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Acute and Chronic Respiratory Disorders

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1 Acute and Chronic Respiratory Disorders
Chapter 30 &31 Acute and Chronic Respiratory Disorders

2 VENTILATION Commonly understood to mean movement of air
Accomplished by the pulmonary system, consisting of the airways and lungs, the blood vessels perfusing them, the muscles of the thorax and abdomen, and the innervation of these structures

the movement of atmospheric air into and out of the lungs depends on open airways and contractions of muscles to create pressure gradients for air flow ventilation is the critical first step in the complex process of respiration

4 Primary functions of the respiratory system
provides oxygen for metabolism in the tissues removes carbon dioxide, the waste product of metabolism

5 Secondary functions of the respiratory system
facilitates sense of smell produces speech maintains acid-base balance maintains body water levels maintains heat balance



8 BREATHING normally approx 500 ml of air is inhaled and exhaled
APNEA-temp interruption in normal breathing, no air movement occurs dyspnea-difficulty breathing orthopnea-difficulty breathing while in a lying position See Table 30-1 for types of breathing patterns

9 MEDULLA respiratory center of the brain located just above the spinal cord in the brain stem stimulated by changing levels of CO2 & Oxygen Chemoreceptors in the aorta and carotid artery monitor the PH and the amount of carbon dioxide and oxygen in the blood stream.


11 NOSE Humidifies, warms, and filters inspired air

12 SINUSES air-filled cavities within the hollow bones that surround the nasal passages provide resonance during speech

13 PHARYNX (Throat) located behind the oral and nasal cavities
divided into the nasopharynx, oropharynx, laryngopharynx passageway for both the respiratory and digestive tracts

14 LARYNX (Voice Box) located above the trachea and just below the pharynx at the root of the tongue contains two pairs of vocal cords, the false and true cords opening between true vocal cords is the glottis the glottis plays an important role in coughing coughing is the most fundamental defense mechanism of the lungs

15 EPIGLOTTIS leaf-shaped elastic structure that is attached alone one end to the top of the larynx it prevents food from entering the tracheobronchial tree by closing over the glottis during swallowing


17 TRACHEA (Windpipe) located in front of the esophagus
branches into the right and left mainstem bronchi at the carina passageway for air to reach the lungs

18 MAINSTEM BRONCHI begins at the carina
a ridgelike structure between the openings of the right and left bronchus the right bronchus is slightly wider, shorter, and more vertical than the left bronchus most foreign bodies from the trachea usually enter the right bronchus the mainstem bronchi divides into five secondary or lobar bronchi that enter each of the five lobes of the lung

19 MAINSTEM BRONCHI the bronchi are lined with cilia, which propel mucus up and away from the lower airway to the trachea where it can be expectorated or swallowed

20 BRONCHIOLES branch from the secondary bronchi and subdivide into the small terminal and respiratory bronchioles they contain no cartilage and depend on the elastic recoil of the lung for patency the terminal bronchioles contain no cilia and do not participate in gas exchange

alveolar ducts branch from the respiratory bronchioles alveolar sacs, which arise from the ducts, contain clusters of alveoli, which are the basic units of gas exchange cells in the walls of the alveoli secrete surfactant, a phospholipid protein that reduces the surface tension in the alveoli, without this alveoli collapse

22 LUNGS innervation of the respiratory structures is accomplished by the phrenic nerve, vagus nerve, and thoracic nerves the parietal pleural lines the inside of the thoracic cavity including the upper surface of the diaphragm the visceral pleura covers the pulmonary surfaces

23 LUNGS CONT’ a thin fluid layer, which is produced by the cells lining the pleura, lubricates the visceral and parietal pleura, allowing them to glide smoothly and painlessly during respiration blood flows through the lungs occurs via the pulmonary system and the bronchial system

24 accessory muscles of respiration
scalene muscles elevate the first two ribs sternocleidomastoid muscles raise the sternum trapezius and pectoralis muscles fix the shoulders

the diaphragm descends into the abdominal cavity during inspiration causing negative pressure in the lungs the negative pressure draws air from the area of greater pressure, the atmosphere, into the area of lesser pressure, the lungs in the lungs, air passes through the terminal bronchioles into the alveoli to oxygenate the body tissues

at the end of inspiration, the diaphragm and intercostal muscles relax and the lungs recoil as the lungs recoil, pressure within the lungs becomes greater than atmospheric pressure causing the air that now contains the cellular waste products of carbon dioxide and water to move from the alveoli in the lungs to the atmosphere

27 AGE RELATED CHANGES ATROPHY (pharynx and larynx)

reduced chest movement decreased ability to inhale and exhale less effective cough increased work of breathing less tolerance for exercise and stress

smoking allergies frequent respiratory illnesses chest injury surgery exposure to chemicals and environmental pollutants crowded living conditions family history of infectious disease geographic residence and travel to foreign countries

Chief complaint and hx of present illness past medical hx review of systems functional assessment

31 PRESENT ILLNESS cough pain dyspnea fever sweating nausea/vomiting
effort to treat response to treatment

32 COUGH: onset-one week ,activity, lying down?
duration-each episode, how long frequency-frequent, occasionally, constantly type-dry hacking, wet productive, irritating and scratchy severity-hard enough to throw up?

33 COUGH sputum production & characteristics
COLOR-green, yellow, clear, rusty, blood tinged CONSISTENCY-thick, thin, ODOR-there either is or there isn’t AMOUNT-scant, copious, large, small pain-does it hurt when you cough? have they tried anything to treat it and has it helped

34 Dyspnea: onset duration severity precipitating events
associated symptoms

35 Pain: location onset duration precipitating events
effects on breathing relief measures associated symptoms

36 PAST MEDICAL HISTORY Colds pneumonia tuberculosis/last TB test
chronic bronchitis emphysema asthma cancer of resp. tract cystic fibrosis immunizations Sinus infections ear infections diabetes mellitus heart disease allergies / current meds trauma surgeries hospitalizations/ last CXR conditions that suppress the immune system

37 Family history Major respiratory conditions smoking history

38 Review of symptoms fatigue weakness fever chills night sweats earaches
nasal obstruction sinus pain sore throat hoarseness edema dyspnea orthopnea

39 Functional Assessment
occupation exposure to pathogens exposure to respiratory irritants typical day usual diet fluid intake smoking history # yrs smokedX pkg/d this equals pack years role in family stressors coping strategies

40 PHYSICAL EXAM be alert to any unusually rapid or slow breathing and to tachycardia, which may be a sign of hypoxia remember normal respiratory rate is breaths per minute

41 GENERAL SURVEY alertness speech pattern obvious distress VS Ht. & Wt.
Appearance facial expression posture alertness speech pattern obvious distress VS Ht. & Wt.

42 HEAD AND NECK NOSE patency of nares nasal flaring(sign of air hunger)
swelling discharge bleeding foreign bodies mucosa should be bright red in color deviation of nasal septum

43 HEAD AND NECK SINUSES LIPS PHARYNX palpate sinuses for tenderness
pursed-lip breathing, common technique for decreasing dyspnea for pts with chronic resp dz inspect lips, tip of nose, top of auricles, gums and under tongue for cyanosis, a bluish color R/t inadequate O2 PHARYNX Redness, tonsil exudate or enlargement

44 TRACHEA inspect for deviation, can be indicative for a large atelectasis, pleural effusion, aortic aneurysm, enlargement of part of the thyroid gland, and tension pneumothorax

45 THORAX look for deformities and lesions
observe breathing pattern and effort, should be regular and symmetric palpate for lumps and symmetry palpate for tactile fremitus (What is this?) A tremulous vibration of the chest wall during breathing that is palpable on physical examination. It may indicate inflammation, infection, or congestion. auscultate lungs in systematic manner, usually posterior, sides, anterior

46 THORAX listen for normal movement of air and abnormal sounds
WHEEZE-high-pitched sound caused by air passing through narrowed passageways, as with asthma or COPD

47 THORAX RHONCHUS-dry rattling sound caused by partial bronchial obstruction CRACKLES(RALES)-associated with many cardiac and pulmonary disorders, sounds like rubbing strands of hair between the thumb and forefinger next to the ear

48 THORAX COARSE CRACKLES- sounds like a velcro fastener being separated
PLEURAL FRICTION RUB-grating, scratchy noise similar to a creaking shoe

49 ABDOMEN inspect the abdomen for distention that might interfere with full expansion of the lungs

50 EXTREMITIES check color of extremities and edema
finger clubbing/chronic resp problems

51 HOMAN’S SIGN dorsiflex pts foot
suspect thromboplhlebitis if this elicits pain behind the knee or in the calf important to know, the legs and the pelvis are the source of most pulmonary emboli

should have regular pattern even depth rate breaths/min this is the normal respiratory drive

53 TACHYPNEA should have regular pattern even depth
rate is faster than 20 breaths/min may be caused by fever, pain, anxiety, respiratory disorders, shock

54 BRADYPNEA should have regular pattern even depth
rate is slower than 12 breaths/min may be caused by sedatives, narcotics, alcohol; brain, metabolic, and respiratory disorders

55 SIGHING RESPIRATIONS should have regular pattern
uneven depth; periodic deep breaths (more than 3 sighs/min) rate is 12 to 20 breaths/min may be caused by severe anxiety

breaths are progressively deeper, then becoming more shallow, followed by period of apnea may be caused by severe brain pathology

should have a regular pattern deep respirations rate is faster than 20 breaths/min may be caused by metabolic acidosis, diabetic ketoacidosis, renal failure

should have an irregular pattern depth varies, sudden periods of apnea may be caused by neurologic disorders

59 obstructive breathing, rising end-expiratory level with forced expirations
gradual rise in end-expiratory level during forced rapid breathing may be caused by emphysema


61 CHEST X-RAY STUDY used to provide information regarding the anatomical location and appearance of the lungs Pre-procedure: remove all jewelry and other metal objects from the chest area, assess ability to inhale and hold breath, question females regarding pregnancy or the possibility of pregnancy Post procedure: assist the client to dress

62 SPUTUM SPECIMEN a specimen obtained by expectoration or tracheal suctioning to assist in the identification of organisms or abnormal cells

63 SPUTUM-PREPROCEDURE determine specific purpose of collection and check with institutional policy for appropriate collection of specimen obtain an early morning sterile specimen from suctioning or expectoration after a respiratory treatment, if prescribed obtain 15 mL of sputum

64 SPUTUM-PREPROCEDURE instruct client to rinse mouth with water before collection; instruct client to take several deep breaths and then cough deeply to obtain sputum ALWAYS collect specimen before starting antibiotics

if culture of sputum is prescribed, transport to laboratory immediately assist the client with mouth care

66 BRONCHOSCOPY direct visual examination of the larynx, trachea, and bronchi with a fiberoptic bronchoscope Used to visualize abnormalities, take biopsy samples or lesions, or remove foreign bodies.

67 BRONCHOSCOPY pre-procedure
obtain informed consent NPO from midnight before the procedure ( or 6- 8 hours) obtain vital signs monitor coagulation studies remove dentures or eyeglasses prepare suction equipment administer medication for sedation as prescribed

68 BRONCHOSCOPY pre-procedure
have emergency resuscitation equipment readily available

69 BRONCHOSCOPY post procedure
monitor vital signs maintain semi-Fowler’s position assess gag reflex maintain NPO status until gag reflex returns monitor for bloody sputum monitor respiratory status monitor for asymmetric chest movement monitor for swelling of face and neck monitor for dyspnea, diminished lung sounds

70 BRONCHOSCOPY post-procedure
monitor for complications such as brohnchospasm, bacteremia, bronchial perforation indicated by facial or neck crepitus, dysrhythmias, fever, hemorrhage, hypoxemia, and pneumothorax notify physician if fever or difficulty in breathing occurs after the procedure

71 Pulmonary Angiography
an invasive fluoroscopic procedure after injection of iodine, radiopaque, or contrast material through a catheter inserted through the antecubital or femoral vein into the pulmonary artery or one of its branches

72 Pulmonary Angiography-preprocedure
obtain informed consent assess for allergies to iodine, seafood, and other radiopaque dyes maintain NPO status for 8 hours before the procedure monitor vital signs monitor coagulation studies establish an IV access

73 Pulmonary Angiography-preprocedure
administer sedation as prescribed instruct client to lie still during the procedure instruct client that he or she may feel an urge to cough, or flushing, nausea, or salty taste after injection of the dye have emergency resuscitaiton equipment available

74 Pulmonary angiography-postprocedure
monitor VS avoid taking blood pressures in the extremity used for injection for 24 hours monitor peripheral neurovascular status assess insertion site for bleeding monitor for delayed reaction to the dye

75 Thoracentesis Removal of fluid or air from the pleural space via a transthoracic aspiration Pleural fluid is aspirated and examined for pathogens, other abnormal components. Cells studied for malignance See figure 30-8 page 522

76 Thoracentesis-preprocedure
obtain informed consent obtain baseline vital signs prepare client for ultrasound or chest x-ray study if prescribed before procedure assess coagulation studies note that client is positioned sitting upright with arms and head supported by a table at the bedside during the procedure

77 Thoracentesis-preprocedure
if the client cannot sit up, the client is placed lying in bed on the unaffected side with the head of the bed elevated 45 degrees inform client not to cough, breathe deeply, or move during the procedure

78 Thoracentesis-postprocedure
monitor VS monitor respiratory status patient is positioned on the unaffected side after the procedure apply a sterile, pressure dressing and assess puncture site monitor for signs of pneumothorax, air embolism, and pulmonary edema observe for uneven chest movements, respiratory distress and hemorrhage Document amount and color of fluid removed

79 Pulmonary function test (PFT)
included a number of different tests used to evaluate lung mechanics, gas exchange and acid-base disturbance through spirometric measurements, lung volumes, and arterial blood gases examples: measures of: total lung capacity, forced respiratory volume, functional residual capacity, inspiratory capacity, vital capacity, forced vital capacity (see table 29-4 for definitions)

80 PFT used to diagnose pulmonary disease monitor disease progression
evaluate the extent of disability assess the effects of medication

81 PFT-preprocedure determine if an analgesic that may depress the respiratory function is being administered consult with physician regarding holding bronchodilators before testing instruct client to void before procedure and to wear loose clothing

82 PFT-preprocedure remove dentures
instruct client to refrain from smoking or eating a heavy meal for 4 to 6 hours before the test

83 PFT-post procedure resume normal diet and any broncholilators and respiratory treatments that were held before the procedure

84 Spirometry an instrument that measures the ventilatory function of the lungs measures volume of air that the lungs can hold the rate of flow of air in and out of the lungs the compliance (elasticity) of lung tissue involves inserting mouthpiece, taking as deep a breath as possible and blowing as hard, as fast, and as long as possible See Table 30-2 for Lung Volumes and Capacities

85 Pulse Oximetry noninvasive measurement of arterial oxygen saturation
A beam of light passes through the tissue , and the amount of light absorbed by oxygen saturated hemoglobin is measured. sensor clipped to earlobe or fingertip factors that interfere with an accurate reading include: hypotension, hypothermia, vasoconstriction, and finger movement, also dark fingernail polish if it is placed on the nail

86 Bronchogram visualizes the bronchial tree radiographic procedure
pts throat and bronchi are anesthetized

87 Bronchogram dye is instilled into the bronchial tree through a catheter or a fiberoptic bronchoscope pt is tilted in different positions for dye to spread in specific directions complications include: pneumonia, delayed hypersensitivity reaction and laryngospasm

88 Lung Biopsy a percutaneous lung biopsy is performed to obtain tissue for analysis by culture or cytological examination a needle biopsy is done to identify pulmonary lesions, changes in lung tissue, and the cause of pleural effusion

89 Lung Biopsy-preprocedure
obtain informed consent maintain NPO status before the procedure inform the client that a local anesthetic will be used by that a sensation of pressure during needle insertion and aspiration may be felt administer analgesics and sedatives as prescribed

90 Lung Biopsy-postprocedure
monitor vital signs apply a dressing to the biopsy site and monitor for drainage or bleeding monitor for signs of respiratory distress and notify the physician if they occur monitor for signs of pneumothorax and air emboli and notify physician if they occur prepare client for chest x-ray study if prescribed

91 Ventilation-perfusion lung scan
Demonstrated lung ventilation and perfusion. the ventilation scan determines the patency of the pulmonary airways and detects abnormalities in ventilation Detects pulmonary embolism and other obstructive conditions a radioactive substance may be inhaled or injected for the procedure


93 Ventilation-perfusion lung scan-preprocedure
obtain informed consent assess for allergies to dye, iodine, or seafood remove jewelry around the chest area review breathing methods that may be required during testing establish an IV access

94 Ventilation-perfusion lung scan-preprocedure
Administer sedation if prescribed Usually NPO for 4 hours May take 2 hours Have emergency resuscitation equipment available

95 Ventilation-perfusion lung scan-postprocedure
monitor client for reaction to the radionuclide for 1 hour for anaphylaxis for 24 hours after the procedure, rubber gloves are worn when urine is being discarded; they should be washed with soap and water before removing, and then the hands should be washed after the gloves are removed( radioactive material is excreted in the urine)

96 Ventilation-perfusion lung scan-postprocedure
Instruct the client to wash hands carefully with soap and water for 24 hours after the procedure when voiding (lets hope they already do this)

allows visualization of slices or layers of the chest a camera rotates in a circular pattern around the body for a three dimensional assessment of the thorax usually used to look for the presence of lesions or tumors radioactive dye containing iodine may be injected IV

98 CT preparation explain the test to the patient
they lie on a platform while a special doughnut- shaped radiographic scanner rotates around them stress the importance of remaining still during the scanning assess iodine allergy, if contrast is used, if there is, report it to the radiologist NPO may be required

99 CT postprocedure note side effects of contrast: nausea, vomiting, headache

100 MRI similar to CT but without harmful radiation
doughnut-shaped magnet used pt lies on a stretcher that slides into a tubelike device mechanical clanging noises are heard as machine operates

101 MRI metal implants such as cardiac pacemakers and orthopedic implants may be affected by MRI, but are not absolute contraindications aneurysm clips, intraocular metal, heart valves made before 1964, and middle ear prostheses generally contraindicate MRI

102 MRI preparation explain test to patient get consent form signed
assess for claustrophobia anxious pt may require sedation have pt remove metal watch and jewelry

103 MRI postprocedure safety precautions if sedated; otherwise, no special after care is needed

104 Tuberculin skin tests Determine past or present exposure to tuberculosis A patient who has ever been vaccinated with BCG will test positive regardless of actual exposure Bacille Calmette-Guérin (BCG) is a vaccine against tuberculosis that is prepared from a strain of the attenuated (weakened) live bovine tuberculosis bacillus, Mycobacterium bovis, that has lost its virulence in humans by being specially cultured in an artificial medium for years.

105 Multipuncture (tine) test (PPD)
purified protein derivative or old tuberculin is introduced into the skin using a device with four tines the device is firmly pressed on the anterior forearm for 1 sec. This site is marked, recorded, and inspected in 48 to 72 hours for redness and swelling a reaction equal to or greater than 2 mm at one or more puncture sites is positive

106 PPD preparation cleanse puncture site
tell pt. The procedure causes pain briefly stress need to return in hr to evaluate response pt should not scratch site tell pt skin reaction may persist for a week

107 Mantoux test if PPD is positive this test is done
old tuberculin is injected intradermally in the lower anterior forearm this site is marked, recorded and inspected after hr for swelling and redness a reaction of 5 mm or more is positive for tuberculosis exposure

108 Mantoux preparation tell pt to expect some pain with injection
return in hours for evaluation of response swelling may persist up to a week

109 Sputum analysis May be performed when respiratory disease is suspected
May contain bacterial or malignant cells Also examined for volume, consistency, color, and odor Thick foul smelling, and yellow, green, or rust colored sputum usually indicates a bacterial infection

110 Culture and sensitivity
Ordered to determine the presence of bacteria, identify the specific organisms and identify appropriate antimicrobials Collect specimen before antimicrobial therapy is begun

111 Acid-fast test Performed to determine the presence of acid-fast bacilli Including the bacteria that causes tuberculosis Usually collected on 3 consecutive days Cover and refrigerate or deliver to lab within 1 hour Use sterile container

112 ABG’s measures pH, PaCO2, PaO2, HCO3 and O2 saturation
detects alkalosis or acidosis, and alterations in oxygenation status that may occur with many respiratory, cardiac, and metabolic disorders

113 ABG’s Normal Values for adults
PH: PaCO2: mm Hg PaO2: mm Hg HCO3: mEq/L O2 saturation: %

114 ABG Preparation tell the patient a blood sample will be drawn from an artery (usually radial) an Allen’s test should be done before an arterial puncture to ensure that the arteries to the hand are patent (page 465) The patients hand is formed into a fist while the technician compresses the ulnar artery. Compression of the ulnar artery is continued while the fist is opened. If blood perfusion through the radial artery is adequate, the hand should flush and resume a normal pinkish coloration.


116 ABG postprocedure apply pressure to the puncture site for 5-10 minutes
note the concentration of any oxygen therapy on lab slip transport the blood gas syringe to the lab in an ice bath within 15 minutes respiratory therapist will usually take sample and analyze it Go to slide 140- (just had ABG’s)

117 hydrogen ions (H+) are vital to life expressed as pH
body’s pH is normally alkaline between and 7.45)

118 ACIDS: Produced as end products of metabolism contain hydrogen ions
the number of hydrogen ions in body fluid determines its acidity, alkalinity, or if it is neutral

119 BASES contain no H+ hydrogen ion acceptors
accept H+ from acids to neutralize or decrease the strength of a base or to form a weaker acid

120 Regulating H+ concentration in the blood
BUFFERS: hemoglobin, plasma proteins, carbonic acid/bicarbonate system, phosphate buffer system LUNGS KIDNEYS POTASSIUM

121 Lungs regulating system
interacts with the buffer system to maintain acid base balance in acidosis: pH goes down and the respiratory rate and depth go up in an attempt to “blow off” acids the carbonic acid created by the neutralizing action of bicarbonate can be carried to the lungs where it is reduced to C)2 and water and exhaled, thus H+ are inactivated and excreted

122 Lungs regulating system
in alkalosis, the pH goes up and the respiratory rate and depth go down, the CO2 is retained, and the carbonic acid builds to neutralize and decrease the strength of excess bicarbonate the action of the lungs is reversible in controlling an excess or deficit

123 Lungs regulating system
the lungs can hold H+ until the deficit is corrected or can inactivate H+, changing them to water molecules to be exhaled as CO2, thus correcting the excess the lungs are capable of inactivating only H+ carried by carbonic acid (H2CO3); excess H+ created by other problems must be excreted by the kidneys

124 Respiratory Acidosis the total concentration of buffer base is lower than normal, with a relative increasing hydrogen ion (H+) concentration; thus a greater number of H+ are circulating in the blood than can be absorbed by the buffer system

due to primary defects in the function of the lungs or by changes in normal respiratory patterns from secondary problems remember that any condition that causes an obstruction of the airway or depresses respiratory status can cause respiratory acidosis hypoventilation COPD, CAL, COLD

pulmonary edema pneumonia atelectasis asthma bronchitis or bronchiectasis infection medications such as sedatives, narcotics, or anesthetics

brain trauma

128 DATA COLLECTION in an attempt to compensate, the respiratory rate and depth increase pH less than 7.35 and PCO2 greater than 45 mm Hg mental status changes such as confusion drowsiness restlessness weakness

129 DATA COLLECTION dizziness dyspnea hyperkalemia

130 IMPLEMENTATION maintain patent airway
monitor for signs of respiratory distress administer oxygen as prescribed place client in semi-Fowler’s position unless contraindicated encourage and assist the client to turn, cough, and deep breathe prepare to administer chest physiotherapy and postural drainage as prescribed

131 IMPLEMENTAION encourage hydration to thin secretions unless excess fluid intake is contraindicated suction the client as necessary monitor electrolyte values avoid the use of tranquilizers, narcotics, and hypnotics because they further depress respirations administer antibiotics for infection as prescribed

132 Respiratory alkalosis
a deficit of carbonic acid (H2CO3) or a decrease in H+ concentration results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids

133 Causes of respiratory alkalosis
due to conditions that cause overstimulation of the respiratory status hyperventilation hypoxemia fever early stages of salicylate poisoning reactions to certain medications pain

134 Causes of respiratory alkalosis
anxiety hysteria

135 DATA COLLECTION initially, the hyperventilation and respiratory stimulation will cause abnormal rapid and deep respirations (tachypnea) in an attempt to compensate, respiratory rate and depth then go down pH is greater than 7.45 and PCO2 is less than 35 mm Hg altered mental status pallor around the mouth

136 DATA COLLECTION tingling of the fingers dizziness
spasms of the muscles of the hands hypokalemia

137 IMPLEMENTATION maintain a patent airway
provide emotional support and reassurance to the client encourage appropriate breathing patterns

138 IMPLEMENTATION provide cautious care with ventilator clients so that the client is not forced to take breaths too deeply or rapidly monitor electrolyte values administer sedatives as prescribed

139 THERAPUTIC MEASURES IPPB artificial airways mechanical ventilation
Thoracentesis breathing exercises chest physiotherapy suctioning humidification & aerosol oxygen IPPB artificial airways mechanical ventilation chest tubes thoracic surgery video thoracoscopy drug therapy

140 Breathing Exercises performed to aid in lung expansion and expectoration of respiratory secretions indicated when pts are immobilized or after general anesthesia

141 Deep Breathing and Coughing
sit in a semi-Fowler’s position for maximal lung expansion place on hand on the abdomen to feel it rise and fall with breathing inhale deeply through the nose, pause 1 to 3 seconds, and exhale slowly through the mouth

142 Deep Breathing and Coughing
after 4 to 6 deep breaths, cough deeply from the lungs to aid in the expectoration of sputum after thoracic or abdominal surgery, splint the incision with a pillow to minimize discomfort and support the incision

143 Pursed-Lip Breathing used to inhibit airway collapse and to decrease dyspnea in pts with chronic lung disease instruct pt to pucker lips as if to whistle, blow out a candle, or blow through a straw then they should inhale through the nose and slowly exhale through pursed lips exhalation should last twice as long as inhalation

144 Chest physiotherapy chest percussion and vibration postural drainage

145 Suctioning goal is to improve oxygen and carbon dioxide exchange in the lungs by removing excessive mucous secretions with a suction catheter

146 Suctioning Key Points use strict aseptic technique
administer oxygen before inserting the suction catheter because the procedure temporarily interferes with the patient’s air flow moisten the catheter in sterile water and insert the catheter through the nose or mouth before applying suction

147 Suctioning Key Points apply suction intermittently as the catheter is rotated and withdrawn from the airway maintain the pressure gauge between 80 and 100 mm Hg limit each suction pass to 10 seconds (try holding your breath while you do this) allow the patient to rest briefly, encourage deep breathing, and rinse the catheter with sterile solution between suction attempts

148 Suctioning Key Points monitor the patients response to suctioning
if tachycardia or increased respiratory distress develops, stop the procedure and give the patient oxygen as ordered document the amount, color, odor, and consistency of the patient’s secretions as well as the patient’s status before and after the procedure

149 Humidifiers creates water vapor to raise the relative humidity of inspired gas to 100% there are room humidifiers and medical oxygen is humidified as it bubbles through a container of water sterile water should be used to prevent the spread of bacteria

150 Aerosol therapy suspended liquid particles of bronchodilators or inactive fluids such as water or saline delivered by devices called nebulizers (pts call them puffers sometimes) can be hand held may be connected to an oxygen mask pt should sit upright and slowly inhale, hold the breath briefly and exhale slowly

151 Oxygen therapy Air in the atmosphere contains approximately 21% oxygen, which is usually sufficient Individuals with pulmonary disease or injury may need supplemental oxygen Oxygen is considered a drug and should be treated as such, you need an order and there may be serious side effects as well as benefits

152 Oxygen therapy If you observe a patient becoming lethargic or bradypneic, immediately notify a supervisor or physician, these are symptoms of adverse effects of oxygen therapy Oxygen is delivered from a bulk system, mounded on the wall of a patient’s room or it can be delivered from a cylinder unit on wheels

153 Oxygen therapy A tube is needed to connect the flowmeter to the specific oxygen delivery device This tube is then attached to the patient via nasal cannula or mask Oxygen therapy is ordered in liters per minute or FIO2 FIO2 mean fraction of inspired oxygen It is written as 0.30, which means 30% oxygen concentration

154 Oxygen therapy The most common used delivery device is the nasal cannula It fits around the face and directly into the nares by way of two prongs It is designed to deliver a flow of oxygen from 1 to 6 L/min with approximate FIO2 of 0.24 to 0.44 or 24 to 44% oxygen concentration delivered

155 Nasal Cannula (nasal prongs)
1 L/min 2 L/min 3 L/min 4 L/min 5 L/min 6 L/min Anything over 6 L/min will not increase the % of O2 delivered, using nasal cannulas

156 Nasal Cannula (nasal prongs)
If you notice, anytime you add a liter, you have a 4% increase in the O2 delivered, you can remember 1L will give you 24% then add 4% every time you go up a liter

157 Nasal Cannula (nasal prongs)
Used for client with chronic airflow limitation (CAL, COPD) and for long-term oxygen use The CAL or COPD pt who retains CO2 should never receive O2 at a rate higher than 2 to 3 liters/min The potential for apnea or respiratory distress occurs

158 Implementation Place the nasal prongs in the nostrils with the openings facing the patient Add humidification as prescribed when a flow rate higher than 2 liters /min is prescribed Check the water level and change the humidifier as needed Monitor the client for changes in respiratory rate or depth

159 Implementation Assess mucosa as high flow rates have a drying effect and increase mucosal irritation Monitor skin integrity as the oxygen tubing can irritate the skin Provide water-soluble jelly to the nares PRN Do not use any petroleum based lubricant

160 Masks There are 4 types of available Simple oxygen mask
Partial rebreathing mask Nonrebreathing mask Air entrainment (Venturi) mask

161 Simple mask Designed to deliver an FIO2 ranging from 0.35 to 0.55
Which is 35% to 55% It must be 6 L/min at least If not 6L/min, CO2 may build up in the mask, which would be very dangerous for your patient Seen on page 525

162 Simple mask Flow rate must be set to at least 6 L/min
55%-60% at 8 L/min

163 Partial rebreathing mask
Includes a reservoir bag to elevate the potential FIO2 Pt rebreathes part of their own exhaled gas Design of the mask allows almost no rebreathed gas to contain CO2 from pts lungs, only enriched oxygen Expected FIO2 range (35 to 60%) Flow setting must be at least 6

164 Nonrebreathing mask None of the pts exhaled gas is rebreathed
Includes a reservoir bag Series of valves to direct fresh supply of gas with each breath Expected FIO2 should be 1.0(100%) Controversy stating only 0.7 (70%)(because experimentally the highest F1O2 is approximately 0.7%) Also must be 6-10 on flow meter Used most often in client who may need to be placed on a ventilator

165 Air entrainment mask (Venturi)
Provides a specific FIO2 Usually must place an attachment to the mask % of oxygen delivered is determined by the color of the attachment, must read the manufacture’s instructions Example: Pink=50%, Blue=60% etc. This mask delivers the highest concentration of O2 when compared with the other masks

166 Implementation Be sure mask fits securely over nose and mouth, as a poorly fitting mask reduces the FIO2 delivered Monitor the skin and provide skin care to the area covered by the mask because pressure and moisture under the bag may cause skin breakdown Monitor the client closely for risk of aspiration because the mask limits the client’s ability to clear the mouth, especially if vomiting occurs

167 Implementation Provide emotional support to decrease anxiety to the client who feels claustrophobic Consult with physician regarding switching the client from a mask to a nasal cannula during eating With a reservoir bag, make sure it does not twist or kink, which results in a deflated bag

168 Face tent Fits over the client’s chin, with the top extending halfway across the face O2 content varies Useful instead of a tight-fitting mask for the client who has facial trauma and burns

169 Tracheostomy collar and T piece
Can be used to deliver high humidity and the desired oxygen to the client with a tracheostomy Special adapter called the T piece can be used to deliver any desired FIO2 to the client with a tracheostomy, laryngecotmy, or endotracheal tube Oxygen delivered 24% to 100% with flow rates at least 10L/min

170 Implementation Change delivery system to a nasal cannula during mealtimes Ensure that aerosol mist escapes from the vents of the delivery system during inspiration and expiration Empty condensation from the tubing to prevent the client from being lavaged with water and to promote an adequate flow rate Ensure that there is sufficient water in canister and change the aerosol water container as needed Keep the exhalation port on T-piece open and uncovered(if occluded, the client can suffocate)

171 Key points with oxygen therapy
Monitor the liter flow to be sure it is as prescribed Assess the patient’s response to therapy; monitor reports of blood gas analyses Inspect the tubing for kinks, obstructions, loose connections, listen for hissing sound in O2 mask: feel for adequate O2 flow Maintain sterile water in the humidifier reservoir

172 Key points with oxygen therapy
Clean and replace oxygen therapy equipment according to agency policy Post a no smoking sign and advise the patient and visitors that smoking is not allowed because oxygen supports combustion

173 Implementation Assess color and vital signs before and during treatment Place an “oxygen in use” sign at client’s bedside Assess for presence of chronic lung problems Humidify the oxygen

174 IPPB Intermittent Positive Pressure Breathing Treatments
Used to achieve maximal lung expansion The IPPB equipment delivers humidified gas with positive pressure, which forces air into the lungs with inhalation and allows passive exhalation. Facilitates maximal exchange of oxygen and carbon dioxide gases in the alveoli and promotes a productive cough. Mucolytics and bronchodilators common

175 Artificial Airways Oral airway Nasal airway Endotracheal tube

176 Endotracheal tubes Orotracheal Nasotracheal

177 Endotracheal tubes Used to maintain a patent airway
Indicated when the client needs mechanical ventilation If client requires artificial airway for longer than 10 to 14 days, a tracheostomy may be created to avoid mucosal and vocal cord damage than can be caused by the endotracheal tube The cuff located at the distal end of the tube, when inflated, produces a seal between the trachea and the cuff to prevent aspiration and ensure delivery of a set tidal volume when mechanical ventilation is used, an inflated cuff also prevents air from passing to the vocal cords, nose or mouth

178 Orotracheal Allows use of a larger diameter tube and reduces the work of breathing Indicated when the client has a nasal obstruction or a predisposition to epistaxis Uncomfortable and can be manipulated by the tongue causing airway obstruction; an oral airway may be needed to keep the client from biting on the tube

179 Nasotracheal Smaller-sized tube increased resistance and increases client’s work of breathing Discouraged in clients with bleeding disorders More comfortable for the client, and the client is unable to manipulate with tongue

180 Implementaion Placement is confirmed by chest x-ray study (correct placement is 1 to 2 cm above carina) Placement is assessed by auscultating both sides of chest while manually ventilating with resuscitation bag If breath sounds and chest wall movement are absent on the left side, the tube may be in the right mainstem bronchus

181 Implementaion Auscultation over the stomach is performed to rule out esophageal intubation If the tube is in the stomach, louder breath sounds will be heard over the stomach than over the chest, and abdominal distention will be present Secure the tube immediately after intubation with adhesive tape

182 Implementaion Monitor position of tube at lip or nose
Monitor skin and mucous membranes Suction only when needed (Why)

183 Implementaion The oral tube needs to be moved to the opposite side of the mouth daily to prevent pressure and necrosis of the lip and mouth area, prevent nerve damage, and facilitate inspection and cleaning of the mouth; moving the tube to the opposite side of the mouth should be done by two health care providers

184 Implementaion Prevent pulling or tugging on the tube to prevent dislodgement; suction, coughing and speaking attempts by the client place extra stress on the tube and can cause dislodgement Keep a resuscitation (Ambu) bag at bedside at all times Assess pilot balloon to ensure cuff is inflated

185 Extubation Hyperoxygenate the client and suction the endotracheal tube and the oral cavity Place client in semi-Flower’s position The cuff is deflated and the tube is removed at peak inspiration Instruct the client to cough and deep breathe to assist in removing accumulated secretions in the throat

186 Extubation apply oxygen therapy as prescribed
Monitor respiratory status for signs of obstruction and notify physician if they occur Inform client that hoarseness or a sore throat is normal and to limit talking if it occurs

187 Tracheostomy A tracheotomy is a surgical incision made into the trachea to establish an airway A tracheostomy is the stoma or opening that results from the tracheotomy The tracheostomy can be temporary or permanent

188 Implementation Monitor respirations Monitor ABGs and pulse oximetry
Encourage coughing and deep breathing Maintain a semi-to high-Fowler’s postion

189 Implementation Monitor for bleeding, difficulty breathing, absence of breath sounds, and crepitus, which are indications of hemorrhage, pneumothorax, and subcutaneous emphsema

190 Implementation provide respiratory treatments as prescribed
Suction as needed: hyperoxygenate the client before suctioning If client is allowed to eat, sit the client up for meals and ensure that the cuff is inflated(if the tube is not capped) for meals, and for 1 hour after meals

191 Implementation Assess the stoma and secretions for blood or purulent drainage Follow physician’s orders and agency policy for cleaning the tracheostomy site and inner cannula; usually half-strength hydrogen peroxide is used Administer humidified oxygen as prescribed as the normal humidificaiton process is bypassed in a client with a tracheostomy

192 Implementation Obtain assistance in changing tracheostomy ties: cut and remove old ties holding the tracheostomy in place Keep a resuscitation (Ambu) bag, obturator, and a tracheotomy set at the bedside

193 Complications of a Tracheostomy
Tube obstruction Tube dislodgement Pneumothorax Subcutaneous emphysema Bleeding Infection Tracheal stenosis Tracheoesophageal fistula Trachea-innominate artery fistula

194 Mechanical Ventilation
Used to overcome the client’s inability to ventilate or oxygenate adequately It may be intermittent or continuous, short or long term

195 Mechanical Ventilation
Depending on the patients needs, ventilators may be programmed to control or assist the rate of ventilation. Ventilators deliver oxygen ranging in concentration from 21% oxygen to 100% oxygen. (Oxygen concentration = FI02) Tidal volume is the present amount of oxygenated air delivered during each ventilator breath (usually 10 – 15ml/kg) Respiratory rate setting is the total number of breaths delivered per minute. Positive end expiratory pressure may be prescribed to keep the pressure in the lungs above the atmospheric pressure at he end of expiration. This reduces collapse of small airways and alveoli, increasing the functional residual capacity and improving ventilation.

196 Implementation Assess the client first and the ventilator second
Assess vital signs, respiratory status, and breathing patterns Monitor color, particularly in the lips and nail beds Monitor the chest for bilateral expansion Obtain a pulse oximetry reading

197 Implementation Assess the need for suctioning and observe type, color, and amount of secretions Ensure that the alarms are set If a cause of an alarm cannot be determined, ventilate the client manually with a resuscitation bag until the problem is corrected

198 Implementation Empty ventilator tubings when moisture collects
Turn client at least every 2 hours or get client out of bed as prescribed to prevent complications of immobility Have resuscitation equipment available at the bedside Establish an alternate method of communication because the patient cannot speak while intubated

199 Causes of high pressure alarms
Increased secretions in the airway Wheezing or bronchospasm causing decreased airway size Displacement of the endotracheal tube Obstructed endotracheal tube because of water or a kink in the tubing Client coughs, gags, or bites on the tube Client is anxious or fights the ventilator

200 Causes of low pressure alarms
Disconnection or leak in the ventilator or in the client’s airway cuff The client stops spontaneous breathing

201 Complications of ventilation therapy
Hypotension caused by the application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart Respiratory complications such as pneumothorax or subcutaneous emphysema as a result of positive pressure

202 Complications of ventilation therapy
Gastrointestinal alterations as stress ulcers Malnutrition Infections Muscular deconditioning Ventilator dependence or inability to wean

203 Weaning The process of going from ventilator dependence to spontaneous breathing

204 CPAP Continuous positive airway pressure
Maintains positive pressure in the airway during sleep Avoids apnea Small and have a nose mask that is worn during sleeping

205 Chest Tubes ( watched video)
Inserted to drain air or fluid from the “PLEURAL SPACE” of the lungs Permits re-expansion of a collapsed lung Used in pts with hemothorax, pneumothorax or pleural effusion Inserted under sterile conditions by physician Page 523

206 Chest Tubes Performed in OR or at bedside/ED
Small incision made to insert tube Fourth intercostal space to remove air (pneumothorax) Eigth or ninth intercostal space to remove fluids (hemothorax) Tubes are sutured in place at insertion and an air tight, sterile dressing is applied

207 Chest Tubes The other end of the plastic chest tube (distal end) is connected to a rubber tubing that leads to a pleural drainage device This device has three chambers: The collection chamber The water seal chamber The suction chamber

208 Collection chamber Chest fluid and air drain into the collection chamber Air is diverted to the water seal chamber When the drainage chamber is full, it can be changed without changing out the whole device The collection chamber just twists out and a new one is twisted in

209 Waterseal chamber Air is diverted here
It can be seen bubbling up through the water It should not be a constant bubbling, more like an intermittent bubbling If it is constant there may be an air leak

210 Waterseal chamber Agency policy may permit the chest tubing to be clamped for 10 seconds while the leak is found Check your connections and your dressing at the site of insertion You should have hemostats in the room for just this purpose

211 Suction Control Chamber
Suction pressure is controlled here Gentle bubbling is expected in the suction chamber Inside the chamber is a tube that is partially submerged in water The depth of the tube in the water regulates the amount of suction

212 Suction Control Chamber
This tube is hollow and will have a water in it There will be a rise and fall of water in this tube during inspiration and expiration (tidaling) During chest tube insertion, the water is added to the control chamber and how much is instilled is determined by the physician depending on the amount of suctioning required

213 Chest Tubes A chest radiograph is obtained to confirm placement of the tube

214 Implementation Monitor VS and breath sounds frequently
Assess dressing to be sure a tight seal is maintained Tape tubing connections and inspect frequently to detect air leaks Coil extra tubing on the bed to avoid kinks

215 Implementation Keep drainage system on the floor
Monitor drainage for blood clots or lung tissue which could clog the tube

216 Implementation Observe the water seal chamber for bubbling, it is usually seen unless the lung has reexpanded or the tubing is occluded After checking for kinks or occlusion of the tubing, notify the charge nurse or physician of reexpansion Always chart the bubbling and if there is no bubbling, checking for occlusion and finding none and then notifying the physician or CN

217 Implementation Drainage is monitored by marking the drainage level on the drainage receptacle, do this on your first assessment of the patient and chart it! You will then have the correct amount of drainage that occurred by the end of your shift, which you will chart as output

218 Heimlich Flutter Valve
An alternate to the large chest drainage system The valve is a disposable unit that is attached to the chest tube and to a sterile drainage receptacle air and fluid can flow in but cannot flow backward into the chest This is good for the client who can ambulate

219 Thoracic Surgery Thoracotomy The surgical opening of the chest wall
Reasons for thoracic surgery To evaluate chest trauma Removal of tumors and cysts

220 Surgical procedures on the Lungs
Pneumonectomy Lobectomy Segmental resection Wedge resection

221 Pneumonectomy The removal of an entire lung

222 Lobectomy The removal of one lobe of a lung

223 Segmental resection The extensive dissection and removal of a section of the lung

224 Wedge resection The removal of a small, triangular section of lung tissue

225 Decortication Stripping of the membrane that covers the visceral pleura

226 Thoracoplasty The removal of ribs

227 Preoperative nursing care
Everything that goes along with any type of surgery What you want to stress are breathing exercises and explanation of a chest tube if one may be required

228 Postoperative nursing care
Everything that goes with any type of surgery What you want to stress Vital signs Lung sounds Mental state Dressings Chest tube function and drainage

229 Drug Therapy View table on page

230 Decongestants are adrenergic agents

231 Decongestants Mimic the action of epinephrine and norephinephrine
Cause constriction of nasal blood vessels and reduce the swelling of mucous membranes Sudafed (common over the counter) With systemic vasoconstriction they may elevate the blood pressure Systemic effects are less severe with topical drops and sprays People with hypertension, heart disease, and hyperthyroidism should not take over the counter cold remedies without talking to the Dr or pharmacist.

232 Antitussives suppress the cough reflex
Antitusives Antitussives suppress the cough reflex

233 Antitussives When a cough is nonproductive, creates pain and interferers with sleep or wound healing cough suppression may be indicated Codeine is effective (but is an opioid with many side effect) Dextromethorphan is commonly used Be careful suppressing the cough because it is a protective mechanism.

234 Antihistamines are also called histamine 1 blockers

235 Antihistamines They block the effects of histamine(one of the chemicals that causes allergic symptoms) Prescription and over the counter Dry nasal secretions Benadryl - common first generation antihistamine May cause dizziness, dry mouth, constipation, blurred vision, urinary retention, tachycardia, drowsiness and impaired judgment

236 Antihistamines Second generation
Claritin – less likely to cause drowsiness

237 Thin respiratory secretions
Expectorants Thin respiratory secretions

238 Expectorants Thin respiratory secretions so they are more readily mobilized and cleared from the airways

239 Kill or inhibit the growth of bacteria, viruses, or fungi
Antimicrobials Kill or inhibit the growth of bacteria, viruses, or fungi

240 Antimicrobials Usually treat only bacterial infections because they are not effective against viruses or fungi Specific antimicrobials are best selected after culture and sensitivity tests are performed on a specimen of respiratory secretions Instruct on proper self medications

241 Relax smooth muscle in the bronchial airways and blood vessels
Bronchodilators Relax smooth muscle in the bronchial airways and blood vessels

242 Bronchodilators Asthma and COPD
Primary drawback is their tendency to cause cardiac and CNS stimulation Some bronchodilators act primarily to prevent bronchial constriction where as other relieve it.

243 Anti-inflammatory drugs
Corticosteroids Anti-inflammatory drugs

244 Corticosteroids Parenterally, orally, inhalation
Reduce inflammation and edema in the respiratory tract Less commonly used to treat COPD Do no discontinue steroid therapy abruptly

245 Used to prevent acute asthma attacks
Mast Cell Stabilizers Used to prevent acute asthma attacks

246 Mast Cell Stabilizers Intal Tilade
Not useful in stopping an attack after it starts

247 Leukotriene Inhibitors
Leukotriens Mediate allergic responses

248 Leukotriene Inhibitors
Useful in the treatment of asthma – they inhibit the allergic response helping to prevent but not interrupt acute asthmatic attacks Accolate Zyflo Singulair

249 Reduce the viscosity and elasticity of mucus
mucolytics Reduce the viscosity and elasticity of mucus

250 mucolytics Mucomyst is used as an inhalant to thin the secretions
Important for the patient to remain well hydrated

251 Thrombolytics Dissolve blood clots

252 Thrombolytics Streptase Abbokinase Alteplase Activase

253 9 Lung Herbs For Colds and Respiratory Help

254 Mullein Mullein is a soothing expectorant that makes the mucous more fluid and less sticky, hence it can be coughed up more easily. It also helps relax the muscles in the bronchial passage. It is used for bronchitis, colds, persistent coughs, tuberculosis, pleurisy, and whooping cough

255 Angelica Angelica is a warming remedy that is good for the digestive system as well as the respiratory system. It is an expectorant, which means it will encourage coughing and the elimination of excess mucous. It helps strengthen the lungs when they are weakened, and was traditionally used for many types of infections.

256 Ginger Ginger is great in cases of excess phlegm, and bronchitis, and can also be used at the beginning of a cold. Like many of these lung herbs, its great for the digestive system also. Ginger is often used for nausea, and helps circulation.

257 Garlic Garlic has been studied a lot for its immune benefits. Its great both in the digestive system, and the lungs. It helps 'sterilize' the bronchial passage in the lungs, and has been used in bronchial infections like tuberculosis. It's great for the 'common cold', and garlic capsules can be bought. Kyolic garlic is excellent. even though its an aged garlic. Fresh garlic, consumed within 15 minutes of being cut open, in a tea with honey and lemon juice, is also an excellent remedy, with very strong antibacterial and antimicrobial benefits. It's great for tonsillitis, throat infections, and similar. As well as its cleansing effect on the lungs, garlic helps encourage mucous to coughed up.

258 Cinnamon Cinnamon should not be used in pregnancy. As a lung herb it's more warming than angelica, and can be used at the beginning of chesty colds. Mills suggests making a tea of powdered cinnamon and fresh ginger. It is also used in chest infections. Cinnamon is also great for the digestive system, and was also traditionally used in convalescence.

259 Elecampane This is a great lung herb for getting rid of excess mucous through coughing. It is very soothing, however, and the types of coughs it encourages are not dry hacking coughs that just produce more irritation. Its great for chronic bronchitis in the elderly, or for those who are weakened physically in some way. It can also be used for nervous coughing, and is a digestive tonic similar to angelica

260 Coltsfoot Coltsfoot is also an expectorant. It's great for dry coughs, and because of its mucilage content, is very soothing when the bronchial passages are irritated.

261 Thyme More than a seasoning for cooking, this lung herb has antiseptic properties as well as being an expectorant and digestive tonic. It helps 'disinfect' the air passages, and also has a calming effect on the bronchial tube. It is generally used for more asthmatic conditions and dry coughs, but not really for bronchitis. Large amounts of thyme should not be taken during pregnancy.

262 Wild Cherry Bark This lung herb is used as a cough suppressant, which as indicated above, should only be used under some circumstances. But it is used in helping treat strong and incessant coughing to the point of exhaustion.



265 SIGNS AND SYMPTOMS Last 2 - 14 days, first 3 days most contagious
headache sneezing stuffiness sore throat runny nose Fatigue lethargic Fever and chills in severe cases


267 TREATMENT Rest fluids diet antipyretics analgesics
Antivirals (not commonly used) Vitamin C antihistamines decongestants

268 Acute Bronchitis

Follows a cold or the flu usually viral Bacterial: Streptococcus pneumoniae, haemophilus influenzae Irritation and inflammation : increase mucous





274 Etiology and Risk Factors
Acute viral respiratory infection Several types then subtypes (A,B,C) Most susceptible: very young elderly institutionalized chronic disease you

275 COMPLICATIONS Bronchitis Viral or Bacterial Pneumonia myocarditis
pericarditis Rye Syndrome confusion Guillain-Barre’ toxic shock Myositis (swelling of the muscles) renal failure

276 SIGNS AND SYMPTOMS Chills fever muscle pain headache dry hacking cough


278 TREATMENT Rest fluids diet analgesics antipyretics
Antivirals (Symmetrel, Flumadine, Tamiflu, Relenza for type A & B) prevention; flu shot


280 Etiology and Risk Factors
Inflammation of the alveoli & bronchioles infectious Psuedomonas Candidia noninfectious fumes dust chemicals Nosocomial poor hand washing poor sterile technique contaminated equipment contact


282 PATHOPHYSIOLOGY Lobar Pneumonia one or more lobes Bronchopneumonia
bronchioles & alveoli Interstitial pneumonia lung tissue surrounding the alveoli Gram + bacteria pneumococcal staphylococcal streptococcal Gram - bacteria pseudomonas influenza legionnaires’ disease Viral

DELAYED RESOLUTION EMPYEMA SYSTEMIC COMPLICATIONS pericarditis arthritis meningitis endocarditis

284 SIGNS & SYMPTOMS Fever chills sweats chest pain cough
sputum production hemoptysis dyspnea headache

285 SIGNS & SYMPTOMS BACTERIAL VIRAL abrupt onset severe shaking chills
sharp stabbing lateral chest pain intermittent cough productive of rusty sputum VIRAL burning or searing chest pain in sternal area continuous barking hacking cough with small amount of sputum production headache

286 DIAGNOSIS History exam CXR sputum gm. Stain sputum C&S CBC
Blood culture

287 TREATMENT 3L of fluid/24 hours bedrest analgesics antipyretics oxygen
IPPB antibiotics Vaccine not recommended for children under age 2 only given once in a lifetime/There have been some questions regarding the once in a lifetime

288 Nursing diagnoses Ineffective airway clearance R/T
Increased sputum production Thick secretions Ineffective cough

289 Ineffective airway clearance
What can a nurse do? Decrease production of sputum and promote expectoration by administering antimicrobials, decongestants and expectorants as ordered Teach and encourage deep breathing and coughing Change positions at least every 2 hours to help mobilize secretions Chest physiotherapy and aerosol therapy Suctioning if needed Provide tissues and receptacle Chart amount, color, consistency of secretions Ausculate lung sounds frequently to assess the effects of interventions

290 Impaired gas exchange Edema and secretions with pneumonia may interfere with gas exchange Pt may have hypoxemia-low O2 in blood or hypercapnia-accumulation of CO2 in blood Need to improve gas exchange

291 Impaired gas exchange What’s a nurse to do?
Monitor vital signs, lung sounds and skin color to assess gas exchange Be alert for signs of hypoxemia: restlessness, tachycardia and tachypnea Report abnormal ABGs Check hemoglobin values, signals less O2 carrying ability Mobilize secretions as mentioned before Elevate HOB Administer O2 as ordered

292 Activity intolerance Activity usually restricted but may range from bed rest to BRP Schedule nursing care to prevent over tiring Allow periods of uninterrupted rest Provide assistance until pt is able to do self-care Encourage visitors not to tire pt with long visits Evaluate ability to tolerate ADLs

293 Altered nutrition: less than body requirments
What’s a nurse to do? Assess pts usual dietary habits Monitor weight by weighing pt before breakfast using same scale Monitor albumin and lymphocyte blood counts to detect low levels that are common with inadequate protein Typical diet: high protein, soft Assist pt with meal if needed Document intake Provide oral care before meals Elevate HOB arrange tray in attractive and convenient manner Nasal cannula recommended during meals If pt tires, more frequent smaller meals would be better

294 Risk for fluid volume deficit
Fever, mouth breathing and inadequate intake may increase the risk for this diagnosis Dehydration causes secretions to be thicker and more difficult to expectorate

295 Signs and symptoms of fluid volume deficit
Decreased skin turgor Concentrated urine Dry mucous membranes Elevated hemoglobin and hematocrit

296 Fluid volume deficit What’s a nurse to do?
Encourage 3L of fluid daily unless contraindicated Administer IV fluids as ordered If permitted give hard candy which stimulates thirst and fluid intake Record intake and output

297 Fluid volume deficit Monitor temp q2-4h
Administer antipyretics as ordered Keep pt dry and lightly covered Keep room comfortable temp, avoid chilling Tepid sponge baths for fevers as ordered Hypothermia blanket as ordered to reduce temp

298 Pain Administer analgesics as ordered Position pt for comfort
Encourage splinting painful areas during deep breathing and coughing Massage to promote comfort Notify the physician if pain is unrelieved or worsens

299 What to teach regarding pneumonia
Gradually increase activities as you recover, fatigue may persist for several weeks Avoid people with colds or other infections Get plenty of rest, good nutrition and 3 L of fluids each day unless contraindicated Complete any prescribed drugs after discharge Nursing Care Plan page 539 Teaching Plan for Pneumonia 540 Nutrition Concepts page 540



302 Prevention measures: Keep suction equipment on hand
Position upright with neck in neutral position Thinken liquids

303 Prevention of Aspiration Pneumonia
Elevate the head of bed if enteral feeding Measure residual before each bolus feeding If greater than 100ml with hold the feeding and notify the physician Stop continuous feeding for min before lowering the patients head If they must be kept flat then place on right side Check the residual every 4 hours and if more than 20% of hourly rate consult the physician

304 Inflammation of the pleura
PLEURISY Inflammation of the pleura

305 Common Causes Pneumonia tuberculosis chest wall injury
pulmonary infarction Tumors

306 Symptoms Abrupt and severe pain one side of the chest
breathing and coughing aggravate the pain

antitussives antimicrobials local heat

308 Nursing diagnoses for pleurisy
Pain R/T inflammation Ineffective breathing pattern R/T splinting, pleural effusion

309 Interventions for pain
When reported, obtain complete description Location Severity Precipitating factors Alleviating factors Use pain scale

310 Interventions for pain
Administer ordered analgesics Splinting for the affected side Splint rib cage when coughing Apply heat if ordered Give antitussives if ordered to decrease painful coughing If on bed rest, assist pt with regular position changes Administer NSAIDs as ordered to reduce pain and inflammation

311 Ineffective breathing pattern
Monitor breathing pattern, pay attention to chest symmetry during breathing Encourage pt to turn, take deep breaths and couth Encourage to ambulate if permitted Elevate HOB

312 Complications If pleural effusion develops, progressive dyspnea, decreased or absent breath sounds in the affected area and decreased chest wall movement on the affected side, a thoracentesis may be done to remove accumulated fluid If done at bedside you, the nurse will assist So be ready!!!


PENETRATING Gunshot, stab wounds pneumothorax tears of aorta, vena cava, other major vessels NONPENETRATING MVA, Falls, Blast rib fx pneumothorax pulmonary contusions cardiac contusions

315 SIGNS & SYMPTOMS Obvious trauma chest pain dyspnea
asymmetrical chest wall movement cyanosis weak rapid pulse decreased blood pressure tracheal deviation distended neck veins bloodshot or bulging eyes

316 MEDICAL TREATMENT Stabilization prevention
dressing tape three sides(called a vented dressing) An airtight dressing could cause a tension pneumothorax do not remove impaled objects VS LOC O2 semi-fowlers

317 PNEUMOTHORAX An accumulation of air in the pleural cavity that results in complete or partial collapse of a lung. Air enters the space between the chest wall and the lung either through a hole in the chest wall or through a tear in the bronchus, bronchioles, or alveoli.

air is repeatedly entering the pleural space lung on affected side collapses mediastinal shift Open chest wound air moves in and out freely lung on affected side collapses medistinal flutter

319 SIGNS & SYMPTOMS Dyspnea tachypnea tachycardia restlessness
pain anxiety decreased movement of the involved chest wall Asymmetric chest movement diminished breath sounds progressive cyanosis chest wound sucking chest wound (air can be heard or felt from wound)

320 TREATMENT Needle aspiration of fluid/air from pleural space
chest tube insertion surgical repair of a tear If persistent air leak( variety being studied) intrapleural tetracycline blood patches fibrin glue

321 Nursing care If chest tube: monitor insertion site
Document amount and characteristics of drainage Add to I&O Give chest tube care Monitor for increasing respiratory distress: Tachycardia Dyspnea Cyanosis Restlessness Anxiety

322 Nursing care Inspect trachea for deviation which may be caused by mediastinal shift occurs when a lung collapses and the heart, trachea, esophagus, and great blood vessels shift toward the unaffected side Mediastinal flutter Occurs with an open pneumothorax, everything may shift back and forth toward the unaffected side with inspiration then toward the affected side with expiration

323 Nursing care/ineffective breathing pattern
Check ABGs for hypoxemia and hypercapnia Immediately report deteriorating respiratory status Protect chest tube and monitor its function

324 Nursing care/ineffective breathing pattern
Position pt for comfort in a Fowler’s or semi- Fowler’s position, avoid side-lying until affected lung has re-expanded, could cause mediastinal shift Support and encourage pt to deep breath and cough q2h while awake Administer O2 as ordered

325 Nursing care/fear Speak calmly to pt, explain every procedure
Tell pt about chest tube Give pt opportunity to ask questions and express fear

326 Nursing care/risk for decreased cardiac output
Monitor pulse and blood pressure If blood pressure falls and pulse rate increases, you should suspect mediastinal shift, notify physician immediately, this could be fatal

327 Nursing care/pain Monitor for signs of pain
Document characteristics of pain Administer analgesics as ordered Document the effects of drug therapy Rate pain on 0-10 scale Use positioning, massage, distraction etc. Notify physician if measures fail and pain is not relieved

328 Nursing care/risk for infection
Monitor for signs and symptoms of infection Fever Increased pulse and respirations Foul drainage from tube insertion site Elevated WBC

329 Nursing care/risk for infection
Use sterile technique for invasive procedures and dressing changes Administer prescribed antimicrobials Monitor hydration status and promote fluid intake of 2 to 3 L/d unless contraindicated Before discharge instruct pt on chest tube care and to notify physician of S/S of infection Fever or increasing redness, swelling, or drainage from insertion site

330 HEMOTHORAX Accumulation of blood between the chest wall and the lung
Pressure around the lung increases, causing partial or complete collapse of the lung Results from lacerated or torn blood vessel, lung malignancy, pulmonary embolus May also be caused by anticoagulation therapy

331 Hemothorax treatment Essentially like a pneumothorax, nursing care is similar Surgical intervention may be necessary to control bleeding Pt is at risk for decreased cardiac output due to hemorrhage

332 RIB FRACTURES Most common chest injuries
blunt injury/MVA-hit steering wheel Ribs 4 to 9 most commonly affected Takes approx 6 wks to heal

333 SIGNS & SYMPTOMS Pain at injury site (especially during inspiration)
bruising Swelling Visible bone fragments at site of injury shallow breathing protective holding of the chest

334 TREATMENT Pain relief to allow adequate chest expansion
intercostal nerve blocks no binders or rib belts restricts expansion of chest encourage deep breathing every four hours Complication: pneumonia or atelectasis due to inadequate chest expansion

335 Nursing care Goal: effective breathing pattern
Breathing exercises to prevent pulmonary complications Instruct splinting while deep breathing and coughing Adequate pain control is essential, monitor q2h, rate pain on scale 0-10 Administer prescribed analgesics Provide a calm environment Encourage pt to rest Evaluate effects of pain measures Inform physician if pain isn’t controlled

336 FLAIL CHEST Two adjacent ribs on the same side of the chest are broken in two or more places. Results in paradoxical movement

337 SIGNS & SYMPTOMS Severe dyspnea cyanosis tachypnea tachycardia
paradoxical movement-affected part will move in with inspiration and moves out with expiration- opposite of how it should be

338 DIAGNOSIS History Exam CXR ABG

339 TREATMENT Adequate oxygenation Respiratory Distress
Cough & deep breathing IPPB pain management Respiratory Distress intubation ventilator

340 PULMONARY EMBOLUS Foreign substance carried through the blood
Usually blood clots but may be fat, air, tumors, bone marrow, amniotic fluid or clumps of bacteria Ventilation-perfusion mismatch. Alveoli are ventilated + no blood flow= no gas exchange

341 If a large pulmonary vessel is obstructed, alveoli collapse, cardiac output falls, there is constriction of the bronchi and the pulmonary artery, and sudden death may ensue.

342 Etiology and risk factors
Surgery of the pelvis or lower legs Immobility Obesity Estrogen therapy Clotting abnormalities If a large pulmonary vessel is obstructed, alveoli collapse, cardiac output falls, there is constriction of the bronchi and the pulmonary artery, and sudden death may occur

343 SIGNS & SYMPTOMS Sudden chest pain worsens with breathing tachypena
dyspnea apprehensive diaphoretic cough hemoptysis Crackles may be heard on auscultation fever tachycardia

344 DIAGNOSIS History and physical ABG EKG lung scan Pulmonary angiogram

345 TREATMENT MEDICAL SURGICAL embolectomy vena cava interruption
Heparin to establish and maintain (PTT times the normal rate) Coumadin 6 months Fibrinolytics oxygen intubation ventilation SURGICAL embolectomy vena cava interruption venous thrombectomy See pg 546 for pictures of filters

346 Nursing care Must monitor risk factors that led to the embolism
Homans’ sign assessed in each leg

347 Nursing care/altered cardiopulmonary tissue perfusion
Monitor respiratory rate and effort Breath sounds Skin color Pulse Blood pressure

348 Nursing care/altered cardiopulmonary tissue perfusion
ABGs report abnormalities to physician Elevate HOB Administer O2 as prescribed Administer prescribed IV fluids Document I&O Active/passive ROM Early ambulation after surgery Antiembolism and pneumatic compression stockings

349 Nursing care/anxiety Remain calm Tell pt what is being done
Explain equipment and procedures in terms pt can understand Encourage pt to express concerns and ask questions Permit family member to remain with the patient

350 See patient teaching plan page 547 for pulmonary embolism

351 ARDS Acute Respiratory Distress Syndrome

Progressive pulmonary disorder that follows lung trauma. Infiltrate development fluid shift pulmonary edema atelectasis Cardiac dysrhythmias renal failure stress ulcers thrombocytopenia DIC (disseminated intravascular coagulation) oxygen toxicity sepsis

353 SIGNS & SYMPTOMS Increased respiratory rate fine crackles restless
agitated confused increased pulse rate cough Dyspnea with retractions cyanosis diaphoresis diffuse crackles and rhonchi

354 DIAGNOSIS History exam CXR ABG pH increases Co2 falls
O2 falls despite O2 pH decreases respiratory acidosis

355 TREATMENT Intubation with ventilator treat underlying cause
corticosteroids debatable issue

356 Pulmonary Contusion Characterized by interstitial hemorrhage associated with intraalveolar hemorrhage resulting in decreased pulmonary compliance The major complication is acute respiratory distress syndrome (ARDS)

357 Signs and Symptoms Dyspnea Hypoxemia Increased bronchial secretions
Hemoptysis Restlessness Decreased breath sounds Rales and wheezes

358 Implementation Maintain airway and ventilation
Place client in high Fowler’s position Administer oxygen as prescribed Monitor for increased respiratory distress Maintain bed rest and limit activity to reduce oxygen demands Prepare for mechanical ventilation as prescribed

359 Respiratory failure Occurs when the client cannot eliminate carbon dioxide from the alveoli The carbon dioxide retention results in hypoxemia Oxygen reaches the alveoli but cannot be absorbed or used properly The lungs can move air sufficiently but cannot oxygenate the pulmonary blood properly

360 Respiratory failure Respiratory failure occurs as a result of mechanical abnormality of the lungs or chest wall, a defect in the respiratory control center in the brain, or an impairment in the function of the respiratory muscles

361 Respiratory failure/Signs and Symptoms
Dyspnea Headache Confusion Restlessness Tachycardia Cyanosis Dysrhythmias Decreased level of consciousness Alterations in respirations and breath sounds

362 Respiratory failure/what to do?
Identify and treat the cause Administer O2 as prescribed to maintain the PaO2 level above 60 mm Hg Place the client in high Fowler’s position Encourage deep breathing Administer bronchodilators as prescribed Prepare the client for mechanical ventilation if supplemental O2 cannot maintain acceptable PaO2 levels

363 Pleural effusion The collection of fluid in the pleural space
Any condition that interferes with either secretion or drainage of this fluid will lead to pleural effusion

364 Pleural effusion/signs and symptoms
Pleuritic pain that is sharp and increases with inspiration Dyspnea on exertion Dry nonproductive cough caused by bronchial irritation or mediastinal shift Malaise

365 Pleural effusion/signs and symptoms
Tachycardia Elevated temperature Decreased breath sounds CXR shows pleural effusion and a mediastinal shift away from the fluid

366 Implementation Identify and treat underlying cause Monitor vital signs
Monitor breath sounds Place client in high Fowler’s position Encourage coughing and deep breathing Prepare client for thoracentesis

367 Chronic Obstructive Pulmonary Disease (COPD)
5th leading cause of death in US

A combination of asthma, chronic bronchitis, & emphysema. May see only one or two, but usually all three. COLD- Chronic Obstructive Lung Disease CAL – Chronic Airflow Limitation

Pulmonary function test common diagnostic procedure Provides info about airway dynamics, lung volumes, and diffusing capacity Airway dynamics – patients ability to inhale or exhale by force Diffusing capacity – ability of gases to diffuse across the alveolar capillary membrane Test are effort dependent – patient must be mentally alert, cooperative and able to follow directions.

370 Reactive Airway Disease

371 Asthma Attacks Early /acute episode:
Begins when triggers ( allergens, irritants, infections, exercise) activate the inflammatory process Airway constrict & becomes edematous Mucus secretions increases, forming plugs in the ariways Tenacious sputum is produced Usually occur within minutes after exposure to the trigger and resolve some minutes later Fig 31-1 page 551

372 Asthma Late Phase Begins 5-6 hours after the early phase
Red & white blood cells infiltrate the swollen tissues of the airways Lasts several hours or days Risk for another acute episode until the phase subsides

373 Bronchospasm Constriction of the bronchi & broncioles.
Results in a ventilation perfusion mismatch Severe, persistent bronchospasm is called status asthmaticus



ABG’s if moderate to severe symptoms


CONTROLLERS – PROVIDE LONG TERM CONTROL Beta 2 receptor agonists are the most often used relievers Controllers: inhaled glucocorticoids, leukotriene inhibitors, long acting beta 2 receptor agonists, mast cell stabilizers and xanthines.


380 Chronic Bronchitis Inflammation caused by inhaled irritants, including cigarette smoke At first, only large airways are affected, but smaller airways are eventually involved. Mucus obstructs the airway, causing air to be trapped in distal portions of the lungs Alveolar ventilation is impaired and hypoxemia may develop See Teaching Plan page 561 for Chronic Bronchitis and Emphysema

381 Cor-Pulmonale Right sided heart failure secondary to pulmonary disease.

382 Emphysema ( Pink Puffer)
Centrilobar cigarette smoking Affects mainly the respiratory bronchioles Panlobular hereditary deficiency of alpha 1 -antitrypsin Affects the respiratory bronchioles and the alveoli. May have both at the same time Figure 31-4 Page 554

383 Emphysema Alveolar walls breakdown cause permanent distention of air spaces & decrease in elastic recoil. Partially collapsed airways. Bullae & blebs develop

384 Complications Heart failure Respiratory failure Increased PaCO2
Decreased PaO2

385 Factors Leading to Complications
Infection air pollution smoking adverse drug reaction Left ventricular failure MI PE Spontaneous Pneumothorax

386 Signs & Symptoms Bronchitis Productive Cough External Dyspnea Wheezing
Elevated RBC Cor Pulmonale- dyspnea, cyanosis, peripheral edema, “blue bloater”

387 Emphysema Dyspnea on exertion, then on rest thin patients
use accessory muscles increase in chest diameter “barrel chest” “Pink Puffers”

388 Emphysema without Chronic Bronchitis
Diagnosis: History & exam, PFT decrease in forced expiratory volume and forced vital capacity increase in residual capacity and volume and total lung capacity

389 Treatment Drug therapy oxygen therapy Chest physiotherapy Exercise
Nutrition Surgical Treatment (lung volume reduction surgery) LVRS

390 Lung Volume Reduction Surgery
Up to 30% of the hyperinflated lung tissue is excised to improve the mechanics of breathing, enabling the patient to breath more deeply Effectiveness still being evaluated Recovery period is long Mortality rate 5%-10%

391 Bronchiectasis Abnormal dilation and distortion of bronchi & bronchioles, usually confined to one lung lobe or segment. Typically follows recurrent inflammatory conditions infections or obstruction. Some times congenital.

392 Signs and Symptoms Coughing.
Production of purulent sputum in large quantities. Fever hemoptysis nasal stuffiness sinus drainage Fatigue weakness

393 Treatment Control symptoms prevent spread. Antibiotics oxygen therapy
chest physiotherapy

394 Cystic Fibrosis Hereditary disorder

395 Cystic Fibrosis

396 Cystic Fibrosis Hereditary disorder Dysfunction of the exocrine gland
Production of thick tenacious mucous Obstruction of the pancreatic ducts so that pancreatic enzymes cannot be delivered to the GI tract Stools bulky and foul smelling Women have reduced fertility Males often have vas deferens absent

397 Complications Infection. Emphysema. Atelectasis.

398 Treatment of Cystic Fibrosis
Pancreatic enzyme replacement Chest physiotherpay Aerosol & nebulizer treatments Bronchodilators Anti-inflammatory agents Inhaled deoxyribonuclease Lung transplantation

399 Nursing Care GOAL: Effective airway clearance
Prevention/treatment of infection Adequate nutrition Effective therapeutic regimen management

400 Restrictive pulmonary disorders Reduce lung volumes
TB Sarcoidosis pneumoconiosis Interstitial fibrosis Lung cancer

401 Tuberculosis (TB) A highly communicable disease caused by Mycobacterium tuberculosis A nonmotile, nonsporulating, acid-fast rod that secrets niacin; and when the bacillus reaches a susceptible site, it multiplies freely

402 Tuberculosis (TB) Because it is an aerobic bacterium, it primarily affects the pulmonary system, especially the upper lobes where oxygen content is greatest, but can also affect other areas of the body such as the brain, intestines, peritoneum, kidney, joints, and liver

403 Tuberculosis (TB) An exudative-type response causes a nonspecific pneumonitis and development of granulomas in the lung tissue Has an insidious onset, and many clients are not aware of symptoms until the disease is well advanced

404 Tuberculosis (TB) A multidrug-resistant strain (MDR-TB) of TB can exist as a result of improper or noncompliant use of treatment programs and the development of mutations in the tubercle bacilli The goal of treatment is to prevent transmission, control symptoms and prevent progression of the disease

405 Tuberculosis (TB)/risk factors
Alcoholism Intravenous drug use Malnutrition Infection The elderly The homeless

406 Tuberculosis (TB)/risk factors
Refugees Minority groups Individuals from a lower socioeconomic group Children younger than 5 years old Individuals living in crowded areas such as long- term care facilities, prisons, and mental health facilities

407 Tuberculosis (TB)/risk factors
Individuals in constant, frequent contact with an untreated or undiagnosed individual Individuals with immune dysfunction, human immunodeficiency virus (HIV), or who are immunosuppressed from medication therapy Drinking unpasteurized milk if the cows are infected with bovine TB

408 TB-Transmission Via aerosolization or airborne route by droplet infection When an infected individual coughs, laughs, sneezes, or sings, droplet nuclei containing TB bacteria enter the air and may be inhaled by others

409 Tuberculosis (TB) transmission
Identification of those individuals in close contact with the infected individual is important so that they can be tested and treated as necessary When contacts have been identified, these people are assessed with a tuberculin test and chest x-ray study to determine infection with TB After the infected individual has received TB medication for 2 to 3 weeks, the risk of transmission is greatly reduced

410 TB-Disease progression
Droplets enter the lungs and the bacteria form a tubercle lesion The body’s defense systems encapsulate the tubercle, leaving a scar If encapsulation does not occur, bacteria may enter the lymph system, travel to the lymph nodes, and cause an inflammatory response called granulomatous inflammation

411 TB-Disease progression
Primary lesions form; the primary lesions may become dormant, but can be reactivated and become a secondary infection when reexposed to the bacterium In an active phase, TB can cause necrosis in the lesions, leading to rupture and the spread of necrotic tissue, and damage to various parts of the body

412 TB-client history Past exposure to TB
Client’s country of origin and travel to foreign countries in which there is a high incidence of TB Recent history of influenza, pneumonia, febrile illness, cough, and foul-smelling sputum production

413 TB-client history Previous tests for TB and what the results were
Recent bacille Galmette-Guerin (BCG) vaccine (a vaccine containing attenuated tubercle bacilli that may be given to people in foreign countries or to persons traveling to foreign countries to produce increased resistance to TB)

414 TB-client history An individual who has received BCG will have a positive skin test and should be evaluated for TB with a chest x-ray study

415 TB-clinical manifestations
May be asymptomatic in primary infection Fatigue Lethargy Anorexia Weight loss

416 TB-clinical manifestations
Low-grade fever Chills Night sweats Persistent cough and the production of mucopurulent sputum, which is occasionally streaked with blood, or rust colored Chest tightness and a dull, aching chest pain may accompany the cough

417 Chest assessment Physical exam of chest does not provide conclusive evidence of TB Chest XR study is not definitive, but the presence of multinodular infiltrates with calcification in the upper lobes suggests TB If the disease is active, inflammation may be seen on the chest XR

418 Advanced disease Dullness with percussion over involved parenchymal areas, bronchial breath sounds, rhonchi, and /or crackles Partial obstruction of a bronchus, caused by endobronchial disease or compression by lymph nodes, may produce localized wheezing and dyspnea

419 Sputum cultures Sputum specimens are obtained for an acid-fast smear
A sputum culture identifying M. tuberculosis confirms the diagnosis After medications are started, sputum samples are obtained again to determine the effectiveness of therapy Most clients have negative cultures after 3 months of compliance to medication therapy

420 The hospitalized TB client
The client with active TB is placed on respiratory isolation precautions in a well-ventilated negitive pressure room The room should have at least six exchanges of fresh air per hour and should be ventilated to the outside environment if possible

421 The hospitalized TB client
The nurse wears a particulate respirator (a special individually fitted mask -N-95) when caring for the client and a gown when there is a possibility of contamination of clothing Hands are always thoroughly washed before and after caring for the client

422 The hospitalized TB client
If the client needs to leave the room for a test or procedure, the client is required to wear a mask Isolation is discontinued when the client is no longer considered infectious

423 The hospitalized TB client
After the infected individual has received TB medication for 2 to 3 weeks, the risk of transmission is greatly reduced When the results of three sputum cultures are negative, the client is no longer considered infectious

424 The client at home Provide the client and family with information about TB and ally concerns about the contagious aspect of the infection Instruct the client to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand

425 The client at home Advise the client of the side effects of the medication and ways of minimizing them to ensure compliance Reassure the client that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone Inform the client that activities should be resumed gradually

426 The client at home Instruct about need for adequate nutrition to promote healing Instruct to increase foods rich in iron, protein, vitamin C Respiratory isolation not necessary, family have already been exposed

427 The client at home Cover mouth and nose when coughing, sneezing; put used tissues in plastic bag Teach handwashing Inform client sputum culture is needed q 2-4 wks once medication is initiated

428 The client at home Inform client when results of 3 sputum cultures are negative, client is no longer infectious and can return to employment Avoid excessive exposure to silicone or dust, con cause further lung damage Instruct importance on treatment and follow-up care See Patient Teaching Plan on page 565

429 First-line medications for TB
Isoniazid (INH) Do not skip doses and take for full length of prescribed therapy Do not take with any other medication Avoid alcohol Take on empty stomach with 8 oz glass of water Avoid taking antacids with medication Avoid tyramine containing foods Notify doc if vision changes occur

430 First-line medications for TB
Rifampin Do not skip doses and take full prescribed therapy Do not take with any other medication Avoid alcohol Take on empty stomach with 8 oz glass of water, no antacids Urine, feces, sweat and tears will be red-orange in color, soft contact lenses can become permanently discolored Notify physician if jaundice develops

431 Interstitial Lung Disease
Several conditions in which there is inflammation of the lower respiratory tract and thickening and fibrosis of the alveolar walls May be cause by: Inhaled substances Connective tissue disorders No specific cause

432 Idiopatic Pulmonary Fibrosis
Formation of scar tissue in the lung tissue after inflammation or irritation Cigarette smoking Frequent aspiration Exposure to environmental or occupation substances

433 Complications Pulmonary hypertension (increased pressure in the pulmonary artery caused by obstruction to blood flow in pulmonary vessels) Cor pulmonale Ventilatory failure

434 Signs & Symptoms Medical Treatment Nonproductive cough
Progressive dyspnea Inspirational crackles Clubbing of fingertips Medical Treatment Corticosteriods Bronchodilators O2 Lung Transplant for end stage

435 Occupational Lung Disease
Inhalation of various particles in the work setting

436 Dust Ammonia Chlorine Plant and animal proteins Silica Asbestos Coal dust

437 Acute Respiratory Irritation
Ammonia or chlorine causes acute respiratory irritation Usually temporary Maybe develop pulmonary edema or alveolar damage if lower airways affected Cough Wheezing Dyspnea Tx focuses on the management of symptoms and avoidance of future exposure

438 Occupational Asthma Plant or animal proteins may cause allergic reaction Tx same for bronchial asthma Usually last only a few hours May have hyperactive airway for years

439 Hypersensitivity Pneumonitis
Allergic inflammatory response of the alveoli to inhaled organic particles Few days or may contract pulmonary edema with permanent effects Corticosteroids and avoidance of the irritants is recommended May need respiratory support if severe

440 Pneumoconiosis Inhalation of various dusts
Response to repeated exposure to silica, asbestos, or coal dust Characterized by diffuse pulmonary fibrosis and restrictive lung disease

441 Sarcoidosis Inflammatory condition that may affect the skin, eyes, lungs, liver, spleen, bones, salivary glands, joints, and heart

442 Sarcoidosis Cause is unknown
Unknown factor triggers a series of immune processes leading to the formation of clusters of cells and debris in affected tissues called granulomas May have periods of remissions and exacerbations

443 What to look for Dry cough Dyspnea Chest pain Hemoptysis Fatigue
Weakness Weight loss Fever

444 Implementation Administer corticosteroids as prescribed to control symptoms Lung transplant is the only option for patients with end stage pulmonary disease

445 Nursing Care Focuses on monitoring the patient for progressive dysfuncions

446 Histoplasmosis A pulmonary fungal infection caused by spores of Histoplasma capsulatum Transmission occurs by the inhalation of spores, which are commonly located in contaminated soil Spores are also usually found in bird droppings

447 Histoplasmosis/what to look for
Dyspnea Chills Chest px Elevated temperature Pulmonary infiltrates on chest XR

448 Histoplasmosis/what to look for
Elevated WBC count Positive skin test Positive agglutination test Splenomegaly Hepatomegaly

449 Histoplasmosis/what to do?
Administer oxygen as prescribed Administer antiemetics, antihistamines, antipyretics, and steroids as prescribed Administer fungicidal medications as prescribed Encourage coughing and deep breathing

450 Histoplasmosis/what to do?
Place client in semi-Fowler’s position Monitor vital signs Monitor respiratory status Monitor for nephrotoxicity from fungicidal medications Instruct client to spray area with water before sweeping barn and chicken coups

451 Occupational lung disease (Silicosis)
Known as asbestosis and coal workers’ pneumoconiosis Fibrotic disease of lungs caused by inhalation of inorganic dusts over long periods Common in miners and sandblasters Tuberculosis (TB) is frequent complication

452 What you might expect to see
Frequent respiratory infections Blood-streaked sputum Cough Nodular lesions in lungs seen on CXR

453 What to do? Administer antitussive as prescribed for cough
Administer medications for TB as prescribed Eliminate toxic substances Administer oxygen as prescribed Encourage coughing and deep breathing

454 Leading cause of death in the US
Lung Cancer Leading cause of death in the US

455 Lung Cancer Two major categories Small (oat cell) lung carcinoma
Non small cell lung carcinoma

456 Signs and Symptoms Persistent cough Hemoptysis Chest pain
Recurring pneumonia Recurring bronchitis Dyspnea Wt loss Pain in the shoulder arm or hand

457 Diagnosis CXR CT MRI Fibroptic bronchoscopy Sputum cytology Biopsy

458 Medical Treatment Early detection is the key Radiotherapy Chemotherapy
Targeted Biologic Therapies Surgical (see pulmonary resection figure page 567)


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