Respiratory Disorders IAtelectasis Pneumonia, SARS, Swine Flu Pulmonary Tuberculosis Pleural Effusion Pulmonary Fibrosis

What do they have in common?A 19 year old with rib fractures A 35 year old s/p open cholecystectomy A 56 year old with severe ascites A 21 year old in her 9th month of pregnancy

Potential for:

Atelectasis

Risk FactorsPost op patients immobility low TV Mucous plugging- airway obstruction Ca Incorrect intubation Pregnancy, obesity, ascites Pleural effusion hemo/pneumthorax

Clinical ManifestationsThey all have: Low grade fever, O2 Sat HR & RR SOB, cough Pleuritis, pleural friction rub Decreased breath sounds Localized crackles For massive atelectasis there will be significant s/s of respiratory distress

AtelectasisClosure or collapse of the alveoli Can be caused by obstruction or compression Can be a small or large portion of one or both lung fields

Obstructive AtelectasisDue to an obstruction between the alveoli and trachea = reabsorption of alveolar gas = alveolar collapse may be secondary to a foreign body, benign or malignant tumor, secretions, mucus plug, blood clot, granulomas, inflammation or a side effect of radiation

Obstructive Atelectasisd/t a lung tumor which is obstructing the right main bronchus

Obstructive: incorrect ETT placementBlue: correct ETT placement Red: ETT in right main-stem bronchus

Atelectasis Overinflation

Compressive AtelectasisA space-occupying lesion of the thorax compresses the lung and forces air out of the alveoli.

ConsequencesAtelectasis can lead to: Pneumonia Respiratory Failure Death Avoid at all costs in those with impaired pulmonary history or lung surgery (**pneumonectomy**)

Diagnosis & TreatmentCXR & physical findings Best treatment is PREVENTION! Early ambulation IS q 1-2 hr WA Vibropercussion Inhalants TCDB q 2 hrs & prn Postural drainage Bronchodilators Suction prn

Administer pain meds & teach splinting

If preventative measures fail:PEEP or IPPB Bronchoscopy ETT & mechanical ventilation Thoracentesis/paracentesis Thorocotomy tube (chest tube) Surgery or radiation

PneumoniaInfection/inflamation of the lung CAP* vs FAP or (HAP) caused by bacteria, viruses, fungi & parasites 6th most common disease cause of death most common fatal nosocomial infection

CAPMost common bacterial: Strep pneumoniae Mycoplasma H. influenza Viral common in infants & children Immunocompromised: Cytomegaloviris Herpes simplex

What do these people have in common?Client #1 takes 10 mg prednisone qd Client #2 is receiving chemotherapy Client #3 is severely malnourished Client #4 has AIDS Client #5 has been on life-support for 5 years

Pneumoccal VaccinePrevents pneumonia 65-85 % Recommended for: > 65 y/o/a Chronic illnesses Functional or anatomic asplenia Immunocompromised College students***Avoid 1st trimester

FAPEnterobacter E. Coli H. Influenzae Pseudomonas S. PneumoniaeGram can cause consolidation & bacteremia

Kiebsiella Proteus Serratia MRSA*

Risk Factors for FAPImpaired host defenses NGT/ETT

Supine positioning & aspiration Narcotics/ALOC/coma Malnutrition Cross contamination Hypotension Overuse of antibiotic

CM of PneumoniaMaliase, fatigue Fever, tachycardia*, tachypnea (25-45 bpm) Cough & purulent sputum* LeukocytosisRusty sputum is seen with streptococcal, staphlococcal & klebsiella pneumonias

DiagnosisCXR: infiltrates Sputum culture**rinse mouth with H2O *deep breathe several times *cough *expectorate into sterile container *send immediately to lab

Blood cultures x 2-3*drawn utilizing sterile technique

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CMAll CM depend upon causal agent, co-morbities & if client is immunosuppressed:

Pleuritic chest pain* Orthopnea Accessory muscles AnorexiaIndications of consolidation:

Whispered pectoriloquy + Tactile fremitus (99) Dullness to percussion Egophony (E becomes A)

CDC Recommendations1. Staff education 2. Infection & micro-surveillance 3. Prevention of transmission 4. Modify host risk

Nursing DiagnosesIneffective airway clearance r/t copious tracheobronchial secretions Activity intolerance r/t impaired respiratory function Imbalanced nutrition: less than requirements Deficient knowledge re: treatment regimen & prevention Risk for deficient fluid volume r/t fever & increased RR

Collaborative DiagnosesPotential for:Shock Respiratory failure Atelectasis Pleural effusion Superinfection

GoalsImproved airway patency Ability to perform ADLs Adequate fluid volume Adequate nutrition Understanding of treatment protocol & prevention measures Absence of complicationsAEB:

Treatment: Obtain cultures PTACAP Azithromycin (Zithromax) Clarithromycin (Biaxin) Doxycycline (Vibramycin) Levofloxacin (Levaquin) FAP IV Cefuroxime (Zinacef) IV Ceftriaxone (Rocephin) IV Ampicillin (Unasyn) IV LevaquinAminoglycosides

Viral InfectionsAntibiotics are ineffective against viral pneumonia unless there is the presence of:

a secondary bacterial infection bronchitis sinusitis

What precautions should a nurse take with ATB Rx?Cultures? Allergies? During & after administration? S/S anaphylaxsis? Side effects? C & S results?

ATBPrevent antibiotic resistant organisms:*use narrow-spectrum ATB if possible *Stop ATB for strep pneumonia 72 hrs after pt is afebrile* *Give on time* *Give ALL of the ATB*

Other InterventionsIVF & FF * (2-3 L/d) Fever management Antitussives Antihistamines Nasal decongestants Bedrest

Respiratory tx & O2 with humidification Titrate O2 to maintain O2 Sats > 92% (94% with anemia) Pain medications

InterventionsETOH & Smoking cessation* Rescue position for high risk patients Oral care Clean respiratory equipment Hand washing TCDB & Chest PT Suctioning prn Early ambulation IS

InterventionsElevate the head of the bed Pace activities Relieve abdominal distention Inspect skin for diffuse red rash

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Monitor for ComplicationsIf no improvement in 24-48 hrs after tx, consider other disorders* If BP drops, consider septic shock Monitor CXR for atelectasis, plural effusion If fever reoccurs, consider superinfection If client becomes confused, restless consider hypoxemia or sepsis*

EvaluateCXR VS ABG & O2 Sats BBS No DOE Adequate fluid balance & dietary intake Exhibits no complications

SARSSevere Acute Respiratory Syndrome Coronavirus spread by cough/sneeze droplets that deposit on nearby mucous membranes of another person OR Touching a surface or object contaminated with droplets

CM of SARSHigh fever Headache Malaise Diarrhea (10-20 %) Dry cough (2-7 days later) Progressive hypoxemia & pneumonia

ContagiousWhen s/s are present During the second week of the illness Contact with should be restricted until 10 days post fever and improvement of s/s

Screen for SARS if: Confirmed pneumonia by CXR or ARDS of unknown etiology AND if, within 10 days of symptom onset, the patient: Has traveled or has close contact to someone who is ill and has traveled to mainland China, Hong Kong, or Taiwan OR Is employed in a high risk occupation Is part of a cluster of cases of atypical pneumonia

SARS PrecautionsConsult CDC Negative pressure isolation room PPE & Hand hygiene Environmental cleaning techniques Containment of secretions

Containment of SecretionsCover the nose/mouth Use tissues Dispose of tissues in no-touch receptacles Perform hand hygiene with soap & H2O or alcohol-based hand rub after contact withrespiratory secretions and contaminated objects/materials.

Containment of SecretionsOffer masks to persons who are coughing Encourage coughing persons to sit at least 3 feet away from others Healthcare workers should wear a surgical or procedure mask for close contact A single patient room is preferred

When single rooms are limited:Prioritize patients who have excessive cough and sputum production for single-patient rooms Place together in the same room (cohort) patients who are infected the same pathogen If it becomes necessary to place patients who require Droplet Precautions in a room with a patient who does not have the same infection: Avoid patients who are immunocompromised or have prolonged lengths of stay Ensure that patients are >3 feet apart & curtain is drawn Change protective attire and perform hand hygiene between contact with patients in the same room

H1N1 (Swine) Flucommon respiratory disease in pigs people who work with pigs have sometimes caught swine flu Suspect the pigs caught bird flu which mutated so that the pigs could infect people

Swine FluThis strain appears to be a subtype not seen before Contains genetic material from pigs, bird and humans Unlike most cases of swine flu, this one can spread from person to person Do not catch from eating pork*

Spread of the VirusContagious for 1-7 days Spread by coughing or sneezing OR touching something with flu viruses on it and then touching their mouth or nose*

CMFever Fatigue & anorexia Coughingsome people also develop a runny nose, sore throat, vomiting or diarrhea

If you suspect:Stay home from work or school Don't get on an airplane Call your doctor to ask about the best treatment Do not simply show up at a clinic or hospital that is unprepared for their arrival

TreatmentSensitive to the anti-viral drugs Relenza and Tamiflu only Take within the first 48 hours after symptoms appear Anti-virals can help people recover a day or two sooner Doctors sometimes prescribe anti-virals to household members of people with the flu to prevent them from getting sick.

PreventionH1N1 vaccine may be available this fall Wash hands, cover mouth Stay home until you have been afebrile 24 hours Clean surfaces with alcohol, chlorine, etc

Get help for children if there is:Dyspnea or tachypnea Bluish/gray skin color Not drinking enough fluids, severe vomiting Not waking up,not interacting or so irritable that the child does not want to be held Symptoms improve but then return with fever and worse cough

Get help for adults if there is:Dyspnea or SOB Pain/pressure in the chest or abdomen Sudden dizziness or confusion Severe or persistent vomiting Symptoms improve but then return with fever and worse cough

Pulmonary TBInfectious disease caused by Mycobacteriumtuberculosis

Affects lungs primarily* AFB, grows slowly, sensitive to heat & UV light Infects 1/3 of the world Leading cause of infectious disease death in the world

TBExpected to be eradicated by 2000 in USA *HIV *Increased immigration *Multidrug-resistant strains *Increased homelessness *Decreased detection *Inadequate funding of the US public health system

TransmissionAirborne droplet Initial infection occurs 2-10 weeks after exposure 10% of the people who are initially infected develop active disease

Risk FactorsClose contact with infected persons or crowded conditions* Immunocompromised & Substance abuse Inadequate health care*homeless *minorities *children & young adults *immigrants

Preexisting medical conditions & Malnourishment Certain health care professionals*

CMLow grade fever, night sweats Cough* > 3 wks, hemoptysis, chest pain Fatigue, anorexia, weight loss

Diagnostic TestsTuberculin skin tests (Mantoux) ID AKA TST CXR: lesions AFB: mycobacteria

Positive skin testReaction of 0-4 is not significant 5 + mm may be significant in pts at risk (HIV) 10+ mm is considered significantSignificant reaction = past exposure to TB or vaccine (in Latin America & Europe)

Skin TestRead 48-72 hrs Reaction indicated by BOTH erythma & induration (hardness)*

Skin TestSignificant reaction does not indicate active disease is present nor do Negative results exclude disease in the immunosupressed

QuantiFERON-TB Gold Test (QFT-G)Approved in 2005 Results in less than 24 hr Not affected by prior vaccination Recommended by the CDC to replace the TST

CXRLesions or Infiltrates are usually in the upper lobes

Miliary TB

Nursing DiagnosesIneffective airway clearance related to copious tracheobronchial secretions Deficient knowledge about treatment regimen & preventative health management Activity intolerance related to fatigue, altered nutritional status and fever

Collaborative DiagnosesPotential for:

Malnutriton Adverse side effects of medication therapy Multi-drug resistance Spread of TB infection (miliary TB)

GoalsAdequate airway Increased knowledge Adherence to the medication regimen Increased activity tolerance Absence of complications.AEB:

OrdersAdmit all suspected/confirmed cases to AFB isolation (Airborne Precautions < 5 microns)Have a high degree of suspicion in pts with undiagnosed pulmonary disease, especially if they are HIV +

Negative pressure roomsat least 6 air exchanges/hr exhausted directly outside

Ultraviolet light Disposable particulate respirators Monitor HCP for s/s TB

Airborne IsolationHCP wears:Standard Precautions* Particulate Mask

Client Transport:Limit only for essential purposes Client wears mask Notify personnel in receiving dept Instruct client how to prevent spread in transport

ProblemWhen clients are identified as positive for TB but precautions were not taken: Follow up with all HCW, patients and visitors that were exposed to TB

TreatmentChemotherapy for 6 12 months: Often meds are given in combination Initial phase (0-8 wks) Continuation phase (given for 4-7 months)

Isoniazid (INH) & Rifampin (Rifadin) 1st choice Pyrazinamide Ethambutol (Myambutol)

Streptomycin if resistance to other drugs

Side effectsHepatitis, hepatotoxicity Thrombocytopenia Skin rash, purpura Fever, arthralgias, GI distress

These are caused by bleeding underneath the skin. Petechiae measure less than 0.5 cm, purpura 0.5 1 cm, and ecchymoses are greater than 1 cm (Tongue)

Side EffectsTake on empty stomach or 1 hr before meals INH: avoid foods that contain tyramine & histamine (tuna, aged cheese, red wine, soy sauce & yeast) These foods & INH = headache, flushing, hypoesnion, lightheadedness, palpatations, diaphoresis

Side EffectsRifampin increases the metabolism of:Beta-blockers Coumadin Oral hypoglycemics Digoxin Oral contraceptives Theophylline Verapamil

Decreasing effectiveness which may require increasing dosage Avoid contact lenses, may discolor them

Side EffectsCk for hepatitis, skin rash & neurological changes (hearing loss, neuritis) Monitor Liver enzymes, BUN & Cr, Sputum AFB

Drug ResistanceVital signs: fever, RR Take meds as ordered for the duration* Assess for Miliary TB: Decreased leukocytes Increased spleen Fever Renal/mental changes

TreatmentEducate client regarding: Maintaining drug regimen Hygiene measures Proper disposal of tissues Postural drainage Progressive activity schedule Nutritional consult, supplements

NutritionGet social services & family involved Consider shelters, food kitchens, meals on wheels, etc High-calorie supplements Dietary help developing recipes that increase caloric intake requiring minimal resources

Self-careProper tissue disposal Covering mouth and nose Handwashing Keep follow up appointments

Pleural EffusionAn increased collection of fluid in the pleural space (nl 5-15 mL)

CausesHeart failure Pulmonary infections/emboli & TB Nephrotic syndrome (albumin) Connective tissue disorders Neoplastic tumors

CMS/S underlying disease (occurs with >500 mL): Determined by size & speed* Decreased/absent BS Decreased fremitus Dull, flat to percussion Tracheal deviation

CXRUpright A & P (>300mLs to detect) Lateral Decubitus: (50 mLs to detect)pt lies on the affected side the pleural effusion will layer out fluid & airline is visible

CXR

PEI = width of A divided by B x 100PEI = Pleural Effusion index A = pleural effusion B = width of the hemithorax

Treatment

Treat underlying cause

TreatmentThorocentesis if > 10 mm and stable: Send fluid immediately for:Gram stain C&S AFB RBC, WBC Gl, amylase LDH, protein Cytology pH

TreatmentNote & record pts tolerance, condition afterwards, color /characteristics of fluid Important to know if:transudate: systemic problem: LVHF, cirrhosis exudate: local problem: infection, cancer, pulmonary embolism

TreatmentPosterior Chest tube to drainage Reoccurring P. effusions can occur with malignancy Treatment creates adherence of the pleural to the chest wall

PleurodesisDone to prevent the rate of recurrence of pleural effusions or pneumothorax creates adhesion of the lung to the chest wall by secretion of fibrin Done mechanically by Marlex mesh/gauze chemically by instillation of talc or silver nitrite thermally by using electro cautery, laser or argon beam

Pleurodesis

Mechanical

Chemical

PleurodesisCan be done with thoracentesis or CT Clamp CT 60-90 Assist pt in changing positions to distribute Chest tube is unclamped & remains for several days

PleurodesisMost common SE: CP Fever Pain & fever management Assess respiratory status

Pulmonary FibrosisChronic lung inflammation = Stiffens the lungs & scars the alveolar walls Causes a restrictive disorder & lung compliance

CausesA growing body of evidence points to a genetic predisposition

A mutation in the SP-C protein has been found to exist in families with a history of Pulmonary Fibrosis.

CausesInflammatory conditions:Sarcoidosis Wegeners granulomatosis Infections Asbestos, silica, cigarette smoking Radiation Hypersensitivity pneumonitis* Lupus Rheumatoid Arthritis

Chemotherapy meds:Bleomycin Mitomycin BCNU Busulfan.

CMProgressive: SOB & dry cough Fatigue & weakness Discomfort in the chest Loss of appetite & rapid weight loss

ComplicationsHypoxemia Respiratory failure Pulmonary HTN Cor Pulmonale DVT & PE

Cor Pulmonale

DiagnosisThe origin and development of the disease is not completely understood so misdiagnosis is common.

CXR PFTs Lung biopsy: fibrosis

TreatmentNo effective tx or cure Many experimental trials Steroids (Prednisone) Supplemental O2 Lung transplant

QuestionWhich infection control technique is unnecessary when caring for a client with tuberculosis (TB)? 1. 2. 3. 4. Washing hands before and after contact Always putting on gown, mask & gloves Avoiding face-to-face contact Careful disposal of soiled tissues

QuestionThe drug treatment for TB frequently consists of which of the following? 1. 2. 3. 4. Rifampin & ethambutol Isoniazid & rifampin Streptomycin & ethambutol Isoniazid & streptomycin

QuestionIn what position should the nurse place a client during a thorocentesis? 1. 2. 3. 4. Supine, HOB elevated Side-lying, affected lung up Sitting up, leaning forward Prone, affected lung down

QuestionThe nurse knows that the most positive evidence of active TB is: 1. 2. 3. 4. A positive skin test result An elevation in the WBC count Positive sputum AFB findings Positive chest x-ray findings