Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

1. Timby/Smith: Introductory Medical-Surgical Nursing, 10/e Chapter 21: Caring for Clients with Lower Respiratory Disorders

2. 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) Blood-streaked sputum, Coughing attacks; Inspiratory crackles Treatment: Antipyretics; Expectorants; Antitussives; Humidifiers; Broad-spectrum antibiotics Nursing Management

3. 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

4. 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

5. 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

6. Pneumonia • Complications • Pleurisy • CHF • empyema • Pleural Effusion • Atelectasis • septicemia • Signs and Symptoms in Elderly • New-Onset • Confusion • Lethargy • Fever • Dyspnea

7. Pneumonia • Treatment: • Antibiotic (bacterial) PO or IV • Hydration • Chest physical therapy • Analgesics/Antipyretics • Antiviral Medication (Zovirax) • Bronchodilators • Expectorants or cough suppressants • Oxygen • Nursing Management

8. 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 Pleurisy

9. 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

10. 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

11. Pleural Effusion

12. 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 Influenza

13. 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

14. 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

15. Therapeutic Interventions • Technique to destroy; Transmission • Combination of Drugs for 6 - 24 Months (toxicity, resistance); • INH • Rifampin • PZA • Ethambutol • Streptomycin • Occasional Surgical Removal: Segmentalresection; Wedge resection; Lobectomy; Pneumonectomy • Isolation • Nursing Management (see ATI pg 125-126

16. 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

17. COPD • Combination of • Chronic Bronchitis • Emphysema • (Asthma) • Chronic Airflow Limitation • (in & out)

18. COPD (cont’d)

19. Obstructive Pulmonary Disease Airflow in lungs is obstructed caused by 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

20. COPD Etiology • Smoking • Passive Smoke Exposure • Pollutants • Familial Predisposition • α1AT Deficiency (Emphysema)

21. Effects of Smoking

22. COPD Prevention Smoking!!

23. Chest X-Ray CT Scan ABGs CBC Spirometry Sputum Analysis PFT PULSE OX H/H Chest physiotherapy AAT levels Peak expiratory flow meters COPD diagnositics

24. 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) COPD signs and symptoms

25. 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

26. Stop Smoking!! Oxygen 1-2 L/m Supportive Care Pulmonary Rehab Surgery Mechanical Ventilation End-of-Life Planning Medications Bronchodilators Corticosteroids Expectorants NMT/MDI COPD Therapeutic Interventions

27. Bronchiectasis Pathyphysiology • Chronic Infection • Dilation of One or More Large Bronchi • Airway Obstruction • Etiology • Secondary to CF, Asthma, TB

28. Bronchiectasis Signs and Symptoms • Dyspnea • Cough • Large Amounts of Sputum • Anorexia • Recurrent Infection • Clubbing • Crackles and Wheezes

29. Bronchiectasis Therapeutic Interventions • Antibiotics • Mucolytics, Expectorants • Bronchodilators • Chest Physiotherapy • Oxygen • Surgical Resection

30. 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

31. Chronic Bronchitis Prolonged inflammation of bronchi; low grade fever; hypertrophied mucous glands in bronchi; impaired ciliary function; Gradual development Ineffective airway clearance Signs/Symptoms: Chronic, productive cough; Thick mucus; Frequent respiratory infections, lasting several weeks (winter) Treatment: Prevent pulmonary irritation; Medications Nursing Management

32. 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

33. MDI

34. Spacer

35. NMT

36. Incentive Spirometer

37. Chest Physiotherapy

38. Pulmonary Rehabilitation

39. 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

40. 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

41. Asthma

42. Asthma Therapeutic Interventions • Monitor with Peak Flow Meter • Avoid Triggers • Avoid Smoking

43. Asthma Therapeutic Interventions (cont’d) • Bronchodilators • Adrenergic (Ventolin, Serevent) • Leukotriene Inhibitors (Accolate, Singulair) • Theophylline (Rare) • Corticosteroids • Inhaled, IV, PO • Mast Cell Inhibitors (Exercise Induced) • Antihistamines • Oxygen PRN

44. Nursing Diagnoses: COPD • Impaired Gas Exchange • Ineffective Airway Clearance • Ineffective Breathing Pattern • Activity Intolerance • Imbalanced Nutrition • Anxiety • Fatigue

45. Monitor Lung Sounds, Respiratory Rateand Effort Dsypnea Mental Status SaO2, ABGs Position Fowler’s Good Lung Down Administer Oxygen Teach Breathing Exercises Discourage Smoking Impaired Gas Exchange

46. Monitor Lung Sounds Sputum Encourage Fluids Deep Breathing Coughing Administer Expectorants Turn q2h or Ambulate Suction prn Consider CPT or Mucus Clearance Device Ineffective Airway Clearance

47. Monitor Respiratory Rate, Depth, Effort ABGs, SaO2 Determine/Treat Cause Position Teach Diaphragmatic Breathing Ineffective Breathing Pattern

48. 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 Activity Intolerance

49. Patient Education • Assist Patient to Stop Smoking! • Pulmonary Rehabilitation • Breathing Exercises • Energy Conservation

50. Postural Drainage