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68C 2014 P2 Test 5

Lower Airway Disorders

QuestionAnswer
Bronchitis Defined as an inflammation of the mucous membranes of the major bronchi and their branches, resulting in tenacious secretions (become a culture medium for bacterial growth)
Bronchitis causes/related: Usually secondary to an Upper Respiratory Infection (URI); May also be related to exposure to inhaled irritants
Bronchitis Clinical manifestations: Productive cough; Low grade fever; Diffuse rhonchi/wheezes, dyspnea; Chest pain; Generalized malaise, and headache
Bronchitis Subjective: question patient regarding health and presence of headache, and/or aching chest pain
Bronchitis Objective: Frequent assessment with vital signs; Auscultating breath sounds noting wheezing and basilar crackles
Bronchitis Diagnostic tests: Chest x-ray to view lung fields; Sputum culture to determine presence of bacterial infection
Bronchitis Medical Management: Bronchodilators (albuterol (Ventolin, Proventil)); Antibiotics- for active infection or prophylaxis (ampicilllin); Cough suppressants (codeine) and antitussives (dextromethorphan(Pertussinn)); Antipyretics (Tylenol)
Bronchodilators: Used to relax bronchial smooth muscle bands to dilate the bronchi and bronchioles that are narrowed as a result of the disease process (COPD, Pneumonia, Atelectasis, Acute Respiratory Distress Syndrome (ARDS))
Bronchodilators 3 Classes: 1. Beta agonist 2. Anticholinergics 3. Xanthine derivatives
Beta agonist Relief of bronchospasm. Commonly used during acute phase of an asthmatic attack to quickly reduce airway constriction.
Anticholinergics Prevent bronchoconstriction. Action is slow and prolonged therefore used for prevention of bronchospasm and not for management of acute phase.
Xanthine derivatives Used to dilate the airways in patients with asthma, chronic bronchitis or emphysema
Bronchodilators Precautions to be used with Beta- Adrenergic agonists Use caution with Beta- Adrenergic agonists due possible dysrhythmias
Bronchodilators Precautions to be used with Anticholinergics Ask client is they are allergic to peanuts, soybeans and other legumes. There have been reported cases of severe anaphylactic reactions to ipratropium inhalers in patients with peanut allergies.
Bronchodilators Precautions to be used with Xanthine derivatives 3. Monitor xanthine users for s/s of dysrhythmias, seizure disorders, hyperthyroidism and peptic ulcers
Bronchodilators Side effects include: 1. Insomnia; restlessness; dysrhythmia; cardiac stimulation; tremors; dry mouth, throat and nose; GI distress; sinus tachy; ventricular dysrhythmia
Infection, risk for, related to retained pulmonary secretions 1) Assess for signs of infection 2) Administer antibiotics and antipyretics, as ordered 3) Frequent vital signs 4) Encourage adequate PO intake 3000 to 4000 mL/day
Airway clearance, ineffective, related to tenacious pulmonary secretions 1) Bed rest with HOB elevated 2) Humidifier 3) Encourage increased fluid intake 3000 to 4000 mL/day
Airway clearance, ineffective, related to tenacious pulmonary secretions 4) Teach/assess understanding of the signs that may indicate worsening infection – purulent sputum and increased dyspnea 5) Teach/assess understanding of the importance of following the prescribed medication regimen
Airway clearance, ineffective, related to tenacious pulmonary secretions 6) Teach/assess understanding of importance of limiting exposure to others 7) Teach patient to avoid smoking or other irritating fumes
Bronchitis is good
Legionnaires’ disease Caused by the microorganism Legionella pneumophila- first identified in 1976 when it caused an outbreak of pneumonia at an American Legion convention in Philadelphia
L. pneumonia is a gram- negative bacillus that in water reservoirs such as humidifiers and air conditioners
Legionnaires’ disease transmitted airborne route
Legionella microbe progresses in two different routes influenza or Legionnaire’s disease
Legionnaire's results in life-threatening pneumonia
Legionnaire's - The pneumonia causes lung consolidation and alveolar necrosis
Legionnaire's - Progresses in less than 1 week and may result in respiratory and renal failure, bacteremic shock, and ultimately death
Legionnaire's Clinical manifestations: Significantly elevated temperature; Headache; Nonproductive cough, Diarrhea; General malaise
Legionnaire's Subjective Data: note patient’s complaints of dyspnea, headache, and chest pain on inspiration.
Legionnaire's Objective Data: 1) Significantly elevated temperature 102-105 (38.8-40.5) 2) Non-productive cough with difficult and rapid breathing 3) Auscultation will reveal crackles and wheezing
Legionnaire's Objective Data: 4) Signs of shock (tachycardia and hypotension) 5) Presence of hematuria indicting renal impairment
Legionnaire's Cultures of blood, sputum, and pulmonary tissue/fluid to confirm presence of L. Pneumophila Chest x-ray reveals patchy infiltrates and small pleural effusions
Legionnaire's Medical Management: (a) Close observation for disease progression is required (b) Patient may need to be placed on mechanical ventilation for respiratory support
Legionnaire's Medical Management: (c) Patient may also require temporary renal dialysis because of acute kidney failure (d) Adequate IV therapy for fluid and electrolyte replacement (e) Oxygen therapy (e) Medications
Legionnaire's Medications: 1) Antibiotics (erythromycin) will be given intravenously in the early course of the disease and than orally for a prolonged period 2) Rifampin is also beneficial 3) Antipyretics to control severe hyperthermia
Legionnaire's Medications: 4) Patient may require vasopressors (dopamine or dobutamine) and/or inotropes (to promote an adequate cardiac output) and to treat shock and analgesic to promote comfort
Nursing interventions Patient will be maintained on bed rest, and I & O’s will be monitored
Tissue perfusion, ineffective cardiopulmonary or renal, related to lack of oxygen 1) Closely monitor and report any S/S of impending shock (decreased BP, Increased HR) 2) Administer vasopressors as ordered and closely monitor vital signs
Tissue perfusion, ineffective cardiopulmonary or renal, related to lack of oxygen 3) Maintain hydration status and urinary output (> 30 ml/hr) 4) Assess for changes in level of consciousness
Breathing pattern, ineffective, related to respiratory failure 1) Asses for S/S of respiratory failure. Note resp rate, rhythm, and effort. 2) Be alert for cyanosis and dyspnea 3) Assist with oxygen therapy or mechanical ventilation
Breathing pattern, ineffective, related to respiratory failure 4) Facilitate optimal ventilation-place patient in semi-fowlers, suction as needed 5) Have patient CDB every 2 hours
Legionnaire's Prognosis: severe, often fatal disease with mortality reaching 15-20%
Anthrax Caused by the spore-forming bacterium Bacillus anthracis- anthrax most commonly infects wild and domestic hoofed animals
Anthrax is spread Through direct contact with bacteria and its spores; dormant, encapsulated bacteria become active when they enter a living host. Spores enter humans via skin, intestines, or lungs. It is not contagious by person-to-person
Three types of anthrax 1) Cutaneous 2) Gastrointestinal 2) Gastrointestinal
Cutaneous Most common type of Anthrax: Occurs after a spore enters the skin through a cut or abrasion. A macule or papule will occur that at first appears as an insect bite until a black eschar forms and becomes edematous. Typically not fatal if treated with antibiotics.
Gastrointestinal Least common type of Anthrax: Occurs after ingestion of contaminated undercooked food causing ulcers through the GI tract. Patient may die from sepsis if not treated early.
Inhalation Most Deadly type of Anthrax: Most deadly type. Develops when spores inhaled deeply in to lungs. Immune cells sent to fight infection will carry bacteria to the lymph system leading to a systemic spread.
Anthrax Diagnostic Test: Chest x-ray helps differentiate from pneumonia 1) A widened mediastinum due to lymphadenopathy is characteristic of inhalational anthrax 2) Infiltrates characterize pneumonia
Anthrax Single Screening: No single reliable screening test is available although the Mayo Clinic developed a rapid DNA test to identify anthrax in people and the environment
Intestinal anthrax Testing Obtain a stool specimen for culture; Obtain a blood smear, culture, and chest x-ray for anyone with symptoms.
Cutaneous anthrax Testing Obtain a culture specimen from the lesion’s vesicular fluid.
Anthrax Medical Management: Antibiotic therapy is indicated for anyone diagnosed with anthrax or exposed to anthrax spores.
Anthrax Medications: Ciprofloxacin (Cipro) is considered the treatment of choice for all three forms of anthrax due to concerns the genetically altered forms may resist older antibiotics (although most strains are susceptible to other antibiotics)
Anthrax therapy recommended: 60 day course of therapy recommended Alternative therapy is 30 days of antibiotics and three doses of the anthrax vaccine if it is available. Anthrax vaccine is available for soldiers
Tuberculosis Chronic pulmonary and extrapulmonary infectious disease.
Tuberculosis Acquired by inhalation of a dried droplet nucleus containing a tubercule bacillus, Mycobacterium tuberculosis, into the alveoli (not easily transmitted, as the upper respiratory system is effective at preventing transmission to alveoli)
Tuberculosis Most commonly affects the lungs but can affect other parts such as skin, gastrointestinal system, genitourinary system, musculoskeletal system, nervous system and lymph nodes
Tuberculosis In the lung, pulmonary macrophages ingest TB bacteria; they engulf the organisms, but do not kill them and eventually form hard capsules called tubercles.
Tuberculosis The tubercle bacillus can remain dormant for more than 50 years; therefore patients who are positive for the infection may develop the disease in later years, if immunocompromised.
Tuberculosis Within 2-10 weeks lymphocytes usually control the initial infection.
Tuberculosis Characterized by stages of early infection (frequently asymptomatic), latency and potential for recurrence
Tuberculosis Infection always precedes active disease, however, only about 10% of infections progress to active disease.
Tuberculosis Infection characterized by the presence of mycobacteria in the tissue of a patient who is free from clinical signs and symptoms and demonstrates antibodies against the mycobacteria. Those infected but not converted will have a positive skin test and a negative chest x-ray
Tuberculosis Disease Pathologic and functional signs and symptoms indicating destructive activity of mycobacteria in host tissue
Tuberculosis Predisposing factors- status of the host’s immune system is the major determinant for the development of active TB. Close contact ( especially children and adolescents) with people with active TB Medically underserved low income populations
Tuberculosis Predisposing factors- Health care workers who provide services to high-risk group. People born in countries with a high prevalence of TB Alcoholics, IV drug users, cocaine and crack users
Tuberculosis Predisposing factors- Residents of long-term care facilities eg nursing homes, prisons, mental institutions, homeless shelters etc. Elderly
Tuberculosis Conditions that increase risk of TB after infection 1) Immunosuppression (especially HIV positive) 2) Diabetes 3) Chronic renal failure 4) Underweight (more than 10% below ideal body weight) 5) Prolonged use of corticosteroids
Tuberculosis Clinical manifestations- May be no clinical manifestations or symptoms may develop insidiously: Early symptoms include Anorexia/weight loss; Productive cough; Fever; Weakness;
Tuberculosis Later symptoms: Daily reoccurring fever with chills Night sweats Hemoptysis
Tuberculosis Subjective note reports of loss of muscle strength and weight loss
Tuberculosis Objective evaluating and reporting characteristics of sputum (amount, color)
Tuberculosis Diagnostic test: Mantoux tuberculin skin test using purified protein derivative (PPD). Known as TB skin test or PPD. Sputum culture-acid fast bacillus (AFB).
Tuberculosis Sputum culture-acid fast bacillus (AFB) will be done to confirm the diagnosis of active TB- three positive acid-fast smears indicate a presumptive diagnosis
Tuberculosis All patients with TB must be reported to the appropriate public health authority for case follow-up and investigation of contacts
Tuberculosis The PPD needs to be read 48-72 hours later. Measure and record the subsequent induration (an area of hardened tissue); do not measure the erythema (redness)
Tuberculosis Mantoux tuberculin skin test A negative reaction is less than 5mm A positive TB test indicates tubercle bacillus is present in body, but not necessarily that the patient has active tuberculosis
Tuberculosis Medical management Isolation Adult patients remain in respiratory isolation during hospital stay. Requires negative pressure room. Patients must wear particulate matter mask when leaving room.
Tuberculosis Infants and children do not generally require isolation because they rarely cough and have low concentrations of AFB in their sputum
Tuberculosis Medications- drug therapy is the specific treatment for active TB, regardless of the organ involved. Infectiousness declines rapidly once treatment has begun.
Tuberculosis Medication Treatment usually consists of a combination of at least 4 drugs. If only one medication is used the patient may become resistant
Tuberculosis Treatment is 6-9 months, if treatment is not continued for a sustained period of time the patient will be at risk for reinfection with a more resistant bacillus
Tuberculosis Nursing interventions Isolation measures (respiratory isolation/ negative pressure) must be implemented immediately for suspected untreated TB.
Tuberculosis Nursing interventions Negative pressure room (air flows intro rather than out of the room) with doors and windows kept closed- room air is vented directly to the outside to prevent contamination. Use of particulate matter mask
Tuberculosis Nursing interventions Focus on preventing complications and illness transmission. Employ drainage and secretion precautions until wounds from patient with extrapulmonary TB stop draining to prevent transmission of organism.
Breathing pattern, ineffective, related to pulmonary infection process 1) Monitor breathing for dyspnea or signs of pneumothorax (decreased breath sounds on affected side, SOB, deviated trachea)
Breathing pattern, ineffective, related to pulmonary infection process 2) Evaluate degree of respiratory effort and assist as needed 3) Assess sputum for hemoptysis 4) Assist patient to turn, cough, and deep breathe Q 2-4 hrs
Infection, risk for (patient contacts), related to viable M tuberculosis in respiratory secretions 1) Proper collection of sputum specimens 2) Instruct patient to cover nose and mouth when coughing or sneezing and proper disposal of expectorated sputum and Instruct the patient on proper hand washing
Infection, risk for (patient contacts), related to viable M tuberculosis in respiratory secretions 3) Use AFB isolation until antimicrobial therapy is effective 4) Employ drainage and secretion precautions for extrapulnmonary TB patient 5) Administer antituberculosis medications as ordered
Infection, risk for (patient contacts), related to viable M tuberculosis in respiratory secretions 6) Teach/assess understanding of the importance to report hemoptysis, dyspnea, vertigo or chest pain 7) Teach/assess understanding of maintaining adequate volume intake and nutritional balance
Tuberculosis Prognosis As many as 50% of patients fail to complete treatment. Numerous drug resistant strains have been reported (esp. in HIV patients) - these strains are often highly virulent and have a mortality rate of 72 to 89%
Antituberculars Use: Treatment and prevention of active tuberculosis. Combinations are used in the treatment of active disease tuberculosis to rapidly decrease the infectious state and delay or prevent the emergence of resistant strains.
Antituberculars Treatment: Treatment of active TB usually consists of a combination of at least 4 drugs. If only one medication is used the patient may become resistant
Antituberculars Treatment: If only one medication is used the patient may become resistant Treatment is 6-9 months, if treatment is not continued for a sustained period of time the patient will be at risk for reinfection with a more resistant bacillus
Antituberculars Treatment: Directly Observed Therapy (DOT) may be instituted for certain patients who are at risk for non-compliance and requires a health care worker to observe the patient ingesting the medications
Antituberculars: Antitubercular drugs fall into two categories: Primary or first-line, and secondary or second-line drugs. First line drugs include Isoniazid (INH) and Rifampin. First line drugs are those that are tried first, whereas secondary drugs are reserved for more complicated cases.
Antituberculars Typical 4 drug regimen consists of isoniazid, rifampin, pyrazinamide (PZA), and ethambutol or streptomycin
Antituberculars work by inhibiting protein synthesis, inhibiting cell wall synthesis, or various other mechanisms.
Antituberculars Major effects include reduction of cough and, therefore, reduction of the infectiousness of the patient. This normally occurs within 2 weeks of the initiation of drug therapy assuming the patient’s TB strain is drug sensitive.
Antituberculars Contraindications: Hypersensitivity. Severe renal or liver dysfunction The urgency of treating a potentially fatal infection may have to be balanced against any prevailing contraindications
Antituberculars Contraindications: Ethambutol requires ophthalmologic follow-up. Safety in pregnancy and lactation not established, although selected agents have been used without adverse effects on the fetus. Compliance is required for optimal response.
Antituberculars Side Effects/Adverse Reactions Most antitubular drugs fairly well tolerated
Antituberculars Side Effects/Adverse Reactions Isoniazid: noted for causing pyridoxine deficiency and liver toxicity. For this reason, supplements of pyridoxine (vit B6) often given concurrently. Increased risk for liver toxicity if alcohol is consumed during treatment.
Antituberculars Side Effects/Adverse Reactions Rifampin: discoloration of all body fluids (red).
Antituberculars Assessment: Mycobacterial studies and susceptibility tests should be performed prior to and periodically throughout therapy to detect possible resistance. Throughout therapy assess lung sounds and character and amount of sputum, liver function, and renal studies.
Antituberculars Implementation: Because drug therapy is the mainstay of treatment of TB and often lasts for up to 24 months, patient education is critical, with special emphasis on adherence to the drug regimen.
Antituberculars Implementation: Advise client of the importance of continuing therapy even after symptoms have subsided. Emphasize the importance of regular follow-up exams to monitor progress and check for side effects.
Antituberculars Implementation: Inform clients taking rifampin that saliva, sputum, tears, urine, and feces may become red-orange to red-brown and that soft contact lenses may become permanently discolored. Drugs may need to be taken with food to minimize GI upset.
Antituberculars Evaluation: Resolution of signs and symptoms of tuberculosis. Monitor for adverse reactions.
Pneumonia Inflammatory process of the respiratory bronchioles and the alveolar spaces caused by an infection- may also be caused by aspiration, over-sedation and inadequate ventilation.
Pneumonia Can occur in any season, but is most common during the winter and spring
Pneumonia Persons of all ages are susceptible, but more common in infants and older adults
Pneumonia Susceptible patients Persons with damaged or altered respiratory defense mechanisms Persons with a disease affecting antibody response Alcoholics (increased danger of aspiration) Persons with delayed WBC reaction to infection
Pneumonia Persons with damaged or altered respiratory defense mechanisms include: COPD, Influenza, Tracheostomy, Recent anesthesia
Pneumonia Classified according to organism and not location of infection (as was done in the past)
Pneumonia Causes Bacterial pneumonia is marked by alveolar pus formation with consolidation (half of the cases of pneumonia are bacterial and half are viral) Viral produces interstitial inflammation with no consolidation or exudates (mycoplasma included here)
Pneumonia Causes Fungal/mycobacterial marked by patchy distribution with necrosis and development of cavities. Chemical- presentation depends on the causative agent.
Pneumonia Bacterial pneumonia Streptococcus pneumoniae (pneumococcal) Hemolytic strep type A Staphylococcus aureus Haemophilus influenza (type B)
Pneumonia Nonbacterial or atypical pneumonia Mycoplasma; Legionnaire’s disease; Pneumocystis carinii
Pneumonia Aspiration pneumonia (usually caused by aspiration of vomitus when the patient's consciousness is altered) Staphylococcus aureus; Escherichia coli; Klebsiella; Pseudomonas; Proteus
Pneumonia Pathophysiology: Pulmonary cilia cannot remove secretions; Retained secretions become infected; Inflammation of the respiratory tract leads to localized edema; The edema leads to decreased oxygen-carbon dioxide exchange, resulting in retained CO2 and hypoxia
Pneumonia Clinical manifestations- dependent on the type of pneumonia Elevated temperature and night sweats; Painful, productive cough; Purulent sputum- color and consistency of sputum will vary depending on the type of pneumonia present; Increased heart rate; Tachypnea with difficult expiration
Pneumonia Subjective Description of onset, duration, and history of cough Complaints of fever and night sweats
Pneumonia Objective Level of consciousness; Vital signs every two hours with emphasis on temperature and respirations; Monitor color, consistency, and amount of sputum; Observe respiratory effort and difficulty with breathing. Note of any cyanosis or dyspnea; Crackles
Pneumonia Diagnostic tests Blood and sputum cultures; Chest x-ray; CBC; Pulmonary function test; ABG; Oximetry
Pneumonia - Blood and sputum cultures identify organism - sputum culture and sensitivity should be collected before initiation of antibiotic therapy to identify causative agent
Pneumonia - Chest x-ray reveals changes in density, particularly in the lower lobes
Pneumonia - CBC WBC may be elevated in bacterial pneumonia and decreased in viral or mycoplasmal pneumonia
Pneumonia - Pulmonary function test to determine if lung volume is decreased
Pneumonia - ABG to identify altered gas exchange
Pneumonia - Oximetry for rapid and continuous assessment of oxygen requirements
Pneumonia Medications Antibiotic therapy as appropriate, depending on the causative organism and sensitivity- common agents: penicillin, erythromycin, cephalosporins and tetracycline Antibiotics should not be used for viral pneumonias
Pneumonia Medical Management: O2 therapy if inadequate gas exchange (If oxygen saturation of less than 91%). Analgesics/antipyretics Expectorants Bronchodilators Vaccine is now available for the most common and important bacterial pneumonia, streptococcal pneumonia
Pneumonia Indicated for: Patients with chronic illness, i.e. respiratory or cardiac or diabetes Patients recovering from serious illness Patients older than 65 Patients in a nursing home or long-term health care facility
Pneumonia Medical Management: Physiotherapy Humidification with humidifier or nebulizer if secretions are tenacious and copious Chest tube if pus in pleural space
Physiotherapy Chest percussion and postural drainage- encourage patient to cough, deep breathe, use incentive spirometer and ambulate, as able to mobilize secretions
Pneumonia Nursing implications Are aimed at assisting the patient to conserve energy
Breathing pattern, ineffective, related to the inflammatory process and pleuritic pain 1) Assess ventilation to include respiratory effort and signs of respiratory distress 2) Elevate HOB to facilitate breathing (High Fowler’s position). Place “good lung down” to improve oxygenation.
Breathing pattern, ineffective, related to the inflammatory process and pleuritic pain 3) Auscultate breath sounds crackles, wheeze, and pleural friction rub frequently. 4) Instruct patient on the importance of consuming large quantities of fluid up to 3L/day and measure I&O.
Breathing pattern, ineffective, related to the inflammatory process and pleuritic pain 5) Encourage patient to conserve energy to prevent fatigue. 6) Administer antibiotics; instruct patient on action, dosage, and frequency of administration and side effects. 7) Encourage deep breathing and coughing.
Gas exchange, impaired, related to alveolar-capillary membrane changes secondary to inflammation 1) Assess patient to identify signs of hypoxia (restlessness, disorientation, and irritability). 2) Analgesics for pain with careful monitoring of respiratory status.
Gas exchange, impaired, related to alveolar-capillary membrane changes secondary to inflammation 3) Monitor color, pulse, respiratory rate, and pulse oximetry readings. Carefully monitor temperature, which may fluctuate due to alterations in metabolism or infection. 4) Administer oxygen if ordered to maintain oxygen saturation above 91%.
Patient teaching should focus on disease process and management Instruct/assess patient understanding of importance of hand washing and on the proper disposal of sputum Instruct/assess understanding of the ability of streptococcal pneumonia vaccine and its impact on the patient's overall health
Patient teaching should focus on disease process and management Teach/assess understanding of when the patient should return to see the physician (change in sputum color or characteristic, decreased activity tolerance, fever despite antibiotics, increasing chest pain)
Pneumonia Prognosis Pneumonia usually resolves within 2-3 weeks with proper treatment Major cause of disease and death in critically ill patients Despite the use of antibiotics, pneumonia and influenza still remain the seventh leading cause of death in North America
Pneumonia Prognosis Bacterial aspiration pneumonia carries a poor prognosis even with antibiotic therapy. It may cause extensive lung damage, resulting in lung abscess or empyema. Mortality ranges between 15 and 70% depending on the causative agent
Older adult considerations: Changes of aging affect respiratory function and ability to fight infection
Older adult considerations: Drier mucous membranes decrease cilia function and increase the risk for inflammation and infection- adequate hydration is important, as it helps liquefy secretions and aids expectoration
Older adult considerations: Kyphosis and calcification of costal cartilage are common changes that cause restriction of the expansion of the thoracic cavity
Older adult considerations: Intercostal muscles and diaphragm lose elasticity results in decrease ability to breathe deeply and cough
Older adult considerations:The elasticity of airways and alveoli, and pulmonary blood decreases, resulting in an increased risk for impaired gas exchange
Older adult consideration: Inactivity and immobility increase the risk of pooling of secretions, increasing the risk for pneumonia
Older adult considerations: Older patients often have trouble expectorating, increasing breathing difficulty and making specimen retrieval more difficult
Older adult considerations Neurologic changes associated with stroke and other conditions increase risk for aspiration pneumonia
Pneumonia: Older adult considerations: Signs and symptoms of pneumonia are often atypical Fever, cough, and purulent sputum are often absent Generalized symptoms such as lethargy, chills, chest pain, tachypnea, vomiting and exacerbation of pre-existing conditions should be viewed with suspicion as they could indicate pneumonia
Pneumonia: Older adult considerations:Older patients living in institutions should have yearly TB screening- many patients are positive for TB infection from childhood, and therefore should receive a yearly CXR
Pneumonia: Older adult considerations: Watch older immigrants and immunosuppressed patients for drug-resistant strains of TB
Antitussives Suppress the body’s natural cough mechanism - Coughing serves to remove potentially harmful foreign substances and excessive secretions from the respiratory tract.
Antitussives - There are times when it is not useful and may even be harmful i.e. after a surgical procedure or in the case of a nonproductive or “dry” cough. Antitussives inhibit this otherwise normal response of coughing.
Antitussives Two main categories (1) Opiods-Codeine and Hydrocodone (2) Nonopioid-less effective Examples most common Dextromethorphan (Pertussin, Robitussin, Theraflu, Vicks) benzonatate (Tessalon)  guaifenesin (Robitussin).
Antitussives Action: 1. Suppressing the cough reflex by direct action on the cough center in the medulla. 2. Opioid antitussives also provide analgesia and have a drying effect on the mucosa of the respiratory tract which increases the viscosity of respiratory secretions
Antitussives Contraindications- Only absolute is drug allergy (1) Dextromethorphan: Hyperthyroidism (2) Codeine and hydrocodone: contraindicated with alcohol use
Antitussives High risk for respiratory depression eg. frail elderly patients or opioid dependency. These patients often able to tolerate lower medication dosages and still get some relief.
Antitussives Side Effects (most common): (1) Dizziness. (2) Drowsiness. (3) Nausea. (4) Vomiting.
Antitussives Interactions: vary amongst products, check individual products for specific information.
Antitussives Patient Teaching: (a) Do not exceed the recommended dosage. (b) If chills, fever, chest pain or sputum production occurs, notify primary health care provider. (c) If cough is not relieved or becomes worse, contact the primary health care provider.
Antitussives Patient Teaching: (d) Avoid irritants such as cigarette smoke, dust or fumes to decrease irritation to the throat. (e) Take frequent sips of water, suck on sugarless hard candy or chew gum to diminish coughing.
Expectorants Aids in expectoration (coughing up and spitting out) of excessive mucus by breaking down and thinning out the secretions Reduces the viscosity of tenacious secretions
Expectorants Used for the relief of a productive cough. By loosening and thinning sputum and bronchial secretions, they may also indirectly diminish the tendency to cough. Guaifenesin is a very commonly used expectorant.
Pleurisy Inflammation of the visceral and parietal pleura (the double membrane covering the lungs)
Pleurisy Causes: Bacterial or viral infection
Pleurisy May occur spontaneously but usually a complication of: Tuberculosis; Pleural trauma; Pulmonary infarction; Lung cancer; Viral infections of intercostal muscles
Pleurisy Clinical manifestation: Sharp inspiratory pain often radiating to the shoulder or the abdomen of the affected side (caused by stretching of the inflamed pleura); Fever and dry cough will result if the patient develops a pleural effusion; Dyspnea; Elevated temperature
Pleurisy Subjective: Patient’s complaint of chest pain on inspiration and possibly elevated temperature
Pleurisy Objective: 1) Assess the nature of inspiratory pain, to include radiation 2) Frequent vital signs, including temperature (Q 2-4 hours) 3) Respiratory rate and rhythm, noting dyspnea 4) Pleural friction rub
Pleurisy Diagnostic tests: Pleural friction rub may be considered diagnostic Chest x-ray is of limited value unless there is presence of a pleural effusion
Pleurisy Medications: Analgesics (demerol or morphine) and antipyretics (Tylenol); Antibiotics to treat underlying cause (penicillin); Oxygen therapy with inadequate gas exchange; Anesthetic block of intercostal nerves
Pain, related to stretching of pulmonary pleura as a result of fluid accumulation 1) Assess for pain. 2) Administer medications as ordered and assess effectiveness 3) Provide non-pharmacologic comfort measures
Pain, related to stretching of pulmonary pleura as a result of fluid accumulation 4) Encourage lying on the affected side occasionally to splint chest wall.
Gas exchange, impaired, related to pain on inspiration and expiration. 1)Assess LOC, noting any increase in restlessness or disorientation 2)Auscultate lungs for wheezes, crackles, and pleural friction rub
Gas exchange, impaired, related to pain on inspiration and expiration. 3) Teach patient to cough and deep breathe every 2 hours and to splint rib cage when coughing
Gas exchange, impaired, related to pain on inspiration and expiration. 2) Heat may be applied to the affected side. 3) Elevate head of bed 4) Reposition patient every two hours
Pleural effusion/Empyema Fluid accumulation in the pleural space; may or may not be infected Rarely a primary process, but occurs when the physiologic pressure in the lungs and pleurae is disturbed.
Pleural effusion/Empyema Pancreatitis, cirrhosis of the liver and heart failure are common causes that can alter the permeability in the lungs and pleura
When the fluid is infected, it is called empyema. (Usually bacterial associated with pneumonia, TB and blunt chest trauma) May be acute or chronic If untreated, the pleura may become scarred and fibrosed, losing its elasticity
Pleural effusion/Empyema Clinical manifestations Generally associated with other disease processes, such as pancreatitis, cirrhosis of the liver, pulmonary edema, congestive heart failure, etc. Patient may have persistent fever despite antibiotics
Pleural effusion/Empyema Subjective: Assess patient’s dyspnea and complaints of air hunger. Assess fear and anxiety related to decreased level of oxygen.
Pleural effusion/Empyema Objective: Assess for signs and symptoms of respiratory distress: Nasal flaring, Tachypnea, Dyspnea, Decreased breath sounds, Frequent vital signs, especially temperature
Pleural effusion/Empyema Diagnostic tests: CXR to visualize effusions or fluid accumulation. Thoracentesis to obtain specimen for culture, as well as symptomatic treatment of dyspnea.
Pleural effusion/Empyema Medical Management: Thoracentesis 1) Performed to remove fluid from the pleural space and obtain specimen for culture 2) Fluid should not be removed too rapidly to avoid hypotension (less than 1300-1500 ml at a time is recommended)
Pleural effusion/Empyema Medical Management: Chest tube placement 1) Instituted for continuous drainage (see objective G for chest tube management) 2) Re-establishes a negative pressure in the pleural cavity that will facilitate expansion of the lung, restoring normal pleural pressure
Pleural effusion/Empyema Prognosis: variable, depending on the patient's overall health status
Gas exchange, impaired, related to ineffective breathing pattern. 1) Asses for change in LOC. 2) Monitor ABG and pulse oximetry. 3) Encourage cough and deep breathe 4) Reposition at least every two hours. 5) Assess for atelectasis
Chest Tubes and Drainage System Chest tubes are inserted for continuous drainage of fluid, blood or air from the pleural cavity and for medication instillation. They attach to closed drainage system are placed in the pleural cavity, sutured in place, covered with a sterile dressing.
A closed system is used to prevent lung from collapsing by maintaining normal negative pressure in the pleural space
The anterior chest tube is placed in the anterior chest wall and is used to remove air from the pleural space (chest tube will terminate near the apex of the lung)
The chest tubes are connected to a pleural drainage system with collection, water-seal, and suction control chambers to drain secretions and reestablish negative pressure in the pleural space
Nursing interventions and patient teaching General nursing measures include placing patient on bed rest and ensuring patency of chest tubes.
Areas of concern for maintaining chest tubes and closed system drainage include the following: Proper system function: 1) Ensure that water in the water seal chamber fluctuates when suction is applied 2) Bubbling in the water seal indicates an air leak.
Areas of concern for maintaining chest tubes and closed system drainage: Potential atelectasis resulting from hypoventilation- assess for dyspnea and ensuring serial chest x-ray are done. Increased air in the pleural space noting air leaks and tube patency.
Areas of concern for maintaining chest tubes and closed system drainage: Air leaks will be noted with bubbling in the water seal chamber (often indicates that one of the ports of the CT is outside of the chest- can be controlled with petroleum gauze if small) Check often for blocking of tube with clots, or kinking of tube
Areas of concern for maintaining chest tubes and closed system drainage: Infection: Monitor for increase in WBC Monitor for purulent drainage
Nursing interventions and patient teaching Position patient on unaffected side to avoid tube kinking, but allow patient to assume a position of comfort and recheck tube for kinks. Facilitate incentive spirometry, cough, and deep breathe.
Nursing interventions and patient teaching Document amount and characteristic drainage by marking the drainage level at the end of each shift (mark drainage device each shift and document on I&O)
Nursing interventions and patient teaching Carefully position drainage system (should not have dependent loops and should not go over side rails) and secure connections (with tape) to avoid accidental removal of the chest tube.
Nursing interventions and patient teaching Ambulation is not contraindicated as long as water seal remain below level of chest patients are usually not allowed to ambulate around the ward until the chest tube rainage is controlled enough for patient to go to water seal).
Atelectasis The collapse of lung tissue; May be limited to a small area or larger areas of the lung; Prevents the exchange of carbon dioxide and oxygen.
Atelectasis Causes: Ineffective clearance of secretions due to shallow breathing postoperatively hypoventilation); Mucous accumulation; Prolonged bed rest and hypoventilation; Aspiration of food or vomitus (blocking of a bronchiole); Compression in lung tissue by tumors
Atelectasis: Hypoventilation causes all or part of the lung to collapse
Atelectasis: Mucous accumulation leads to bronchial obstruction
Atelectasis: Can lead to stasis pneumonia because the retained secretions can lead to bacterial growth
Atelectasis: Clinical manifestations: Depends on the site and degree of the obstruction. If a small bronchiole becomes obstructed, there may be few, if any, symptoms, as the remainder of the lungs will attempt to compensate.
Atelectasis Clinical manifestations: If the mainstem bronchus is obstructed, severe ventilator compromise occurs
Atelectasis Clinical manifestations: Fever, and dyspnea; Pleural friction rub; Restlessness; Hypertension
Atelectasis Subjective: patient complaints of shortness of breath, air hunger, anxiety, and fatigue
Atelectasis Objective: Decreased breath sounds and crackles; Hypertension initially, followed by hypotension; Monitor respiratory rate and effort; Assess for altered level of consciousness due to hypoxia.
Atelectasis Diagnostic tests: Serial chest x-ray reveals atelectatic changes; Chest CT scan can detect compression of the airway; ABG may reveal PaO2 less than 80mmHg; pulsoximetry may reveal oxygen saturation less than 90%; Bronchoscopy
Atelectasis Medical management: Atelectasis frequently requires chest tube insertion to re-expand lung. (2) Instruct patient to deep breathe and cough to raise secretions. Incentive spirometry 10 times/hr provides visual feedback of respiratory effort.
Atelectasis Medical management: Patient may require intubation and mechanical ventilation. Patient may require suctioning, coughing, and vigorous respiratory therapy. A bronchoscope can be used to remove a thick tenacious secretion or a mucous plug
Atelectasis Medical management: Medications include bronchodilators to facilitate secretion removal, antibiotics to prevent infection and mucolytic agents to reduce viscosity of secretions.
Airway clearance, ineffective, related to inability to clear secretions 1) Assess ability to move secretions 2) Humidifying air and bronchodilators to loosen and remove secretions 3) Incentive spirometry, deep breathing and coughing
Airway clearance, ineffective, related to inability to clear secretions 4) Encourage adequate hydration to liquefy secretions 5) Auscultate breath sounds 6) Assess color, amount, and consistency of sputum 7) Chest physiotherapy with postural drainage
Coping, ineffective, related to invasive medical regimen Identify patient’s emotional support system 2) Asses patient’s ability to comply with prescribed regimen
Created by: 68C2014