NCLEX RN Preparation Program

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

2. Emphysema + Chronic Bronchitis = COPD Chronic Obstructive Pulmonary Disease Chronic Airflow Limitation Photo Source: National Heart, Lung and Blood Institute (NHLBI http://www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd_WhatIs.html

3. Emphysema • Loss of lung elasticity • Hyperinflation • Air trapped in lungs • Alveoli over-stretched  bullae

4. Chronic Bronchitis • Recurrent inflammation  Vasodilation, Congestion, Edema, Spasm • Excessive thick mucus blocks air flow • Hypoxemia, CO2 retained

5. Causes of COPD • Smoking • Alpha1-Antitrypsin Deficiency • Air pollution • Secondary smoke Photo Source: National Cancer Society, http://visualsonline.cancer.gov/details.cfm?imageid=1997 and http://visualsonline.cancer.gov/details.cfm?imageid=2740

6. Signs of COPD • General • Breathing • Sputum • Sounds • Skin • Finger tips

7. Assess • LOC • Airway status and breathing • Pulses • RR, depth • BP, Heart Rate • SpO 2 level on room air • Color, temperature & capillary refill

8. Is this an emergency? • Dyspnea scale 0-10 • Oxygen saturation < 90% • Peak flow < 300 ml

9. Diagnostic Tests • Arterial Blood Gases • Oxygen Saturation • Chest x-ray • Labs • Pulmonary Function Tests (PFTs)

10. Goal: Patent Airway • Position • Secretions • Mucolytics • Expectoration • Hydration • Humidifier

11. Teach Effective Breathing • Diaphragm • Pursed-lips • Controlled cough • Orthopneic position http://emphysemafoundation.org/pulhthex.jsp

12. Bronchospasm • Bronchodilators • Cholinergic antagonists • Theophyllins

13. Inflammation Infection • Inhaled steroids • Systemic steroids • Prevent pneumonia • Influenza vaccination yearly • Pneumovax q 5 years

14. Conserve Energy • Schedule activities • Don’t rush • Supplemental oxygen • Avoid arm raises

15. Mealtime Strategies • Rest • 4-6 small meals • Bronchodilator ac • Easy chewing • Supplements • Avoid gas-producing foods

16. Stepped Therapy • Combivent (ipratropium + albuterol) • Add beta2 agonist (Albuterol) • Add theophyllin • Add Prednisone

17. Control Anxiety = Dyspnea • Develop a plan • Develop support network • Join support group

18. Complementary/Alternatives • Ask about non-prescribed methods used • Teach relaxation techniques

19. Pneumonia Photo Source: Centers for Disease Control, Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Pneumonia_x_ray.jpg

20. Categories • Viral • Fungal • Bacterial • Aspiration Photo Source: USDS, http://www.ars.usda.gov/is/graphics/photos/sep01/k9606-20.htm]

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

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

23. Who is at greatest risk? Photo Source: National Camcer Society, http://visualsonline.cancer.gov/details.cfm?imageid=1994 and http://visualsonline.cancer.gov/details.cfm?imageid=2193

24. Community Prevention Pneumovax Wash hands Don’t smoke Wear mask: dusty, moldy areas Avoid crowds Eat healthy diet Exercise

25. Nosocomial Prevention • Prevent aspiration - How? • Prevent cross-contamination • Vaccinate inpatients • Education • Mouth care??

26. Signs & Symptoms • Fever, chills • Dyspnea, RR, shallow breathing • Coughing, crackles, wheezing • Pleuritic pain • Anorexia • Hypoxemia • Sputum: purulent, blood-tinged, rusty

27. Diagnosis • Sputum C&S • Leukocytosis • ABG’s • Blood C&S • Chest x-ray • Oxygen saturation

28. Goal: Improve Gas Exchange • Oxygen • Antibiotics • Rest • Incentive spirometry • Raise head of bed • No smoking

29. Goal: Clear Airway • Enhance cough strength • Bronchodilators • Rest • Mucolytics • Corticosteroids

30. Goal: Control Pain and Fever • Pain • Fever control • Adequate volume

31. Pulmonary Tuberculosis Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Mantoux_tuberculin_skin_test.jpg and http://commons.wikimedia.org/wiki/Image:TB_CXR.jpg

32. Tuberculosis: What is it? • Mycobacterium tuberculosis causes inflammation in upper lungs • Bacillus colonies form a lesion (tubercle) • When the colonies die, they cause necrosis & scar tissue (consumption of tissue) Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Mycobacterium_tuberculosis_8438_lores.jpg

33. How do I know I have it? • Cough that will not go away • Feeling tired all the time • Weight loss • Loss of appetite • Fever • Coughing up blood • Night sweats

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

35. Skin Testing • Mantoux • 0.1 ml PPD • 48-72 hours • induration • False-positive • False-negative Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Mantoux_tuberculin_skin_test.jpg

36. Chest X-ray • To confirm positive PPD • When PPD cannot be done • Cavitation • Caseation

37. Sputum Testing • First morning specimen • 3 days • Acid-fast Bacilli • Tb C & S Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:TB_Culture.jpg

38. How is it treated? • Initial Therapy may include: • Isoniazid (INH) • Rifampin • Pyrazinamide (PZA) • Ethambutol or Streptomycin • After two months: • Isoniazid • Rifampin

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

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

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

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

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

44. Hospitalization • Isolate all patients with active pulmonary TB in negative-pressure rooms with high-volume air replacement and circulation • Continue isolation until combined drug treatment has been administered for 2 weeks, and three consecutive sputum smears have tested negative.

45. Transplant Recipients • Immune suppressed • Donor organ with latent TB • Reactivate pt’s latent infection • Diagnosis difficult • Decreased PPD reaction

46. HIV positive • Increased risk: Why? • Interactions with protease inhibitors • Decreased CD4 cell count  anergy (impaired or absent ability to react to common antigens administered through skin) • PPD testing early in HIV infection • Use control to rule out anergy • ?? INH prophylaxis

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

48. Drug Resistance • Multi-drug resistant TB (MDRTB) • Second-line drugs • Increased time of treatment

49. Non-compliance • Failure of treatment • Resistant bacilli • Intermittent dosing? • Arrest the patient?

50. Patient/Family Teaching • Prevention • Phone contact • Test entire family • Use precautions • Follow-up sputum cultures • Diet