameter in all four directions to locate the margins or edges of induration. A positive TB test result does not confirm that the patient has active Tuberculosis (Tb Disease). The patient may have a positive Tb test reaction if s/he has: been exposed to Mycobacterium tuberculosis Had tuberculosis before and has been cured (successfully treated) Been immunized for tuberculosis with the BCG vaccine Tuberculosis False-positive reactions to the tuberculosis skin test typically occur because of: an infection with nontuberculous mycobacteria: An infection with nontuberculous mycobacteria is an infection caused by mycobacteria other than M. tuberculosis. BCG vaccination: The BCG vaccination is a vaccine used for preventing tuberculosis in many countries. However, it is not used in the United States because of concerns with its effectiveness Booster Phenomenon: The "Booster Phenomenon" in Purified Protein Derivative (PPD) tuberculosis testing occurs when a person's immune system has "forgotten" about an infection by Mycobacterium tuberculosis until years later when the person is tested again for tuberculosis; the PPD test "reminds" the immune system about the infection. Although the initial PPD test was negative, a second PPD test, performed years later, may "boost" the immune system's ability to react to the tuberculin; therefore, there is no way of knowing if the positive result was due to a recent tuberculosis infection or due to the booster phenomenon. If you will be undergoing regular Tb testing (e.g. annual Tb testing for a job), the best way to avoid this from happening is to perform a two-step Tb test. There are several reasons why a false-negative Tuberculosis skin test occurs: Anergy: When a person's immune system is weakened by a disease, such as HIV, cancer or even severe Tuberculosis itself, the body may not be able to react to the Tubercuolsis skin test. Recent Tuberculosis Infection: If a person has been infected within the past ten weeks, the body's immune system may not be able to react to the tuberculin. This is because the Tuberculosis skin test cannot detect a Tuberculosis skin infection for several weeks after infection. Age: Babies less than 6 months old may have false-negative Tuberculosis skin test results because their immune systems are not fully developed yet. Test Administration: A false result may occur if the Tuberculosis skin test is not administered correctly. Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons,

Chest X-ray To confirm positive PPD When PPD cannot be done Cavitation
Caseation Chest x-ray: this is done to confirm any positive skin test. Anyone with a positive skin test must always have a chest x-ray – they may have a severe adverse reaction if skin tested again. The radiologist is looking for cavitation and caseation on the x-ray. These are areas of necrosis indicating an active infection. Cavitation: cavities in lung tissue with mycobacterium tuberculi infection Caseation: cheesy-appearing necrotic tissue

Sputum Testing First morning specimen 3 days Acid-fast Bacilli
Tb C & S Sputum is first tested for acid-fast bacillus. If this is positive, further testing is indicated. A sputum culture for M. tuberculosis was the definitive test allowing diagnosis within 1-3 weeks. Collect the first morning sputum specimen before eating Send to the lab quickly to preserve organisms Send a specimen every day for 3 days to confirm diagnosis Acid-Fast Bacilli Smear: (AFB) This is a rapid screening test to confirm pulmonary Tb or to monitor treatment. A positive AFB indicated high suspicion for tuberculosis, but other organisms can cause positive AFB smears. Tuberculosis Culture This test will confirm pulmonary Tb diagnosis within hours. Antibiotic sensitivity testing is then performed on the specimen to identify the most effective anti-mycobacterial drugs. Cultures are repeated after 3 months of therapy and should then be negative. Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons,

How is it treated? Initial Therapy may include: After two months:
Isoniazid (INH) Rifampin Pyrazinamide (PZA) Ethambutol or Streptomycin After two months: Isoniazid “The primary goals of antituberculosis chemotherapy are to kill tubercle bacilli rapidly, prevent the emergence of drug resistance, and eliminate persistent bacilli from the host's tissues to prevent relapse. To accomplish these goals, multiple anti-tuberculosis drugs must be taken for a sufficiently long time. “CDC guidelines for anti-tubercular drugs include first-line and second-line drugs. Most patients are treated successfully with only first-line drugs, usually two or three in combination. If the patient has a bad reaction to a drug or his infection is resistant, the second-line drugs will be prescribed.”

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

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

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

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

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

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.

Transplant Recipients
Immune suppressed Donor organ with latent TB Reactivate pt’s latent infection Diagnosis difficult Decreased PPD reaction Prophylaxis with 300 mg of INH for six months significantly decreases the risk in high-risk individuals. As a result of the use of immunosuppressive agents, transplant recipients are not only predisposed to primary tuberculous infections, but they are also uniquely at risk for reactivation of latent infection acquired prior to transplantation or transmitted via the donor organ. The diagnosis of pulmonary tuberculosis can be even more elusive in the setting of lung transplantation where other pulmonary complications can make diagnosis difficult.

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 The incidence of tuberculosis in HIV positive individuals is 41 times higher than the general population. With this increased risk and the increasing prevalence of Tb, the importance of aggressive prevention measures can not be stressed enough. Because anergy increases as the CD4 count declines, PPD testing early in the course of HIV is essential. Control antigens should always be used to detect anergy. Some researchers are now advocating the use of isoniazid (INH) prophylaxis in anergic individuals with low CD4 counts, especially in areas where the prevalence of tb is high such as New York and Miami. Prophylaxis with 300 mg of INH for six months significantly decreases the risk in high-risk individuals. However, the incidence increases postprophylaxis. Therefore, reprophylaxis after 24 months should be considered. Prophylaxis with 300 mg of INH for six months significantly decreases the risk in high-risk individuals. However, the incidence increases postprophylaxis. Therefore, reprophylaxis after 24 months should be considered

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

Drug Resistance Multi-drug resistant TB (MDRTB) Second-line drugs
Increased time of treatment Multi-drug Resistant Tuberculosis Failure of sputum culture conversion to normal within 3 months raises the possibility that drug-resistant organisms are present. Patient noncompliance with the medication regimen can cause both failure of treatment and emergence of resistant bacilli. Treatment for drug-resistant TB is guided by drug susceptibility studies. Typically, some second-line drugs need to be substituted for some of the first-line drugs.

Non-compliance Failure of treatment Resistant bacilli
Intermittent dosing? Arrest the patient? Non-Compliance: Nonadherence to the antituberculosis treatment regimen is well known to be the most common cause of treatment failure, relapse, and the emergence of drug resistance. Administration of therapy on an intermittent basis, as opposed to daily dosing, facilitates supervision of therapy, thereby improving the outcome.

Patient/Family Teaching
Prevention Phone contact Test entire family Use precautions Follow-up sputum cultures Diet Patient Teaching Since most tuberculosis therapy occurs outside the hospital, it is the nurse’s responsibility to teach the patient about his drug therapy. Use multiple formats including pamphlets and other written information for the patient to read. This information is available from the American Lung Association All members of the family need to be tested for Tb. The patient must use precautions to prevent spreading the Tb: cover the mouth & nose when coughing or sneezing, use plastic bags for tissues, wear a mask in crowds until cultures become negative. Follow-up sputum cultures are needed every 2-4 weeks. Once those become negative, the patient can return to work but must avoid any inhalants that could injure his lungs. Eat a well-balanced diet rich in iron, protein and vitamin C for healing.

Acute Respiratory Failure
Dyspnea, tachycardia Progressive respiratory distress Breath sounds Mental status Clinical Manifestations First, dyspnea and tachycardia Progressive respiratory distress – tachypnea, intercostal retractions, use of accessory muscles, grunting respirations, pallor, cyanosis. The cyanosis may not improve with oxygen therapy. Breath sounds: clear at first, later crackles and rhonchi as fluid moves into alveoli Mental status: due to hypoxemia, become agitated, confused, lethargic

ARDS Aspiration Sepsis Drowning Trauma
Acute Respiratory Distress Syndrome (ARDS) ARDS is a severe form and sub-category of acute respiratory failure. It usually occurs after a sudden catastrophic event in people with no previous lung problems. It has also been called non-cardiogenic pulmonary edema, shock lung, wet lung. Types of injuries that can lead to ARDS include: Aspiration of gastric contents Sepsis Drowning Trauma The causes are very different, but once ARDS begins, the progression is similar: Damaged alveolar and capillary walls become more permeable. Plasma proteins and red blood cells leak out from the capillaries into the interstitial spaces As the pressure rises, the fluid is pushed into the alveoli Hypoxemia becomes unresponsive even with supplemental oxygen The protein-rich fluid in the alveoli damages the cells that produce surfactant Fibrin and cell debris combine to form a hyaline membrane that lines the inside of the alveoli. CO2 cannot diffuse across the hyaline membrane

Diagnostic Tests pO2 < 60 mmHg pCO2 > 50 mmHg
O2 saturation < 90% Chest x-ray – increasing infiltrates to “white out” Diagnostic Tests Critical values (patients without COPD) are: pO2 less than 60 mmHg pCO2 greater than 50 mmHg Oxygen saturation less than 90% Chest x-ray will show increasing infiltrates leading to “white out”, a diffuse hazy appearance like ground glass, through all lung fields

Collaborative Management
Oxygen Mechanical ventilation Collaborative Management Oxygen: to keep the saturation above 90%, ABG pO2 above 60 mmHg NOTE: Watch for oxygen toxicity: related to concentration of oxygen delivered and the duration of therapy, over 48 hours of greater than 50% oxygen. Mechanical Ventilation: This is the mainstay of management for the patient with ARDS. The FiO2 (% oxygen delivered) is set at the lowest level to maintain a pO2 above 60 mmHg and oxygen saturation above 90%. Mechanical ventilation does not cure ARDS, it just provides respiratory support while the underlying problem is identified and treated. Photo Source: Wikimedia Commons / Public Domain image,

Intubation Intubation tray Patient position Bed position Suction
Oxygen flow meter Verify ETT placement Secure ETT Assist with intubation of endotracheal tube (ETT) Intubation tray Position patient supine up to head of bed, remove headboard Pull bed out from wall Set up suction and oxygen flow meter Verify placement of endotracheal tube in trachea above the carina Breath sounds bilaterally Chest on both sides rises and falls with inspiration Always get a chest x-ray to verify placement Secure tube to upper lip and jaw with cloth tape Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons,

Mechanical Ventilation
FiO2 100% Tidal volume (Vt) 6-7 ml/kg Rate 20-28/minute Typical initial ventilator settings: FiO2 100%, tidal volume (Vt ) 6-7 ml/kg, rate breaths per minute

Ventilators Negative pressure Pressure cycled Time cycled
Volume cycled Types of Ventilators: Negative pressure: iron lung, Curass rarely used in the acute care setting. The patient is in an airtight apparatus. It is noninvasive, wraps around the chest wall. During inspiration, the chest is drawn outward and air is pulled into the lungs. Positive pressure: Pressure cycled: not often used. The ventilator pushes air into the lungs until a pre-set airway pressure is reached. The tidal volume and the inspiration time varies. Time cycled: usually used in pediatrics and neonatal patients. Pushes air into the lungs for a preset time increasing the respiratory rate but lowering the tidal volume and pressure used. Volume cycled: most commonly used in adults. Pushes air into the lungs until a pre-set volume is delivered. There is a pressure limit set to prevent excessive pressure in the lungs.

Modes of Ventilation CMV SIMV PSV PEEP CPAP
Modes of ventilation are the different ways in which the ventilator can help the patient to breathe. The ventilator can be programmed to do all the work of breathing or it can be programmed to assist the patient’s efforts to breathe. CMV – continuous mandatory ventilation (formerly assist control) Delivers a mandatory breath with every breath. Each breath will reach a mandatory V whether the patient or the ventilator initiates the breath. Provides the most complete support. Respiratory muscles can rest. SIMV – synchronized intermittent mandatory ventilation. Allows the patient to take spontaneous breaths at his own rate and tidal volume in between ventilator breaths. Ventilator breaths will be synchronized with patient’s own breaths. This mode can also be set up with a pressure limit or a volume limit. PSV – pressure support ventilation –weaning mode (sometimes called flow-by) Patient must be breathing spontaneously, either CPAP or SIMV. Once the pt starts to inspire, the vent delivers a flow of gas. Pressure modes are becoming more popular because the gas flow pattern is decelerating which allows for better gas exchange. PEEP: Positive End Expiratory Pressure. Patient must be receiving breaths from ventilator. Positive pressure at end-expiration. Prevents alveolar collapse at end-expiration CPAP – continuous positive airway pressure. Patient must be breathing spontaneously, no ventilator breaths. Positive pressure is maintained in the airways throughout the respiratory cycle. CPAP helps the alveoli open during inspiration and prevents collapse during expiration.

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) Respiratory causes: hypoventilation from over-sedation, tired, cannot tolerate CPAP or low SIMV rate Treatment: decrease sedation, increase respiratory rate and/or tidal volume

Alkalosis High pH = alkalosis
High pH + high HCO3 = metabolic alkalosis High pH + low CO2 = respiratory alkalosis Respiratory causes: hyperventilation with high tidal volumes on CMV (Assist-Control) Treatment: reassurance, sedation, SIMV

Ventilator Alarms High pressure Low inspiratory pressure
High respiratory rate Low exhaled volume Ventilator Alarms: Common Causes and Corrective Actions High Pressure: Coughing due to secretions in upper airway (most common), coughing due to irritation, mucus plugging ETT, pinched/kinked ETT, pinched/kinked ventilator tubing, decreased lung compliance (worsening disease) Suction patient, Position/stabilize tubing, Remove & replace ETT if condition is deteriorating, Verify all tubing is patent Low Inspiratory Pressure: Tubing is disconnected from ETT or ventilator. Inspiratory demand is higher than machine can deliver Reconnect tubing, Increase air flow rate or sensitivity High Respiratory Rate: Tachypnea due to anxiety, pain, hypoxia, acidosis IV Sedation, IV pain relief, Evaluate cause of hypoxia and increase FiO2, Find cause of acidosis and correct Low Exhaled Volume: Apnea, Tubing disconnect Evaluate cause of apnea, Reconnect tubing; When in doubt, remove the patient from the ventilator and "bag" with a manual resuscitator (AMBU bag) Call for help.

Monitor Physiological Response
Breath sounds Breathing pattern Skin color Secretions Oxygen saturation ABGs, daily chest x-ray Nursing Management Monitor patient’s physiological response: Breath sounds Breathing pattern (depth, rate, use of accessory muscles) Skin color Secretions Oxygen saturation ABGs as ordered: at least q shift and q change in settings Daily chest x-ray

Monitor Psychological Response
Anxiety Communication Anticipate questions/needs Monitor patient’s psychological response: Anxiety: may need sedation Communication: provide alternatives to verbal Anticipate questions/needs

Manage the Ventilator Correct settings? Alarms on? Maintain humidity
Monitor inline temperature ETT placement, cuff Tubing adjustments Manage the ventilator: Correct settings: check with vital signs, after physician rounds, family visits Alarms on: most common is high pressure from sputum in airway Maintain humidity with water in reservoir Monitor inline temperature via probe: maintain warm inspired air ETT: measure placement at teeth/gums q shift, q turn; check cuff inflation Tubing adjustments: remove water condensation in tubing, keep adequate length when turning patient, angle of tubing to ETT should not gag patient

Prevent Complications
Barotrauma Stress ulcers Infection: Ventilator-assisted pneumonia (VAP) Ventilator dependence Pressure necrosis Prevent complications: Barotrauma: pneumothorax from high pressures Gastrointestinal ulcers from stress response: anti-acid agents Infection: prevent Ventilator Acquired Pneumonia (VAP) with mouth care using chlorhexidine (Peridex) q 2-4 hours; suction using aseptic technique Ventilator dependence: wean as soon as possible Pressure necrosis from ETT: change ETT position q 24 hours from one side of mouth to the other

Weaning from Ventilator
Awake, rested Muscle strength Heart rhythm Breath sounds ABGs Pulmonary function tests Weaning from the Ventilator Readiness to Wean: Patient is awake and/or rested Good muscle strength intercostals, diaphragm No lethal dysrhythmias Clear or clearing breath sounds and chest x-ray pO2 above 60 mmHg with FiO2 under 40% Negative Inspiratory Force (NIV): Strength of inspiration (done by respiratory therapist) Forced Expiratory Volume in one second (FEV-1): maximum amount of air forcefully exhaled in the first second (done by respiratory therapist) ABGs normal or fully compensated (pH in normal limits)

Weaning Methods SIMV CPAP Pressure Support Weaning Methods:
SIMV: Set rate of mandatory breaths is gradually decreased, shifting the work of breathing back to the patient. Allows gradual transition from mechanical to spontaneous ventilation. Additional work of breathing is required to pull air through small ETT, weaning rate may be slower. CPAP: After SIMV rate lowered, this mode shifts all work of breathing to patient keeps ETT in place if patient gets tired. May take several days, increased work to breath through tube Pressure Support: Used with SIMV and CPAP to make inspiration easier. Amount of pressure is gradually decreased. Decreased work load of spontaneous breathing. Tidal volumes may vary

Extubation Explain procedure Prepare: nasal cannula, towel, Chux
Hyper-oxygenate Suction Deflate pilot balloon Pull tube No talking! Extubation: Explain procedure to patient Prepare nasal cannula (oxygen mask usually not needed) Place towel or Chux on patient’s chest Hyper-oxygenate with AMBU or set FiO2 to 100% for five minutes Suction ETT clear with cuff inflated and deflated Deflate pilot balloon Pull tube in one smooth motion, place on towel Place nasal cannula Warn patient not to speak for first 30 minutes to avoid airway irritation, edema Monitor oxygen saturation, cardiac rhythm, work of breathing closely

Pneumothorax Signs and Symptoms Pleuritic chest pain SOB Tachypnea
Tachycardia Asymmetrical chest wall movement Decreased breath sounds Cyanosis Pneumothorax is the influx of air into the pleural space resulting in rising intrathoracic pressure and lung collapse. A tension pneumothorax occurs when enough air enters the pleural space and the air is not able to escape. This causes compression of the affected lung, major blood vessels and the heart. A hemothorax occurs when traumatic injury of the blood vessels causes blood to escape into the chest cavity. Photo Source: Colorado State University,

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

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

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

Nursing Care of the Chest Tube
Maintain closed system Assess, kinks, water seal, drainage Maintain patency occlusive dressing, tubing, suction Nursing Management Maintain a closed system Assess the chest tube and system at least every 2 hours Check tubes for kinks or loops Check water seal frequently Measure drainage Assess the water level in the suction control chamber Maintain patency of drainage system Place sterile occlusive dressing over insertion site Place drainage tubing to prevent tension on insertion Eliminate any dependent loops Keep drainage system upright and lower than chest Maintain continuous suction as ordered with minimal bubbling If connection is broken at any point, re-connect immediately, ask patient to take several deep breaths Photo Source: Wikimedia Commons, GNU license,

Nursing Care of the Patient
Oxygen Vital signs Chest wall movement, trachea, neck veins Position Watch for distress Nursing care of the patient includes: 1. Administer oxygen 2. Assess vital signs 3. Assess chest wall movement, trachea, and neck veins 4. Position pt in fowlers or high fowlers 5. Change positions frequently 6. Watch for signs of recurrent pneumo/hemothorax

Photo Source: National Heart, Lung and Blood Institute (NHLBI),
Pulmonary Embolus DVT Air Fat Catheter Pulmonary Embolus (PE) is a blockage of the pulmonary vessels usually caused by a clot that has traveled from the deep venous system of the legs or pelvis. This thrombus becomes an embolus that travels via the venous system to the right heart and becomes lodged in the pulmonary artery. This causes local necrosis and the affected lung area is ventilated but not perfused. This leads to decreased oxygen to the arterial system and hypoxia. Etiology/Risk Factors Deep venous thrombosis: congestive heart failure, postoperative, inactivity, dehydration Air embolus: central line, dialysis, placenta Fat embolus: long bone or pelvic fractures Catheter: cut central venous or peripheral intravenous catheter Photo Source: National Heart, Lung and Blood Institute (NHLBI),

Signs/Symptoms Classic triad
Common: dyspnea, tachypnea, pleuritic pain Pleuritic chest pain + dyspnea + predisposing factor Signs and Symptoms Classic triad: hemoptysis, dyspnea, pleuritic chest pain is actually rare. More common: Some kind of dyspnea, tachypnea or pleuritic chest pain occurs in 97% of patients with dyspnea the most frequent complaint Always suspect PE if patient has pleuritic chest pain + dyspnea + predisposing factor

Diagnosis ABGs Chest x-ray V/Q scan Spiral CT Pulmonary angiogram
Lab and Diagnostic Tests ABGs show hypoxemia, hypocapnia, respiratory alkalosis Chest x-ray shows atelectasis V/Q (ventilation-perfusion) scan shows a mismatch between ventilation and perfusion Spiral computed tomography (CT) Pulmonary angiography is most accurate but risky VQ Scan: Air and Blood flow to the lungs. There are two parts to a lung scan, ventilation and perfusion. For the ventilation portion of the scan, the patient will breathe through a mask for approximately five minutes. Images will be taken of the lungs during this time. These images show the airflow of the lungs. The patient then receives an IV injection of Tc99mMAA and eight images are taken of the lungs at various angles showing the pattern of the blood flow to the lungs. These pictures allow the physician to look for blood clots in the lung. The total time for the exam is approximately forty-five minutes Photo Source: CDC/Wikimedia Commons,

Prevention Early ambulation Hydration Anti-embolic stockings
Sequential pumps Avoid lower extremity punctures Aspirate clotted IVs SQ heparin or LMWH Prevention Prevent PE in high risk patients: early ambulation, hydration, antiembolic stockings, sequential pumps, avoid intravenous lines or blood sampling in lower extremities, watch for phlebitis, change intravenous sites, aspirate clotted IVs, subcutaneous heparin or low-molecular weight heparin such as enoxaparin (Lovenox)

Emergency Measures Oxygen HOB up Support Stat ABGs, chest x-ray
Prepare for code blue Emergency Measures Oxygen Elevate head of bed Emotional support - don’t leave alone! Stat ABGs, chest x-ray Prepare to intubate

Collaborative Management
Continue oxygen Bed rest Heparin drip  Coumadin Thrombolytics? Embolectomy, umbrella filter Collaborative Management Non-surgical: Oxygen therapy Anticoagulants to prevent further clots: intravenous heparin infusion followed by warfarin (Coumadin) as patient stabilizes thrombolytics: extremely dangerous, used only for massive PE with hemodynamic instability Surgical: Embolectomy Umbrella filter will prevent further clots Nursing Management Monitor partial thromboplastin time (PTT) and prothrombin time (PT) as applicable Monitor for bleeding Keep patient on bed rest

Teach Bleeding precautions Avoid immobility Avoid dehydration
Avoid aspirin products Teach precautions: no shaving with blades, brush with soft bristles, no floss, use stool softeners, avoid immobility and dehydration, avoid aspirin products

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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