ALTERATIONS IN THE RESPIRATORY SYSTEM

Carol Bowdoin RN, MSNFall 2010

OBJECTIVES1. Compare & contrast various pulmonary infections,

the:a) Incidence, b) Physiologic alteration (pathophysiology), c) Clinical manifestations, & d) Prognosis (Includes complications).

2. Use the nursing process & critical thinking skills to structure an approach (Plan of Care)in caring for an adult client with an acute respiratory disturbance.

a) Would include Nursing Diagnosis, Nursing Interventions, Expected Outcomes & Collaborative Treatment

3. Describe the health teaching needs of client with or at risk for respiratory disturbance.

4. Compare & contrast methods for monitoring clients with alterations in respiratory system

OBJECTIVES5. Identify needs of clients with respiratory

disturbances & provide discharge planning & community-based care.

6. Discuss effects of smoking & air pollution on development of alterations in respiratory function

7. Apply lecture content in developing a comprehensive plan of care for adult clients with respiratory disturbances

RESPIRATORY ASSESSMENT REVIEW SEE SELF STUDY -

VISTA Review

A&PAssessment TechniquesConcepts of:

Oxygenation Hypoxia

Read: Chap 21 Assessment of Respiratory Function

DIAGNOSTIC STUDIES OF THE RESPIRATORY SYSTEM – SEE SELF STUDY - VISTA

Blood studies ABGs

Oximetry Sputum studies Skin tests Pulmonary Function Tests Radiologic Studies

X-rays CT Scans MRI PET Pulmonary Angiography V/Q Scan

Endoscopic Exams Bronchoscope Mediastinoscopy

Thoracentesis Lung Biopsy Exercise testing

Read: Chap 25 Respiratory Modalities & Diagnostic Test

Copyright 2008 by Pearson Education, Inc.

FACTORS THAT INFLUENCE RESPIRATORY FUNCTION Age

Review Chart 21-2 p. 495 Text Structural Changes Functional Changes History & Physical Findings

Environment Exposure to second-hand smoke Allergens & environmental pollutants

Lifestyle Smoking Recreational & occupational exposure

Health status Personal or family Hx of lung disease

Medications Affect respiratory function, gas exchange, acid-base

balance Stress

Chart 21-7 p. 498

MANIFESTATIONS OF POSSIBLE RESPIRATORY DISORDER

Age-related Changes Decrease in elastic recoil of the lungLoss of skeletal muscle strength in thorax and diaphragmFibrosis in the alveoliFewer functional capillariesLess effective coughDecrease in PO2

Normal breath sounds Table 21-5 : vesicular, bronchovesicular, bronchialAbnormal (Adventitious) breath sounds Table 21-6: crackles, wheeze, friction rubs

MANIFESTATIONS OF POSSIBLE RESPIRATORY DISORDER

Nasal Assessment Asymmetry, Redness, swelling, Septum abnormalities, Purulent drainage, Changes in ability to smell

Frontal or Maxillary Sinus Assessment Tenderness

Thoracic Assessment Markedly increased or decreased respiratory rate, Abnormal AP diameter, Intercostal retraction or bulging, Asymmetric chest expansion, Malposition of the trachea, Changes in tactile fremitus, dullness or

hyperresonance on percussion or Asymmetric diaphragmatic excursion

Breath Sound Assessment [Table 21-6] Adventitious sounds, Absence of breath sounds, or Malposition of normal quality breath sounds

Important!

RISK FACTORS FOR RESPIRATORY DISEASE Smoking – single most important

contributor Exposure to second-hand smoke Personal or family history of lung disease Genetic make-up Allergens & environmental pollutant Recreational & occupational exposure

Copyright 2008 by Pearson Education, Inc.

COMMON MANIFESTATIONS OF IMPAIRED RESPIRATORY FUNCTIONHypoxia (Altered gas exchange)

Altered breathing patternsObstructed or partially obstructed airway

UPPER AIRWAY INFECTIONS – SELF STUDY

Infections Rhinitis

Non-allergic Allergic Viral Rhinitis (common cold)

Sinusitis Acute Chronic

Read Chap 22 p. 517 -548 Upper Airway Infections

UPPER RESPIRATORY CONDITIONS – INFLUENZA

INFLUENZA “FLU” Highly contagious viral respiratory disease Transmitted by airborne droplet & direct contact Incubation period: 18 – 72 Hours Usually occurs in epidemics or pandemics Droplet Precautions Seasonal Flu Influenza A

H1N2, H3N2• Influenza B Flu Variants

H1N1 – Swine Flu H5N1 - Avian influenza

Possible pandemics: Seasonal Flu H1N1 – Swine Flu H5N1 - Avian influenza

2010 Flu vaccine includes these 3 strains

FLU PATHO

INFLUENZA “FLU” Acute/Seasonal Flu

Type A Influenza Usually self-limiting febrile illness associated

with URI & LRI Clinical Manifestations:

Sudden onset Fever Headache Non-productive Coughing Sore throat Nasal congestion &/or Rhinorrhea Body aches Chills or rigors Fatigue Malaise

Clients at Risk: Immunocompromised** Elderly* COPD* Alcoholism* Diabetes*

Complication: Hospital acquired Pneumonia* Viral Pneumonia**

This chest film shows diffuse pulmonary infiltration due to acute pulmonary histoplasmosis caused by H. capsulatum.

Photomicrograph of Haemophilus influenzae as seen using a Gram-stain technique.

During the flu outbreak of 1918 H. influenzae was termed Pfeiffer's Bacillus, where it was found in the sputum of many influenza patients, and thought to be the cause of influenza.

INFLUENZA “FLU” Acute/Seasonal Flu

Medications Vaccination Recommendations: People older than 50 years of age, Children 6 to 23 months of age, Pregnant women, residents of extended care facilities, Those with chronic medical diseases or disabilities. Health care providers Household members of high risk groups Prophylaxis Flu vaccine

Ages < 5 & > 50 & high risk individuals – injection (inactivated virus) Flu Mist

Healthy individuals ages 5 – 49(live attenuated virus) Treatment to reduce severity Amantadine Rimantadine Zanamivir Oseltamivir Ribavirin Symptom relief also includes: ASA Acetaminophen NSAIDs Antitussives Antibiotics are not indicated

http://www.cdc.gov/vaccines/pubs/vis/default.htm#flu

2010 Recommendations:

• Every person 6 mons & older•Peak time Jan-Feb – Get now

SWINE FLU – H1N1 Risk

Babies, children, & teens Pre-existing health conditions:

Heart, lung (asthma), kidney Diabetes Weak immune system Pregnancy Long-term care facilities, residential facilities 70% hospitalized pts have 1 or more Med

Dx Clinical Manifestations

Season flu S&S + vomiting & diarrhea

TX Antivirals – 1 course per person diagnosed

Complications Acute bronchitis Secondary Bacterial Chest infection -

Antibiotics Encephalitis

Influenza Infection Control Measures

CLIENT EDUCATION Prevention

Universal precautions Avoid close contact Hand Hygiene Cover mouth when coughing Contain secretions Get Flu Vaccine

INFLUENZA

Nursing DX: Knowledge deficit RT:

Teach health promotion measures Immunization education

FLU VACCINE IMPORTANCE– Risk Reduction activities

– Reduce transmission via hand washing– Avoid crowds– Avoid those who are ill

INFLUENZA

TEACH CLIENT: EMERGENCY WARNING SIGNS - IF YOU BECOME ILL AND EXPERIENCE ANY OF THE FOLLOWING WARNING SIGNS, SEEK EMERGENCY MEDICAL CARE.

Emergency warning signs in children:

Emergency warning signs in adults:

• Fast breathing or trouble breathing

• Bluish or gray skin color • Not drinking enough fluids• Severe or persistent vomiting • Not waking up or not interacting• Being so irritable that the child

does not want to be held • Flu-like symptoms improve but

then return with fever and worse cough

• Difficulty breathing or shortness of breath

• Pain or pressure in the chest or abdomen

• Sudden dizziness • Confusion • Severe or persistent vomiting • Flu-like symptoms improve but

then return with fever and worse cough

INFLUENZA COMPLICATIONS This is an inferior view of a

brain infected with Gram-negative Haemophilus influenzae bacteria.

In the U.S. and other industrialized countries, More than 50% of H.

influenzae serotype b cases present as meningitis with fever, headache, and stiff neck.

3%-6% of cases are fatal; up to 20% of surviving patients have permanent hearing loss.

Gross pathology of subacute bacterial endocarditis involving mitral valve. Left ventricle of heart has been opened to show mitral valve fibrin vegetations due to infection with Haemophilus

parainfluenzae. Autopsy

Meningitis, Haemophilus

SBE

INFLUENZA COMPLICATIONSPneumonia

This chest film shows diffuse pulmonary infiltration due to acute

pulmonary histoplasmosis caused by H. capsulatum.

May be viral or bacterial (more common)

Main cause of death from flu infection May be fatal for

elderly

Bilateral interstitial infiltrates in a 31-year-old patient with atypical influenza pneumonia

REVIEW: WHAT IS THE DIFFERENCE BETWEEN A COLD & THE FLU?

Symptoms Cold FluFever Rare to low grade Temp of 100°F or higher for up to 4

days; present in 80% casesCoughing Hacking, productive Non-productive “dry cough”

Aches Slight body aches & pains Severe aches & pains; “hair hurts”

Stuffy Nose Common & typically resolves within a week

Not common

Chills Uncommon 60% have chills

Tiredness/ Fatigue

Mild Moderate to Severe

Sneezing Common Not Common

Sudden Symptoms

Develop over a few days Rapid onset within 3-6 hrs. Hits hard & includes high fever, aches & pains

Headache Uncommon unless develop sinusitis

80% have headache

Sore Throat Common Not common

Chest Discomfort

Mild to moderate Severe

OBSTRUCTION AND TRAUMATIC DISORDERS OF THE UPPER AIRWAY:

* OBSTRUCTIVE SLEEP APNEA (OSA)* EPISTAXIS

SLEEP APNEA Obstructive sleep apnea

Intermittent absence of airflow through mouth & nose during sleep Partial indicated by low-pitched snoring during inhalation Complete indicated by extreme Inspiratory effort with no

chest movement Obstruction of airflow can occur hundreds of times/night Serious & potentially life-threatening disorder Increases risk for heart disease, HTN, & heart

failure

Risk Factors: Morbid Obesity Large neck Circumference ETOH Abuse CNS Depressants Smoking

SLEEP APNEA Pathophysiology

Periods of asphyxia due to: Loss of normal pharyngeal muscle tone Pharynx to collapse during inspiration Tongue is pulled against posterior pharyngeal

wall Obstruction causes O2 sat, PO2, and

pH to fall, and PCO2 to rise Hypoxemia Acidosis Hypercapnia

Asphyxia causes brief arousal from sleep Restores airway patency and airflow

Episodes may occur hundreds of times a night

SLEEP APNEA Clinical manifestations

Loud snoring during sleep Apnea lasting 15 – 120 sec. Gasping or choking Restlessness/Thrashing during sleep Daytime fatigue Excessive daytime drowsiness Headache Depression Impotence HTN

Diagnostic studies Polysomnography (overnight sleep study)

Nursing and collaborative management: Nursing Diagnoses:

Disturbed Sleep Pattern Fatigue Ineffective Breathing Impaired Gas Exchange Decreased cardiac output related to dysrhythmias

secondary nocturnal hypoxemia Risk for Injury Risk for Sexual Dysfunction

Teach Measures to reduce airway dryness Adequate fluid intake General teaching about process and treatments

CPAP/BiPAP Education Effects are immediate Must wear nightly to achieve adequate sleep Amount of BiPAP pressure prescribed is adjusted to keep

airways open when breathing in & out without tiring patient

SLEEP APNEA

Treatments CPAP BiPAP

Surgical Intervention:o Tonsillectomyo Adenoidectomyo Uvulopalatopharyngoplasty (UPPP)o Tracheotomy

SLEEP APNEA

BIPAP – BI-LEVEL POSITIVE AIRWAY PRESSURE

Developed in the 1980’s Provides more normal

respiratatory ventialtion Provides enough continuous

airway pressure to keep airways open but decreases on exhalation

Synchronizes with patient’s respritations

Best for patients with CHF, certain neuromuscular disorders atlectasis, & lung disorders with CO2 retention

REVIEW QUESTION

Tell whether the following statement is true or false.Cigarette smoking and obesity are potential risk

factors for obstructive sleep apnea.

ANSWER

True.Rationale: •Sleep apnea is more prevalent in men, especially those who are older and overweight. •Cigarette smoking has also been identified as another possible risk factor

EPISTAXIS Aka: Nose bleed May indicate:

Dry environment Allergic rhinitis, colds, or sinusitis Nasal fracture/ trauma Bleeding disorder HTN

Risk factors See Chart 22-5 p 605

Location Anterior Septum - the midline, vertical

cartilage separating nasal chambers Lined with fragile blood vessels Usually not serious & easy to stop Seek medical help if:

Bleeding persists > 15-20 Nose bleeds recur Blood persistently drains down back of

throat Neck or serious head injury suspected This can be a serious problem resulting in

significant blood loss or airway compromise.

NURSING CARE OF PATIENTS WITH EPISTAXIS Assessment of bleeding Monitor airway and breathing Vital signs Reduce anxiety Patient teaching

Avoid nasal trauma, nose picking, and forceful nose blowing

Air humidification First Aid:

Sit & lean forward Pinch nostrils to stop bleeding. If bleeding does not stop in 15

minutes, seek medical attention.

EPISTAXIS

Medications Topical vasoconstrictors

Adrenaline Cocaine Phenylephrine

Chemical agents for cauterization Topical anesthetics if packing is required Prophylactic antibiotic therapy

Procedures Immediate first aid action Packing/ balloon tamponade Chemical or surgical cautery to sclerose

involved vessels Ligation or embolization of internal

maxillary artery

QUESTIONTopical adrenaline is used to reduce blood flow

in the patient with epistaxis. True of False?

AnswerTrue.Rationale: Topical vasoconstrictors, such as

adrenaline (1:1000), cocaine (0.5%), and phenylephrine, may be prescribed.

LOWER AIRWAY OBSTRUCTIONS

RISK FACTORS Smoking Environmental exposure Age related changes

STRUCTURAL /OBSTRUCTIVE DISORDERS - ATELETASIS Collapse of alveoli and lobules in the lung.

Caused by bronchial obstruction by secretions due to: Impaired cough mechanism Conditions that restrict normal lung expansion on

inspiration The affected portion collapses and shrinks The remainder of the lung over expands Results in the loss of the ability of air sacs at the

furthest reaches of the lungs to expand Secondary to obstruction of a bronchus related to:

Pleural effusion, Pneumothorax Cardiomegaly (Enlarged heart), Pericardial effusion, tumor

ATELECTASIS Etiology

Obstruction of the bronchus PneumothoraxPleural effusionTumorLoss of pulmonary surfactant

Risk FactorsCOPDSmokers undergoing surgeryProlonged bedrestMechanical ventilation

Figure 11. 78-year-old man with right middle lobe Atelectasis. Anteroposterior radiograph shows right middle lobe Atelectasis in the tipped up position. The Atelectasis lobe swings forward and lies horizontally. This appearance is similar to the configuration of right middle lobe Atelectasis on the apical lordotic view (Figure 6c).

ATELECTASIS Interdisciplinary Care

Prevention Reversing underlying cause

BiPAP Bronchoscopy Antibiotic therapy

Diagnosis Chest x-ray

ATELECTASIS Nursing Care :

Directed toward airway clearance Treat signs & symptoms Provide bronchial hygiene

*(aggressive pulmonary toileting) Prevention:

TCDB q 2h Promote proper chest expansion (HOB 45-90 degrees,

Orthopnea position) Respiratory Assessment: monitor more often when

administering opioids & sedatives- narcotic antidote: Narcan IV Incentive spirometry q2h Early ambulation Suction if ineffective cough

LOWER RESPIRATORY INFECTIONSACUTE TRACHEOBRONCHITIS ACUTE BRONCHITIS

o Definitiono Inflammation of the bronchi o Viral or bacterialo May be a precursor to developing Pneumonia

o Causeso Impaired immune defenses and smoking

o Clinical Manifestations– Non-productive cough

• Later becomes productive– Cough is paroxysmal (spasmodic) “barking cough”– Cough aggravated by cold, dry, or dusty air – Chest pain– Moderate fever– General malaise–Patient Education - key

PATHOPHYSIOLOGY – TRACHEO “BRONCHITIS”Host Factors Antimicrobals/

other medsSurgery/ invasive devices

Contaminated hands, gloves, devices, water,

solutins

Aaerodigestive colonization

Aspiration

Tracheal colonization/ inoculation

Inoculation /inhalation

Mechanical, cellualr, humoral lung defenses overwhelmed

Inflammation &Tissue Damage

Cap Dilation & edema of mucosa

Exudate & mucosa impaired Cilia irritation

Dry Cough

Tracheobroncitis

Bacteremia Complication:

• PneumoniaTransslocation

from GI

Rhinovirus, Parainfluenza virus, RSV, M. pnuemoniae, C. pneumoniae

Irritation & swelling of trachea & bronchial airways

Risk factors:Lung disease,

smoke, malnourished,

immunocomprised

Low grade temp

(<101F)

Burning chest pain

behind sterum

Dyspnea

Dx : CXR,

decreased PaO2 & Spo2

TRACHEO “BRONCHITIS” NSG DX & CARESecondary to lung disease

Host Factors Antimicrobals/ other meds

Surgery/ invasive devices

Contaminated hands, gloves, devices, water,

solutins

Aaerodigestive colonization

Aspiration

Tracheal colonization/ inoculation

Inoculation /inhalation

Mechanical, cellualr, humoral lung defenses overwhelmed

Inflammation &Tissue Damage

Cap Dilation & edema of mucosa

Exudate & mucosa impaired Cilia irritation

Dry Cough

Tracheobroncitis

Bacteremia Complication

:• Pneumonia

Transslocation from GI

Rhinovirus, Parainfluenza virus, RSV, M. pnuemoniae, C. pneumoniae

Irritation & swelling of trachea & bronchial airways

Risk factors:Lung disease,

smoke, malnourished, immunocompri

sed

Low grade temp

(<101F)

Burning chest pain

behind sterum

Dyspnea

Home Care

•Nsg Interventions (all types)• Monitor resp & O2 status•TEACH:• Cause•Monitor for chgs in resp & O2 status•Take all of meds•Contact MD if: •Persistent cough> 3-4 days or can’t stop coughing•Rash, itching, swelling stomach pain•Lips or nailbeds blue

Nursing DX:Alteration breathing pattern

Hospital Care

•Nsg Interventions:• Monitor resp & O2 status•Bedrest•Pulse Ox•ABGs•CBC•Telemetry•IV/INT•Antibiotics•Bronchodilators•Steroids•Breathing Tx•Postural Drainage•TEACH:• Cause• Prevention

Nursing DX:Impaired gas exchange

•Persistent cough> 3-4 days or can’t stop coughing•Rash, itching, swelling stomach pain•Lips or nailbeds blue

LOWER RESPIRATORY INFECTIONS - PNEUMONIAPNEUMONIA Description:

Acute inflammation of lung parenchyma (alveloi & respiratory bronchioles)

Classes: Viral Bacterial

Types: Community-acquired

Streptococcus pneumonae Klebsiella pneumonae Psudomonas aeruginosa Escherichia coli Haemophilus pneumonae Other influenza viruses

Hospital-acquired Streptococcus pneumonae

Atypical “Walking Pneumonia” Severe Acute Respitatory Sydronme (SARs)

Immunocompromised related Pneumocystis - HIV

Aspirationo Causative Agents:

o Infectious – bacteria, viruses, fungi & other microbeso Non-infectious – aspirated or inhaled substances

Pneumonia - Pathophysiology50% of Community Acquired areStreptococcus Pneumonia

• Pathogens enter the lungs:• Aspiration of

Oropharyngeal secretions

• Inhalation of contaminated air or water

• Through the bloodstream

• Inflammation of lung parenchyma• Fluid accumulates in

alveoli• Edema forms as

alveolar capillaries dilate & allows fluid to leak into interstitial tissues

Aspiration of S. pneumoniae

Release of bacterial endotoxin

Inflammatory response initiated:Attraction of neutrophils; release of inflammatory mediators

Alveolar edema

Exudate formation

Red hepatization & consoldiation of lung

parenchyma

Leukocyte infiltration(neutrophils & macrophages)

Gray hepatization & deposition of fibrin on

pleural surfaces; phagocytosis in

alveoli

Alveoli & respiratory bronchioles fill with serous exudate, red blood cells, fibrin, & bacteria

Resolution of InfectionMacrophages in alveoli ingest

& remove degenerated neutrophils, fibrin & bacteria

Risk factors:Past lung disease (CA,

COPD), Diabetes, Debilitating illnesses,

Malnutrition, immunocomprised

Risk factors:•Prolonged bed rest•Dyspnea•Nasal congestion•Pain with breathing• Table 23-2 pp 635

Pneumonia – Clinical Manifestations

Aspiration of S. pneumoniae

Release of bacterial endotoxin

Inflammatory response initiated:Attraction of neutrophils; release of inflammatory mediators

Alveolar edema

Exudate formation

Red hepatization & consoldiation of lung

parenchyma

Leukocyte infiltration(neutrophils & macrophages)

Gray hepatization & deposition of fibrin on

pleural surfaces; phagocytosis in

alveoli

Alveoli & respiratory bronchioles fill with serous exudate, red blood cells, fibrin, & bacteria

Resolution of InfectionMacrophages in alveoli ingest

& remove degenerated neutrophils, fibrin & bacteria

Fever, chills, headache, myalgias,

restlessness; asymmentric

chest movements

Productive cough,

dyspnea,Sore throat

Decreased PO2Splinting affected areaUse of accessory muscles; Chg in mental status

Crackles,Green or yelow sputumTachycardia

CBC Leukocytsois

CXR•Lobar inflitrate (streptococcal)• Interstitual inflitrates (myocplasmic)• Patchy inflitraes, small pleural effusion (viral)• Single inflitrate & poss. Pleural effusion (Chlamydia)l• Bronchopneumonia unit or bilateral, lobar consoldiation (Legionnaire’s)

Bld culturesBacteremia

Diagnosis: History and clinical presentation CXR to rule out Pneumonia:

Bronchopneumonia Patchy infiltrates

Lobar pneumonia One or more lobes involved

Aspiration pneumonia Caused by aspiration

Leukocytosis Abnormal ABGs Pleural effusion Pneumothorax on x-ray

LOWER RESPIRATORY INFECTIONS - PNEUMONIA

Pneumonia – Nsg Dx & Care

Aspiration of S. pneumoniae

Release of bacterial endotoxin

Inflammatory response initiated:Attraction of neutrophils; release of inflammatory mediators

Alveolar edema

Exudate formation

Red hepatization & consoldiation of lung

parenchyma

Leukocyte infiltration(neutrophils & macrophages)

Gray hepatization & deposition of fibrin on

pleural surfaces; phagocytosis in

alveoli

Alveoli & respiratory bronchioles fill with serous exudate, red blood cells, fibrin, & bacteria

Resolution of InfectionMacrophages in alveoli ingest

& remove degenerated neutrophils, fibrin & bacteria

Fever, chills, headache, myalgias,

restlessness; asymmentric

chest movements

Productive cough,

dyspnea,Sore throat

Decreased PO2Splinting affected areaUse of accessory muscles; Chg in mental status

Crackles,Green or yelow sputumTachycardia

CBC Leukocytsois

Bld cultures Bacteremia

Nursing DX:• Impaired gas exchange •Ineffective breathing pattern

Nursing DX:• Ineffect airway clearance •Hyperthermia•Activity intolerance

Nursing DX:• Inbalanced nutrition less than body requirements

Fatique, anorexia, wt loss

Nursing DX:• Pain•Anxiety

Collaborative TX:•Symptoms •Chart 23-1 pp 630 -633

•Nsg Interventions•Promote rest, hydration•TCDB q 2h•Early moblization•Incentive spirometer•Administer meds & monitor effect•Monitor O2 & resp status q2h•Manage fever•Administer meds/ antibiotics forbacterial)

•Nsg Interventions•Provide nutrtion & hydration•Dietary consult

•Nsg Interventions•Maintain airway•Supplemental O2 PRN•TEACH: meds, activity limits, avoid irritants ie smoke, pollen•DC planningPrevention – immunization for high risk clients•Sx to report toMD after DC

•Nsg Interventions•Administer analgesics•Comfort measures

Expected Outcomes•Clear breath sounds•Normal breathing patterns\•No S&S hypoxia•CXR – WNL•No complications RT pneumonia

Primary Atypical Pneumonia – mycoplasma pneumoniae –

“Walking Pneumonia”• Class:

• Infectious• Young adults, military and college students

• Manifestations: pharyngitis/bronchitis– Highly contagious– Fever– Headache– Myalgias– Arthralgias– Dry, hacking, nonproductive cough

Viral Pneumonia: Older adults and chronic conditions

Causes: Airborne virsuses

Influenza Respiratory syncytial virsus (RSV) Herpes or varicella viruses Rarely common cold virsuses

Manifestations Flu-like symptoms Headache Fever Fatigue Malaise Muscle aches

Complication SARS

Pneumocystis Pneumonia: Aids patients and immunocompromised *****

Class:Opportunistic

Manifestations Abrupt onset Fever Tachypnea Shortness of breath Dry, nonproductive cough Respiratory distress can be significant

Intercostal retractions Cyanosis

Aspiration Pneumonia: Older surgery patients at high risk**

Gastric contents aspirated into lungs causing a chemical pneumonitis

Bacterial pathogens (anaerobic) add to inflammation Emergency surgeries OB Depressed cough/gag reflex Impaired swallowing Enteral nutrition/NG/feeding tubes Silent regurgitation

Class Noninfectious

Clinical manifestations:

Legionnaires’ Disease (Bronchopneumonia): Legionella pneumophilia. Found in sitting water

Risk: Smokers, older adults, chronic diseases, impaired

immune system. Clinical Manifestations

Dry cough General malaise Chills & Fever Headache Confusion Anorexia Diarrhea Myalgia Arthralgias

PNEUMONIA - COMPLICATIONS Atelectasis

Usually clears with cough and deep breathing Bacteremia

Bacterial infection in the blood Lung abscess

Seen when caused by S. aureus and gram-negative pneumonias Empyema

Requires antibiotics and drainage of exudate Pericarditis

Spread of microorganism to heart Meningitis

Patient who is disoriented, confused, or somnolent should have lumbar puncture

Endocarditis Microorganisms attack endocardium and heart

valves Manifestations similar to bacterial endocarditis

Respiratory Failure The level of oxygen in the blood becomes too low or

the level of carbon dioxide in the blood becomes too high.

ACUTE RESPIRATORY FAILURE (ARF)Start here

CLASSIFICATION OF RESPIRATORY FAILURE

Fig. 68-2ARF will be discussed more in Med-surg II

PO2CO2

SEVERE ACUTE RESPIRATORY SYNDROME A serious form of atypical

pneumonia, caused by a virus isolated in 2003Aka “Hong Kong Flu”

Coronavirus (cold virus) - mutated

Transmited by droplets to mucous membranes (mouth, nose, eyes) of a near-by person

S&S occur 2-10 days after contact

Causes acute respiratory distress

Can lead to death

SARS S&S Hallmark symptoms

Fever greater than 100.4 degrees F (38.0 degrees C) Dry Cough Overall discomfort/body aches Difficulty breathing or other respiratory symptoms.

Symptoms in the order of how commonly they have appeared included:

Fever Chills and shaking Muscle aches & joint pain Cough Headache Less common symptoms include (also in order): Dizziness Productive cough (sputum) Low white cell count Sore throat Runny nose Nausea and vomiting Diarrhea Dyspnea due to pneumonia Hypoxia

Contagious during symptoms/2nd week S&S appear 3-7 days after exposure Stay home until 10 days after fever & resp

S&S subside Nursing diagnoses

Impaired gas exchange Risk for infection

SEVERE ACUTE RESPIRATORY SYNDROME

If hospitalized – placed on droplet isolation & in negative pressure room

TESTS & DIAGNOSIS Nasopharyngeal wash & swabs Sputum C&S Blood clotting tests Blood chemistries

ALT and CPK are sometimes elevated. LDH levels are often elevated. Sodium and potassium are sometimes

low. Chest x-ray or chest CT scan Complete blood count (CBC)

White blood cell (WBC) count may be low.

Lymphocyte count may be low. Platelet count may be low.

Bronchoalveloar lavage Tracheal aspirate Pleural fluid tap Stool C&S

SARS TREATMENT Persons suspected of having SARS should

be evaluated immediately by a health care provider

Hospitalized under negative pressure isolation if they meet the definition of a suspected or probable case. PPE Droplet isolation

Treatment same as for CAP May include:

Antibiotics to treat bacterial causes of atypical pneumonia

Antiviral medications High doses of steroids to reduce lung inflammation Oxygen, breathing support (mechanical

ventilation), or chest physiotherapy In some serious cases, blood serum from people

who have already recovered from SARS has been given. There is no strong evidence that these treatments work well.

LUNG ABSCESS Most common etiology:

Aspiration of oral anaerobes Bacterial pneumonia (S. aureus,

Klebsiella) Mechanical or functional bronchial

obstruction At risk population

Decreased level of consciousness Anesthesia Injury Disease of the central nervous system Seizure Excessive sedation Alcohol abuse Swallowing disorders Dental caries Debilitation

LUNG ABSCESS Clinical Manifestations

Insidious onset Productive cough Chills and fever Pleuritic chest pain Malaise Anorexia Temperature elevation Foul-smelling, purulent, blood-streaked

sputum Leukocytosis Dyspnea Weakness Anorexia &weight loss Decreased or absent breath sounds or

crackles Pleural friction rub

Treat with antibiotics such as Flagyl

ASPIRATION Oropharyngeal contents

contaminated lungs with bacteria - cause bacteria pneumonia

Chemical burn from aspiration of acidic gastric contents & acute inflammatory response – cause of atelectasis, pneumonitis & resp failure

Risk factorsSee Chart 23-10

After tube feeding

ASPIRATION Prevention is key:

Elevate HOB. Turn patient to the side when vomiting. Prevention of stimulation of gag reflex

with suctioning or other procedures Assessment and proper administration

of tube feeding Rehabilitation therapy for swallowing Compensate for absent gag reflex or

swallowing difficulty Assess NG/feeding tube placement

Check residual every 4 hrs Promote gastric emptying Manage effects of prolonged intubation

or tracheostomies

PLEURAL CONDITIONS

PLEURAL CONDITIONS Pleurisy:

An inflammation of both layers of the pleurae Pleural Effusion

Accumulation of fluid in the pleural space Empyema:

Accumulation of thick, purulent fluid in the pleural space Pulmonary Edema:

Abnormal accumulation of fluid in the lung tissue, alveolar space or both. Severe & life-threatening

PLEURISY Inflammation of both the

parietal and visceral layers of the pleura

Inflamed surfaces rub together with respirations and cause sharp pain that is intensified with inspiration

Usually accompanies URI

PLEURISY Clinical Manifestations

Severe “knife-like” pain, aggravated by deep breathing, coughing & movement Fever, malaise, Rapid respirations Shallow breathing chest splinting Limited chest wall movement on affected side Diminished breath sounds Pleural friction rub

Treat cause & symptoms Analgesics Topical application of heat or cold Indocin Intercostal nerve block

Teach comfort measures Turn to affected side to splint area & decrease

pain Use hands or pillow to splint rib cage when

coughing

PLEURISY MEDICATIONS NSAIDS

Indocin Bronchodilators

Theodur (PO & IV) Slo-bid (PO) Theophylline (PO) Ventolin or Albuterol (PO & inhaler) Aminophylline (IV or PO)

Monitor Aminophylline level Normal level: 10-20

Corticosterioids Beconase or Beclovent or Vancenase (oral or nasal inhaler) Prednisone (PO) Solu-medrol (IV)

Antibiotics Penicillin G - pneumococcal Erythromycin - mycoplasma, Legionnaires Tetracycline - mycoplasma Cephalosporins - klebsiella Bactrium – pneumocystis

Antitussives Codeine preparations Robitussin DM Guaifenesin or Robitussin

Expectorants Nursing Alert: Water is BEST!---- Force Fluids Guaifenesin or Robitussin Organidin

Antipyretics ASA Acetaminophen Motrin

PLEURAL EFFUSION Definition

AKA “Water on the Lung” Accumulation of fluid in the

pleural space Indicates underlying

pulmonary disease/abnormality A form of restrictive lung disease

Large effusions impair lung expansion and cause dyspnea.

Secondary to other conditions, such as: CHF Pulmonary Embolism Post CABG Pneumonia, Pulmonary infections, Nephrotic syndrome, Inflammatory disease Tumors, Cancer TB Autoimmune disease Chest Trauma

PLEURAL EFFUSION - PATHOPHYSIOLOGYGenetic/ Family

HxEnvironmental Life Style*Secondary to

lung disease

Transudative Pleural

Effusion** Exudative Pleural

Effusion** Empyema** Chylothorax*

*

Increased hydrostatic pressure Ex: CHF*,

Pul Embolus

Pleural fluid contains small amounts protein (CHON)

Decreased oncotic pressure caused by inadequate albumin level Ex: Chronic kidney* & liver

disease* Forces watery pleural fluid from capillaries into pleural space

Pleural fluid contains large amounts protein (CHON)

Inflammatory response causes increases capillary permeability Ex: Pulmonary Infections (Pneumonia), tumors, emboli; Pancreatitis* , Ruptured

esophagusForces thick pleural fluid from capillaries into pleural

space

Pleural fluid contains pus

Forms a pocket (loculates) or abscess between pleura & fissures

Impairs lung expansion

Worsening

Dyspnea

** Dx confirmed by CXR if > 250 ml,

thoracentesis cytology exam, & physical exam

Decreased chest

movement

Decreased breath sounds

Chest dull to

percussion

Pleural friction

rub

Egophony

Disruption of pulmonary lymph vessels due to trauma or surgery

Abnormal accumulation of lymph fluid in pleural space

Produces fat malabsorption in GI tract

Weight loss;

malnutrition

Decreased immunity

Dyspnea,

orthopnea

Fever, persistent cough,

night sweats

Pleuritic chest pain

PLEURAL EFFUSION – NURSING DXGenetic/ Family

HxEnvironmental Life Style*Secondary to

lung disease

Transudative Pleural

Effusion

Exudative Pleural

Effusion Empyema Chylothorax

Increased hydrostatic pressure Ex: CHF*,

Pul Embolus

Pleural fluid contains small amounts protein (CHON)

Decreased oncotic pressure caused by inadequate albumin level Ex: Chronic kidney* & liver

disease* Forces watery pleural fluid from capillaries into pleural space

Pleural fluid contains large amounts protein (CHON)

Inflammatory response causes increases capillary permeability Ex: Pulmonary Infections (Pneumonia), cancer, tumors, emboli; Pancreatitis* , Ruptured

esophagusForces thick pleural fluid from capillaries into pleural

space

Pleural fluid contains pus

Forms a pocket (loculates) or abscess between pleura & fissures

Impairs lung expansion

Worsening

Dyspnea

Decreased chest

movement

Decreased breath sounds

Chest dull to

percussion

Pleural friction

rub

Egophony

Disruption of pulmonary lymph vessels due to trauma or surgery

Abnormal accumulation of lymph fluid in pleural space

Produces fat malabsorption in GI tract

Weight loss;

malnutrition

Decreased immunity

Dyspnea, orthopne

a

Nursing DX:• Ineffective breathing pattern

Nursing DX:•Pain/ Discomfort RT irritation/ inflammation

Nursing DX:• Risk for Infection

Nursing DX:Impaired gas exchange

Fever, persistent

cough, night sweats

Nursing DX:• Imbalance nutrition

Pleuritic chest pain

PLEURAL EFFUSION – NURSING & COLLABORATIVE TX

Genetic/ Family Hx

Environmental Life Style*Secondary to lung disease

Transudative Pleural

Effusion*** Exudative Pleural

Effusion*** Empyema*** Chylothorax

Increased hydrostatic pressure Ex: CHF*,

Pul Embolus

Pleural fluid contains small amounts protein (CHON)

Decreased oncotic pressure caused by inadequate albumin level Ex: Chronic kidney* & liver

disease* Forces watery pleural fluid from capillaries into pleural space

Pleural fluid contains large amounts protein (CHON)

Inflammatory response causes increases capillary permeability Ex: Pulmonary Infections (Pneumonia), tumors, emboli; Pancreatitis* , Ruptured

esophagusForces thick pleural fluid from capillaries into pleural

space

Pleural fluid contains pus

Forms a pocket (loculates) or abscess between pleura & fissures

Impairs lung expansion

Worsening

Dyspnea

Decreased chest

movement

Decreased breath sounds

Chest dull to

percussion

Pleural friction

rub

Egophony

Disruption of pulmonary lymph vessels due to trauma or surgery

Abnormal accumulation of lymph fluid in pleural space

Produces fat malabsorption in GI tract

Weight loss;

malnutrition

Decreased immunity

Dyspnea, orthopnea

Nursing DX:• Ineffective breathing pattern

Nursing DX:•Pain/ Discomfort RT irritation/ inflammation

Nursing DX:• Risk for Infection

Nursing DX:Impaired gas exchange Fever

Nursing DX:• Imbalance nutrition

Pleuritic chest pain

•Nsg Interventions (all types)• Monitor resp & O2 status• Assist with thoracentesis & monitor post for complications• Administer antibiotics, antipyretics, TPN/lipids & monitor effects•Provide supplemental O2•Provide adequate nutrition•TEACH:• Cause•Monitor for chgs in resp & O2 status•Purpose & procedure for thoracentesis

TX:• TPN & IV lipids• Pleurodesis• Med: Octreotide

TX***:• Underlying cause•Thoracentesis: drain pleural fluid•Antibiotic Therapy•Surgery – separate pleural membranes

Expected Outcomes (all) • Resolution or reduction of PF•Afebrile•Control chest wall pain•Adeq CHON intake• RR 12 -24 BPM

MANAGEMENT OF PLEURAL EFFUSION - THORACENTESIS

Thoracentesis or chest tube insertion with drainage of fluid may be needed: Rationale:

Drain accumulated PE > 250 mL Promote lung expansion & gas exchange

Pre-procedure care Verification of signed informed consent Assessing knowledge and understanding of the procedure and its purpose Medication administration as required Positioning the client leaning over an anchored overbed table Teaching about the level of discomfort to expect

Post procedure Relieve discomfort Monitor for complications

Fluid balance S&S hypovolemic shock

PULMONARY EDEMA Definition

Abnormal accumulation of fluid in lung tissue, alveoli or both

Severe, life-threatening condition

PULMONARY EDEMA PATHOPHYSIOLOGYGenetic/ Family Hx: CV Disease,

recent MI, mitral regurgitation

Increased microvascular venous pressure

Abnormal LV cardiac function (heart failure)

Blood backs up into pulmonary vasculature

Fluid leaks into interstitual spaces & alveoli

HypervolemiaSudden increase in intravascular pressure in lung

Pnueomectomy

Cardiac output shifts to remaining lung

Flash pulmonary edema

SOB, air hungerCough, AnxietyGurgling when breathing, Orthopnea, Wheezing, nasal flaring, crackles, cyanosis, pink frothy sputum, paroxysmal nocturnal dyspnea

Excessive sweating,Pale skinRestlessnessDecreased LOC, inability to speak in full sentences

Interruption of gas exchange leads to hypoxemia

Severe Infection Toxic exposure

Fluid overload; liver or kidney failure

CBC, Chemistries, Creatinine, Liver Enz, ABGs, Pulse Ox, C-reactive protein, PT/APTT, BNP, CXR, EKG, Ultrasound heart

Respiratory failure

Untreated: Coma & death

Complication:

• Hypoxia

Nocturia, Pitting ankle edema,

Lung Disease

Inflammation

Thickening of alveolar membrane

Hypoxemia

Nursing DX:• Alteration in fluid balance

Nursing DX:• Ineffective breathing pattern

Nursing DX:Impaired gas exchange

PULMONARY EDEMAMedical /Collaborative Care Concept Map

QUESTIONS?!!