1. Respiratory Part 2 Medical Surgical Nursing

2. Influenza AKA – Flu Highly contagious Pathogen – Viral Epidemic – Rapid and extensive spreading infection and affecting many individuals in an area or a population at the same time

3. FYI Influenza & its complications (primarily bacterial pneumonia) are the 8 th leading cause of death in the US. @60,000 year

4. H1N1 Newly identified stain  Pandemic – (World-wide epidemic)

5. Mode of transmission Airborne droplet Direct contact

6. Influenza Statistics Incubation period – Short Onset – Rapid Duration – Up to a week

7. Influenza: S&S (local) Runny nose Sore throat Cough – Dry – Non-productive  productive – Substernal burning

8. Influenza: S&S (systemic) Chills & fever H/A Malaise Muscle aches Fatigue & weakness

9. Older adults Higher risk of – Complications Pneumonia Death

10. Why are older adult more susceptible to complications of influenza? Cilia –– Chest muscle strength –– Chest wall – Stiffer Cough – Less effective

11. Assessment S&S Vital Signs

12. IDT “Most URI’s are self-limiting”

13. IDT Self-care Symptomatic relief Prevent complications Prevent spread

14. Dx test Throat swab – R/O streptococci CBC – WBC normal Vial – WBC increased Bacterial Chest x-ray – R/O pneumonia

15. Flu Vaccine: Is it effective? Polyvalent influenza virus vaccine 85% effective

16. Flu Vaccine: Who should get it? Age >50 years Nursing home residents Pg women Chronically ill Immunosuppressed Resp. conditions Healthcare workers Fam. members of those at risk

17. Flu Vaccine: Who should not get it? Allergic to eggs

18. Small Group Questions 1.What pathogen is assoc. with flu? 2.Identify 5 S&S of the flu 3.What type of isolation would you use for a client with the flu 4.Mary asks you if she should get the flu vaccine, how do you respond? 5.What priority nursing diagnosis would you give for a person with the flu?

19. Which of the following nursing interventions is appropriate after a client has had a bronchoscopy? A.Report abnormal lab values B.Lay flat for 8 hours with a sand bag to the puncture site C.NPO until gag reflex returns D.Push fluids

20. Tuberculosis AKA – TB

21. Tuberculosis - FYI Causes more death than any other disease. 2 billion world wide, 15 million in the US

22. Tuberculosis - FYI When treated, about 90% of those with active TB survive!

23. Tuberculosis Pathophysiology – Mycrobacterium tuberculosis – Tubercle bacillus

24. Tuberculosis Pathophysiology Mode of transmission – Air-borne  alveoli Multiplies in alveoli

25. Tuberculosis Immune response phase – Macrophages attack TB – TB has waxy cell wall that protects it from macrophages – Immune system surrounds the infected macrophages – Forms a Lesion – Called a Tubercle

26. Tuberculosis Dormant phase – Contagious? No – Symptomatic? No – PPD? positive – chest x-ray? Negative

27. Tuberculosis Active phase – If an infected person has a weakened immune system,  – the TB escapes and infects the body

28. Tuberculosis 5-10% become active Only contagious when active Primarily affect lungs but… – Kidneys – Liver – Brain – Bone

29. Tuberculosis Etiology Assoc. w/ – Poverty – Malnutrition – Overcrowding – Substandard housing – Inadequate health care Elderly HIV Prison

30. Tuberculosis: S&S (active phase) NOC sweats Low grade fever Wt loss Chronic productive cough – Rust colored & thick Hemoptysis SOB

31. Tuberculosis: Dx test PPD – Mantoux skin test – > 10mm in diameter – induration – Indicates: Latent TB – Read 48-72 after – Intradermal: 15-degrees

32. Tuberculosis Diagnostic tests – X-ray – Symptoms – Acid Fast Bacillus

33. Tuberculosis: Tx / Rx INH – isonicotinyl hydrazine – Isoniazid – Toxic to the liver Rifampin – Turns urine red

34. Tuberculosis: Prevention Clean well ventilated living areas Resp. isolation – Negative pressure room If exposed take – INH

35. Tuberculosis: complication Malnutrition S/E of Rx treatment Multi-drug resistance Spread of TB infection

36. Small Group Questions 1.What type of pathogen is TB? 2.What is the mode of transmission? 3.What are the classic S&S of TB ? 4.How to administer and read a PPD? 5.If a pt is PPD +, what does that mean?

37. Small Group Questions 6.What is the standard screening method of TB? 7.That medications are used to treat TB, what are their side effects? 8.Where in the US is TB most prevalent? Why?

38. COPD - overview COPD? – Chronic Obstructive Pulmonary Disease – Broad classifications of diseases

39. COPD Characteristics Airflow limitation Irreversible Dyspnea on exertion Progressive Abn. inflammatory response of the lungs to noxious particles or gases

40. Pathophysiology Noxious particles of gas  Inflammatory response  Narrowing of airway

41. Pathophysiology Inflammation  Thickening of the wall of the pulmonary capillaries

42. COPD Includes – Emphysema – Chronic bronchitis Does not include – Asthma

43. COPD - FYI COPD 4th leading cause of death in the US 12 th leading cause of disability Death from COPD is on the rise while death from heart disease is going down

44. COPD: Risk Factors Smoking Passive smoking Occupational exposure Air pollution

45. COPD risk factors #1 – Smoking Why is smoking so bad?? – ↓ phagocytes – ↓ cilia function – ↑ mucus production

46. Chronic Bronchitis Disease of the airway Definition: – cough + sputum production – > 3 months

47. Chronic Bronchitis Pathophysiology Pollutant irritates airway  Inflammation  secretion of mucus  Bronchial walls thicken  – Lumen narrows – plugs

48. Chronic Bronchitis Alveoli/bronchioles become damaged ↑ susceptibility to LRI

49. Emphysema: Pathophysiology Affects alveolar membrane – Destruction of alveolar wall – Loss of elastic recoil – Over distended alveoli

50. Emphysema Pathophysiology Over distended alveoli  – Damage to adjacent pulmonary capillaries – Impaired passive expiration

51. Emphysema Damaged pulmonary capillary bed –  pulmonary pressure  –  work load for right ventricle  – Right side heart failure

52. Emphysema Nursing Diagnosis – Impaired gas exchange

53. COPD Compare and contrast Chronic Bronchitis is a disease of the ___________? – Airway Emphysema is a disease affecting the ___________? – Alveoli

54. C.O.P.D. Risk factors, S&S, treatment, Dx, Rx - same for Chronic Bronchitis & Emphysema

55. C.O.P.D. Clinical Manifestation (primary) 1.Cough 2.Sputum production 3.Dyspnea on exertion (Secondary) Wt. loss Resp. infections Barrel chest

56. C.O.P.D. Nrs. Assessment Risk factors Past Hx / Family Hx Pattern of development Presence of comobidities Current Tx Impact

57. Dx tests ABG’s – Baseline PaO 2 Rule out other diseases – CT scan – X-ray

58. C.O.P.D. Medical Management Risk reduction – Smoking cessation! (The only thing that slows down the progression of the disease!)

59. C.O.P.D. Rx. therapy Primary Bronchodilators Corticosteriods Secondary Antibiotics Mucolytic agents Anti-tussive agents

60. Bronchodilators Action: –  the size of the lumen – Relieve bronchospasms – Reduce airway obstruction –↑ ventilation

61. Bronchodilators Examples – Albuterol (Proventil, Ventolin, Volmax) – Metaproterenol (Alupent) – Ipratropium bromide (Atrovent) – Theophylline (Theo-Dur)*

62. Glucocorticoids Action – Potent anti-inflammatory agent

63. Corticsteriods S/E – Na+ & H20 retention – Never D/C abruptly

64. Glucocorticoids Examples – Prednisone – Methyprednisone – Beclovent

65. C.O.P.D. Medical Management Treatment – O2 2 L/min – Pulmonary rehab Breathing exercises Pulmonary hygiene

66. Small Group Questions 1.What 2 diseases are assoc. with COPD? 2.Describe the pathophysiology of COPD. 3.What effect does smoking have on the resp. system? 4.Differentiate between chronic bronchitis and emphysema. 5.What are the 3 main S&S of COPD? 6.What 2 classifications of meds are used to treat clients with COPD (what are their actions)?

67. Pneumonia Pathophysiology An inflammatory process in which there is consolidation – In the alveolar spaces. Gas exchange cannot take place in consolidated area

68. Pneumonia Causative agents Viral pneumonia Bacterial Pneumonia – Streptococcus pneumoniae – Pneumocystis Pneumonia Fungal pneumonia Radiation pneumonia Chemical pneumonitis Aspiration pneumonia Hypostatis pneumonia

69. Pneumonia FYI Most common cause of death from infectious agents 66,000 deaths / year $$$

70. Pneumonia: Progression of events Inflammation   Exudate   movement of O2 and CO2  WBC migrate into the alveoli  Fill air-containing spaces   ventilation –  Oxygen saturation

71. Pneumonia: Risk factors Immunosuppressant Smoking Prolonged immobility Depressed cough reflex NPO ETOH intoxication Gen. anesthetic or opiod Advanced age

72. Pneumonia: S&S TYPICAL Onset – Acute Shaking Chills Fever Cough – Productive Sputum – Rust-colored – Purulent

73. Pneumonia: S&S TYPICAL Chest pain – Sharp – Localized Breath sounds – Diminished – Crackles – Respiratory distress

74. Pneumonia: S&S ATYPICAL “Walking pneumonia” Milder symptoms Fever H/A Muscle aches Malaise

75. Pneumonia: S&S ATYPICAL Cough – Hacking – Non-productive Self limited

76. S&S Elderly General deterioration Weak Abd. Symptoms – Anorexia Confusion Tachycardia Tachypnea Do Not C/O – Cough – Pain – Fever – Sputum

77. Pneumonia: Dx Sputum C&S CBC / WBC –– Bacteria –– Viral ABG’s Pulse oximetry Chest x-ray

78. Pneumonia: Medications Primary – Antibiotics – Bronchodilators – Expectorant

79. Antibiotics Action – Attacks pathogens Nursing consideration – Educate to take all – Not contagious after 24 hours on meds

80. Bronchodilators Dilate bronchi Reduce bronchospasms Improve ventilation

81. Expectorants Break up mucus –  viscosity Liquefies mucus  Easier to expectorate Take with lots of water!

82. Pneumonia: Medications Secondary – Antibiotics – Antipyretic – Analgesic

83. Pneumonia: Nursing Fluids – 2,500 – 3,000 mL/day – Humidifier Chest physiotherapy – TCDB – I.S. Assess respiratory status Position – HOB Rest

84. Pneumonia – Nursing Interventions O2 per order Maintaining nutrition – Gatorade – Ensure Promoting the patients knowledge

85. Pneumonia Prevention Vaccine – Pneumonia – Flu Treat URI Avoid irritants

86. Pneumonia: Small Group Questions 1.Describe the pathophysiology of pneumonia. 2.What is the difference btw typical and atypical pneumonia? 3.What causes pneumocystis carinii? 4.What lab values are associated with bacterial pneumonia? / viral pneumonia?

87. Pneumonia: Small Group Questions 5. What is Nosocomial pneumonia 6. Identify 5 risk factors for developing pneumonia 7. What medications might be administered to treat a pt. with pneumonia? 8. What nursing education would you give to a patient with pneumonia? 9. What are the gerontological considerations of caring for the elderly in regards to pneumonia?

88. Lung Cancer Pathophysiology Carcinogen binds to the DNA and changes it  Abnormal growth Usually develops on the wall of the bronchial tree

89. FYI Lung Cancer is the number one cancer killer in the US

90. Lung Cancer Etiology/Contributing factors #1 – Tobacco Smoke (85%) – Second hand smoke Carcinogens – Asbestos – Uranium – Arsenic – Nickel – Iron oxide – Radon – Coal dust

91. Lung Cancer Clinical manifestations: early Insidious and asymptomatic until late stages

92. FYI – 70% of lung CA have metastasized by the time of diagnosis

93. Lung Cancer S&S: Early Objective symptoms – #1: Cough – #2 Repeated respiratory tract infection – Wheezing – Dyspnea

94. Lung Cancer S&S: Late Hemoptysis Chest pain Wt loss Anemia Anorexia

95. Lung Cancer Dx exams/procedures X-ray CT scan Biopsy via Bronchoscopy – cytology

96. Lung Cancer Treatment Surgery – Removal Chemotherapy – Metastasis Radiation – To shrink or reduce symptoms

97. Lung CA Priority Nrs Dx – Ineffective breathing – Ineffective Airway clearance – Ineffective Gas exchange

98. Assessment Resp assessment Smoking hx Lab values S&S of complications

99. Assessment S&S of complications – Edema – H/A – Dizziness – Vision changes – Difficulty breathing – C/O pain

100. Interventions Assess q4hrs HOB Pulmonary hygiene – TCDB – IS O2 per order Suction PRN Emotional support

101. Secondary Nrs Dx Activity intolerance Pain Grieving

102. Activity intolerance Document response to activity – Pulse – Resp. status – Fatigue Planned rest periods Increase activities gradually Enc to remain as active as possible Allow fam. To provide assist PRN Keep frequently used objects nearby

103. Pain Assess pain Administer analgesics PRN

104. PAIN & CANCER “For cancer pain, maintain a continuous medication schedule using opiates, NSAIDs and other drugs as ordered” – Addiction is not a concern for the terminal cancer client; adequate pain relief that does not allow “breakthrough” pain is vital.

105. Pain Assess pain Administer analgesics PRN Alternative pain relief – Massage – Positioning – Distraction – Relaxation techniques

106. Pain Provide diversion activities – TV – Reading – Social events Allow family to remain

107. Grieving Spend time with client & family Answer questions honestly Enc. Pt to express feelings (fear, anxiety, concerns) Assist to understand the grief process

108. Grieving Enc other support systems – Spiritual – Social groups – Social services – Hospice Discuss advanced directives – Living will

109. Lung Cancer Preventative measures Stop smoking

110. Small Group Questions What is the number one carcinogen of lung cancer? What are the early S&S of lung cancer? Who is Lung Cancer diagnosed? How is lung cancer usually treated? What is one priority nursing diagnosis for a client with lung cancer? Identify 3 nursing interventions for this diagnosis