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Timby/Smith: Introductory Medical-Surgical Nursing, 10/e Chapter 21: Caring for Clients with Lower Respiratory Disorders
Acute Bronchitis
Inflammation of Bronchial Mucous Membranes; Tracheobronchitis
Cause: Bacterial and fungal infection; Chemical irritation Diagnostics: Sputum cultures; Chest film Signs/Symptoms: (Initial) Non-productive cough, Fever, Malaise; (Later) Bloodstreaked sputum, Coughing attacks; Inspiratory crackles Treatment: Antipyretics; Expectorants; Antitussives; Humidifiers; Broad-spectrum antibiotics Nursing Management
Pneumonia
Pathophysiology
Inflammatory Process Affecting Bronchioles and Alveoli; Alveoli Filled with Exudate Reduced Surface Area for Gas Exchange Classified by Cause
Etiology
Acute infection Radiation therapy Chemical ingestion, inhalation; Bacteria
Steptococcus pneumoniae pneumocystis carinii(bacteria developed in AIDS pt)
Virus Fungus Aspiration (stroke victims) Artificial Ventilation (VAP) Hypostasis
Pneumonia
At risk:
Very Young Elderly Hospitalized Intubated Immunocompromised
Prevention
(see box 21-2)
Pneumococcal Vaccine Flu Vaccine Coughing and Deep Breathing Hand Washing Frequent Mouth Care, Continuous Suction for VAP
Pneumonia
Diagnostics:
Chest film Blood count Sputum C & S
Signs/Symptoms
Chest Pain Fever, Chills Cough, Dyspnea Yellow, Rusty, or Blood-Tinged Sputum Crackles, Wheezes Malaise
Pneumonia
Complications
Pleurisy CHF empyema Pleural Effusion Atelectasis septicemia
Signs and Symptoms in Elderly New-Onset
Confusion Lethargy Fever Dyspnea
Pneumonia
Treatment:
Antibiotic (bacterial) PO or IV Hydration Chest physical therapy Analgesics/Antipyretics Antiviral Medication (Zovirax) Bronchodilators Expectorants or cough suppressants Oxygen Nursing Management
Pleurisy
Acute Inflammation of Parietal, Visceral Pleurae
Cause: Usually secondary to pneumonia, pulmonary infections, tuberculosis, lung cancer, pulmonary embolism Diagnostics: Chest radiography; Sputum culture; Thoracentesis: Fluid specimen, pleural biopsy Signs/Symptoms: Inspirational severe, sharp pain; Shallow respirations; Pleural fluid accumulation; Dry cough; Dyspnea; Friction rub, fever, elevated WBC Treatment: Treat underlying condition; NSAIDs Analgesics/antipyretic drugs Nursing Management
Pleural Effusion
Pathophysiology
Abnormal Fluid Collection Between Visceral, Parietal PleuraePleural Fluid Not Reabsorbed,May Collapse Lung
Etiology
Transudative
Heart Failure Liver or Kidney Disease PE
Exudative
Pneumonia TB CA
Pleural Effusion cont.
Diagnostics
Chest radiograph; CT scan
Signs/Symptoms: Fever; Pain; Dyspnea;
Dullness upon chest percussion; Dim breath sounds; Friction rub; Tachypnea; Cough
Treatment: Antibiotics; Analgesics; Thoracentesis; Chest tube
Nursing Management
Pleural Effusion
Influenza
Acute Respiratory Disease of Short Duration
Cause: Viral contamination via respiratory transmission; Mutations
Fatalities related to secondary bacterial complications, esp. those immunocompromised
Diagnostics: Chest radiography; Sputum analysis
Signs/Symptoms: See Table 21-2
Treatment: Symptomatic
Nursing Management
Prevention
Yearly Vaccination(85% effective) should not be give to clients with allergy to eggs At-Risk Individuals Health Care Workers Handwashing Avoidance of infected people
Tuberculosis
Pathophysiology
AFB Implant on Bronchioles or Alveoli Tubercle Formed Immune System Keeps in Check 5%-10% Infected Become Ill May Activate with Impaired Immunity
Pulmonary Tuberculosis
Primarily a bacterial infectious disease affects lungs; may infect kidneys, other organs; Affects one-third of world’s population; Leading cause of death from infectious disease, among those with HIV Cause: Tubercle bacilli: Gram-positive; Transmitted via
droplet inhalation; Classifications Diagnostics: Chest radiographs; Tuberculin skin tests; CT scan; MRI; Gastric lavage; Gastric aspiration; Bronchoscopy; C & S tests Signs/Symptoms: Fatigue, weight loss; clients at risk; Low fever; Night sweats; Persistent Cough; Blood-streaked sputum; Weakness; Hemoptysis; Dyspnea At Risk: elderly; alcoholics; crowded living conditions; new immigrants; immunocompromised; lower socioeconomic status; homeless
Therapeutic Interventions
Technique to destroy; Transmission Combination of Drugs for 6 - 24 Months (toxicity, resistance);
INH Rifampin PZA Ethambutol Streptomycin
Occasional Surgical Removal: Segmental resection; Wedge resection; Lobectomy; Pneumonectomy Isolation Nursing Management (see ATI pg 125-126
Prevention of TB Spread
Clean, Well-Ventilated Living Areas Isolation of Patients who have Active TB High-Efficiency Filtration Masks Gowns, Gloves, Goggles If Contact with Sputum Likely
COPD
Combination of
Chronic Bronchitis Emphysema (Asthma)
Chronic Airflow Limitation
(in & out)
COPD (cont’d)
Airflow in lungs isPulmonary obstructed caused by Obstructive Disease bronchial obstruction, congenital abnormalities
Increased resistance to expiration, creating prolonged expiratory phase of respiration COPD
Emphysema Chronic bronchitis Asthma Atelectasis Sleep apnea Cystic fibrosis bronchiectasis
COPD Etiology
Smoking Passive Smoke Exposure Pollutants Familial Predisposition α1AT Deficiency (Emphysema)
Effects of Smoking
COPD Prevention
Smoking!!
COPD diagnositics
Chest X-Ray CT Scan ABGs CBC Spirometry Sputum Analysis
PFT PULSE OX H/H Chest physiotherapy AAT levels Peak expiratory flow meters
COPD signs and symptoms
Chronic Cough Chronic Dyspnea Prolonged Expiration Barrel Chest Activity Intolerance Diminished breath sounds Hypoxemia Hypercarbia Thin extremities
Wheezing, Crackles Thick, Tenacious Sputum Increased Susceptibility to Infection Mucous Plugs Accessory muscles Rapid, Shallow respirations Pallor; cyanosis (late) Hyperresonance
(emphysema)
Complications of COPD
Cor Pulmonale Weight Loss Resting before eating Avoid gas-producing food Eat four to six small meals rather than three large ones Take small bites and chew slow Pneumothorax Respiratory Failure
COPD Therapeutic Interventions
Stop Smoking!! Oxygen 1-2 L/m Supportive Care Pulmonary Rehab Surgery Mechanical Ventilation End-of-Life Planning
Medications
Bronchodilators Corticosteroids Expectorants
NMT/MDI
Bronchiectasis Pathyphysiology
Chronic Infection Dilation of One or More Large Bronchi Airway Obstruction
Etiology
Secondary to CF, Asthma, TB
Bronchiectasis Signs and Symptoms
Dyspnea Cough Large Amounts of Sputum Anorexia Recurrent Infection Clubbing Crackles and Wheezes
Bronchiectasis Therapeutic Interventions
Antibiotics Mucolytics, Expectorants Bronchodilators Chest Physiotherapy Oxygen Surgical Resection
Atelectasis
Collapse of Alveoli Prevents Gas Exchange
Causes: Mucus plug; Aspiration; Prolonged bed rest;
Fluid or air in thoracic cavity; Enlarged heart; Aneurysm; hypoventilation
Signs/Symptoms: (Small area) Few; (Large area):
Cyanosis; Dyspnea; Fever; Pain; Tachycardia; Tachypnea; Increased secretions
Treatment: Removal of cause; Raise secretions;
Bronchodilators; Humidification; O2 administration
Nursing Management: TCDB; incentive spirometer; ambulate
Chronic Bronchitis
Prolonged inflammation of bronchi; low grade fever; hypertrophied mucous glands in bronchi; impaired ciliary function; Gradual development
Signs/Symptoms:
Chronic, productive cough; Thick mucus; Frequent respiratory infections, lasting several weeks (winter)
Treatment:
Ineffective airway clearance
Prevent pulmonary irritation; Medications
Nursing Management
Pulmonary Emphysema
Abnormal Alveoli Distention, Destruction; loss of elastic recoil; damage to pulmonary capillaries; air trapping; disabling disease
Impaired Gas Exchange Signs/Symptoms: (Initial) Exertional dyspnea; (Progressive) Chronic cough; Mucopurulent sputum; “Barrel chest”; Pursed-lip breathing; Prolonged, difficult expiration; Wheezing; (Advanced) Memory loss; CO2 narcosis Treatment: Slow progression; Treat obstructed airways (Bronchodilators, O2, ATB, physical therapy, corticosteroids (limited) Nursing Management
MDI
Spacer
NMT
Incentive Spirometer
Chest Physiotherapy
Pulmonary Rehabilitation
Asthma
Reversible Obstructive Disease of Lower Airway; spasm of bronchial smooth muscles; air trapping
Cause: Inflammation; Airway hyperreactivity to stimuli (Allergic; Non-allergic; Mixed) Diagnostic: allergy skin testing Signs/Symptoms: Paroxysms of SOB, wheezing, coughing; Thick, tenacious sputum; use of accessory muscles; may be worse at night
Asthma
Triggers
Smoking Allergens Infection Sinusitis Stress GERD
Complication
Status Asthmaticus
Severe, Sustained Asthma Worsening Hypoxemia Respiratory Alkalosis Progresses to Respiratory Acidosis May Be Life Threatening
Asthma
Asthma Therapeutic Interventions
Monitor with Peak Flow Meter Avoid Triggers Avoid Smoking
Asthma Therapeutic Interventions (cont’d)
Bronchodilators
Corticosteroids
Adrenergic (Ventolin, Serevent) Leukotriene Inhibitors (Accolate, Singulair) Theophylline (Rare) Inhaled, IV, PO
Mast Cell Inhibitors (Exercise Induced) Antihistamines Oxygen PRN
Nursing Diagnoses: COPD
Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Activity Intolerance Imbalanced Nutrition Anxiety Fatigue
Impaired Gas Exchange
Monitor
Lung Sounds, Respiratory Rate and Effort Dsypnea Mental Status SaO2, ABGs
Position
Fowler’s Good Lung Down
Administer Oxygen Teach Breathing Exercises Discourage Smoking
Ineffective Airway Clearance
Monitor
Lung Sounds Sputum
Encourage
Fluids Deep Breathing Coughing
Administer Expectorants Turn q2h or Ambulate Suction prn Consider CPT or Mucus Clearance Device
Ineffective Breathing Pattern
Monitor
Respiratory Rate, Depth, Effort ABGs, SaO2
Determine/Treat Cause
Position Teach Diaphragmatic Breathing
Activity Intolerance
Monitor Response to Activity
Vital Signs SaO2
Use Portable O2 for Ambulation
Allow Rest Between Activities Obtain Bedside Commode Increase Activity Slowly Refer to Pulmonary Rehabilitation
Patient Education
Assist Patient to Stop Smoking! Pulmonary Rehabilitation Breathing Exercises Energy Conservation
Postural Drainage
Occupational Lung Diseases
•
Cause: Exposure to organic, inorganic dusts and noxious gases of long periods of time Diagnostics: Chest radiograph; Pulmonary function tests
Symptoms: Dyspnea; cough; (Coal dust) Black-streaked sputum Treatment: Conservative; Symptomatic; O2 therapy for severe dyspnea Nursing Management
Pulmonary Arterial Hypertension
Continuous High Pressure in the Pulmonary Arteries
Cause: Rt Ventricular Failure; CAD; Valve Disease; Lung disease Diagnostics: EKG; ABG analysis; Cardiac catheterization; Pulmonary function tests; Echocardiography; Ventilation-perfusion scan; Pulmonary angiography Signs/Symptoms: Dyspnea on exertion; Weakness; fatigue; crackles; cyanosis; tachypnea Treatment: Vasodilators, Anticoagulants; (Rightsided failure) Digitalis, diuretics; Heart–lung transplantation; low sodium diet Nursing Management
Pulmonary Hypertension
Pulmonary Embolism
Pathophysiology
Blood Clot in Pulmonary Artery or branches Ventilation-Perfusion Mismatch Impaired Gas Exchange Lung Infarction
Etiology
Thrombus formed in the venous system or right side of heart DVT Most Common Fat Emboli From Compound Fracture Amniotic Fluid Emboli During L&D
Pulmonary Embolism
Pulmonary Embolism
Obstruction of Pulmonary Arteries or Branches
Cause: Thrombus formed in the venous system or right side of heart Diagnostics: Chest radiograph; Serum enzymes; Lung, CT scan; Pulmonary angiography; Ultrasonography; Impedance plethysmography; D-dimer Signs/Symptoms: (Small area) Pain; Tachycardia; Dyspnea (Large area) Severe dyspnea; Severe pain; Cyanosis; Tachycardia; Restlessness; Shock; Sudden death Treatment: Thrombolytics; Anticoagulation; Surgery; Procedures Nursing Management
Pulmonary Edema
Fluid Accumulation in Interstitium, Alveoli of Lungs
Cause: Right side of heart delivers more blood to pulmonary circulation than left side can handle Signs/Symptoms: Dyspnea; Cyanotic extremities; Skin color; Continual bloodtinged (pink), frothy sputum; Cough Treatment: Emergency treatment for cardiogenic pulmonary edema Nursing Management
Respiratory Failure
Inability to Exchange Sufficient Amounts of O2, CO2
Cause: (Acute) Life-threatening, occurs suddenly; (Chronic) Underlying disease – COPD, aspiration, neuromuscular disorders Diagnostics: Chest radiography; Serum electrolytes; History; ABGs (PaO² 50mm Hg) Signs/Symptoms: Restlessness; Wheezing; Cyanosis; Accessory muscle use for breathing Treatment: Endotracheal, tracheostomy tube; Humidified O2 via nasal cannula, Venturi or rebreather masks; Mechanical ventilation Nursing Management
Respiratory Failure
Acute Respiratory Distress Syndrome (ARDs)
Noncardiogenic Pulmonary Edema, secondary to other clinical condition; Can lead to respiratory failure, death
Pathophysiology
Alveolocapillary Membrane Damage Pulmonary Edema Alveolar Collapse Lungs Stiff and Noncompliant Lungs May Hemorrhage
ARDs Etiology
Acute Lung Injury Septicemia Shock Aspiration Drug ingestion/overdose Hematologic disorders Metabolic disorders Trauma Surgery Embolism; Not Usually in Patients With Chronic Respiratory Disease
Acute Respiratory Distress Syndrome
Diagnostics:
Signs/Symptoms
Chest radiography Evidence of acute respiratory failure ABGs Tachypnea Dyspnea, fine crackles Cyanosis Anxiety Restlessness; Mental confusion
Treatment:
Intubation Mechanical ventilation Colloids Nutritional support
Lung Cancer
Common Cancer, esp. smokers; #1 cause of CA death in U.S. Types
Small Cell Lung Cancer Large Cell Carcinoma Adenocarcinoma Squamous Cell Carcinoma
Lung Cancer Etiology
Smoking
Smokers 13× as Likely to Develop Cancer as Nonsmokers
Environmental Tobacco Smoke Other Carcinogens
Asbestos Arsenic Pollution
Lung Cancer Diagnostic Tests
Chest X-Ray CT, PET Scan MRI Sputum Analysis Biopsy Additional Tests to Find Metastasis
Lung Cancer Signs and Symptoms
None Until Late Dyspnea Cell type, tumor size + location, degree of metastasis determine Recurrent Infection Anorexia and Weight Loss
Cardinal signs
Cough Productive of mucopurulent or blood-streaked sputum Hemoptysis
Pain Wheezing/Stridor
Therapeutic Interventions
Factor dependent, esp. on tumor classification, Stage (TNM System) Chemotherapy (Usually Palliative) Radiation (Usually Palliative)
Lung Cancer Complications
Pleural Effusion Superior Vena Cava Syndrome Ectopic Hormone Secretion
ADH (SIADH) ACTH (Cushing’s Syndrome)
Actelectasis Metastasis
Thoracic Surgery
Remove, repair chest wall traumas, tumors; Obtain biopsy sample Thoracotomy Thoracentesis Pneumonectomy Lobectomy Resection Transplant
Thoracic Surgery Preoperative Care
Monitor Respiratory Status Teach
Routine Preop Teaching What to Expect Visit SICU Include Family
Thoracic Surgery Postoperative Care
Intensive Care Setting Monitor
Vital Signs SaO2, ABGs Hemodynamic Parameters Lung Sounds
Ventilator Chest Tubes
Surgery interferes with normal thoracic cavity pressures; Lung expansion Lungs must be post-operatively reinflated
Draining secretions, air, blood from thoracic cavity via surgically-placed catheter(s) Connected to closed, underwater-seal drainage system: 1 – 2 catheters Anterior: Removes air Posterior: Removes fluid
Thoracic Surgery
Pneumothorax
Pathophysiology
Air in the Intrapleural Space
Complete or Partial Collapse of Lung
Types
Signs and Symptoms
Shallow, Rapid Respirations Asymmetrical Chest Expansion Dyspnea Chest Pain Absent Breath Sounds Over Affected Area
Tension Pneumothorax Signs and Symptoms
Tracheal Deviation Bradycardia Cyanosis Shock and Death If Untreated
Pneumothorax
Diagnostic Tests
History and Physical Examination Chest X-Ray ABGs, SaO2
Therapeutic Interventions
Monitor ABGs and Respiratory Status Chest Tube to Water Seal Drainage Pleurodesis (Sclerosis) for Recurrent Collapse
Pneumothorax Nursing Care
Monitor Respiratory Status Monitor Chest Drainage System
Equipment at bedside
Monitor and assess drainage system for
hemostats or clamps vaseline gauze
amount of suction presence of air leaks integrity of the water seal chamber absence of kinks in the tubing
Report Changes Promptly
Chest Drainage System
Thoracic Surgery
Rib Fractures/Flail Chest
Etiology
Trauma Cough CPR
Cause
Care
Control Pain Encourage Coughing and Deep Breathing Promote Adequate Ventilation
Multiple Rib Fractures Ribcage Not Able to Maintain Bellows Action
Care
Monitor ABGs Mechanical Ventilation
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