respiratory disorders in older adults

8/6/2019 Respiratory Disorders in Older Adults

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DiagnosticStudies and

Therapies


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PPD(Purified Protein Derivative

Intradermal

read 48-72 hours after injection (+) Mantoux test is in duration of 10

mm or more

for HIV positive clients, induration of 5mm is considered positive

(+) Mantoux test signifies exposure toMycobacterium tubercle bacilli


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Practice the client on how

to hold his breath and to dodeep breathing

Instruct the client toremove metals from chest


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Studies the lung and chest inmotion


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Aradiopaque medium is instilled directly into thetrachea and bronchi and the entire bronchial tree or

selected areas may be visualized Nursing interventions before bronchogram

Secure written consent

Check for allergies to sea foods or iodine or anesthesiaNPO for 6-8 hrsPre-op meds: atropine sulfate and valium, topicalanesthesia sprayed; followed by local anestheticinjected into the larynx

Have oxygen and antispasmodic agents ready Nursing interventions after bronchogram

Side-lying positionNPO until cough and gag reflexes returnCough and deep breath client

Low grade fever commom


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The direct inspection and observation of thelarynx, trachea and bronchi through flexibleor rigid bronchoscope

Diagnostic uses:To collect secretions

To determine location of pathologic processand collect specimen for biopsy

Therapeutic uses:

Remove foreign objects

Excise lesions


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Nursing interventions before bronchoscopyInformed consent/permit needed

Atropine and valium pre-procedure; topicalanesthesia sprayed followed by localanesthesia injected into the larynx

NPO for 6-8 hrsRemove dentures, prostheses, contact lenses

Nursing interventions after bronchoscopySide-lying positionCheck for the return of cough and gag reflexes

before giving fluid per oremWatch for cyanosis, hypotension, tachycardia,

arrhythmias, hemoptysis, dyspnea. Thesesigns and symptoms indicate perforation ofbronchial tree.


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Following injection of aradioisotope, scans are taken with ascintillation camera. Measure bloodperfusion through the lungs.Confirm pulmonary embolism orother blood-flow abnormalities

Remain still during the procedure


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Gross appearance

Sputum C&S

AFB staining

Cytologic examination/Papanicolaou examinationEarly morning sputum specimen is to be collected

Rinse mouth with plain water

Use sterile container

Sputum specimen for C&S is collected before thefirst dose of antimicrobial

For AFB staining, collect sputum specimen forthree consecutive mornings


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Transbronchoscopic biopsy-done during bronchoscopy

Percutaneous needle biopsy

Open lung biopsy


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Lymphnode biopsy Scalene or cervocomediastinal

To assess metastasis of lung cancer

Pulmonary Function Studies

Vital capacityThe maximum volume of air that can be

exhaled after a maximum inhalation

Reduced in COPD

Tidal volume The volume of air inhaled and exhaled with

normal quiet breathing


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Inspiratory reserve volume The maximum volume that can be inhaled

following a normal quiet inhalation

Expiratory reserve volume The volume of air that remains in the lungs

after normal, quiet exhalationFunctional residual capacity The volume of air that remains in the lungs

after normal, quiet exhalationResidual volume The volume of air that remains in the lungs

after forceful exhalation


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Purpose: to assess ventilation and acid-base balance

Radial artery is the common site for

withdrawal of blood specimen Allens test is done to assess for

adequacy of collateral circulation of thehand

10 ml pre-heparinized syringe to preventclotting of specimen

Container with ice to prevent hemolysis

of the specimen


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Aspiration of the fluid or air from thepleural space

Nursing intervention before thoracentesis

Secure consentTake initial vital signs

Position: upright leaning on over bed table

Instruct to remain still, avoid coughingduring insertion of needle

Pressure sensation is felt on insertion ofneedle


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Nursing interventions after thoracentesis:

Turn on the unaffected side to preventleakage of fluid in the thoracic cavity

Bed rest until VS is stable

Check for the expectoration of blood.Notify physician

Monitor VS


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Oxygen therapy Tracheobronchial suctioning

a. Client should be in semi-fowlers positionb. Use sterile gloves, sterile suction catheterc. Hyperventilate client with 100% oxygenbefore and after suctiond. Insert catheter with gloved hand(3-5 lengthof catheter insertion)e.Apply suction during withdrawal of catheterf. When withdrawing catheter rotate whileapplying intermittent suction

g. Suctioning should take only 10 seconds(maximum of 15 seconds)h. Evaluate: clear breath sounds onauscultation of the chest


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Bronchial Hygiene Measures

Suctioning:oropharyngeal;nasopharyngeal

Steam inhalation

Aerosol inhalation

Madimist inhalation

Chest Physiotherapy (CPT)

Postural drainage

Percussion

Vibration


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Nursing intervention in CPT

a. Verify doctors orderb. A

ssess areas of accumulation of mucussecretionsc. Position to allow expectoration of mucus

secretions by gravityd. Place client in each position for 10 to 15

minutese. Percussion and vibration done to loosen

mucus secretionsf. Change position gradually to prevent postural

hypotensiong. Procedure is best done 60 to 90 minutes before

meals or in the morning upon awakening andat bedtime

h. Provide oral care after the procedure


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Incentive Spirometry

To enhance deep inhalation Closed chest drainage

(Thoracostomy Tube)

Purpose: to remove air and/or fluidsfrom the pleural space; toreestablished negative pressure and

reexpand the lungs.


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Types:

a. one-bottle system The bottle serves as a drainage bottle and

water-seal bottle

Immerse tip of the tube in 2-3 cm ofsterile NSS to create water-seal bottle

Keep bottle at least 2-3 ft below the levelof the chest to allow drainage from the

pleura by gravity

Never raise the bottle above the level ofthe chest to prevent reflux of air or fluid


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Assess for patency of the device:-observe for fluctuation of fluid along

the tube-observe for intermittent bubbling offluid; continuous bubbling meanspresence of air-leak

In the absence of fluctuation:-suspect obstruction of the device-checkfor kinks along tubing; milk tubingtowards the bottle-if there is no obstruction, consider lungreexpansion; validated by chest x-ray

Air vent should be open to air


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b. Two-bottle system Not connected to the suction apparatus

-the first bottle is drainage bottle; the

second bottle is water-seal bottle-observe for fluctuation of fluid along thetube (water-seal bottle) and intermittentbubbling with each respiration


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Connected to suction apparatus

-the first bottle is drainage and water-seal

bottle; the second bottle is suction controlbottle

-expect continuous bubbling in the suctioncontrol bottle; intermittent bubbling and

fluctuation in the water-seal-immerse tip of the tube in the first bottle in2-3 cm of sterile NSS; immerse the tube ofthe suction control bottle in 10-20 cm ofsterile NSS to stabilize the normal negativepressure in the lungs. This protects thepleura from trauma if the suction pressureis inadvertently increased


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c. Three-bottle system

The first bottle is drainage bottle; thesecond bottle is water-seal bottle, thethird bottle is suction control bottle

Observe for intermittent bubbling andfluctuation with respiration in water-sealbottle; continuous bubbling in the

suction bottle


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The term common cold is a popular phrase for a

group of symptoms including sneezing,congestion, and mild malaise Symptoms can continue for two weeks Clinical presentation:

Sneezing

Sore throatRhinorrheaMild malaise and achinessNon-productive cough

Sinus congestionHeadacheMay include nasal mucosa edema and erythema,

nasal secretions, low-grade fever or milderythema in the larynx


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Treatment:

Decongestants are helpful to relieve

rhinorrhea, sinus congestion, andheadache

Gargling with warm salt water often

soothes a sore throat and can help clearoropharyngeal secretions

Analgesic

Nursing interventionsGood nutrition and adequate sleep

strengthen the immune system

Frequent and thorough hand washing


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A seasonal viral respiratory illness It is similar to common cold in mode

of infection and transmission, being

spread by the aerosol method orclose contact Older adults and those with chronic

illnesses are most at risk forcomplications like pneumonia,exacerbation of commorbidities, anddeath


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Clinical presentation:

ExhaustionChills

Sinus congestion

Nonproduvtive coughHeadache

Myalgias

Fever

Pharyngitis

Cervical adenopathy


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Treatment

Acetamonophen

Analgesia

Nursing interventions

RestIncrease fluid

Those too ill to maintain hydration may

need to be hospitalized. If symptoms donot resolve within 7 days, furthermedical attention is needed.


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URTI

Cigarette smokingAllergic rhinitis

Inflammation

Edema of the mucous membrane

Hypersecretion of mucus

Infection


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Assessment

Pain:

Maxillary: cheek, upper teethFrontal: above eyebrows

Ethmoid: in and around the eyes

Sphenoid: behind eye, occiput, top of the head

General malaise

Stuffy nose

Headache

Post-nasal dripPersistent cough

Fever


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Rest

Increase fluid intakeHot wet packs

Codeine, avoid ASA. It increases the risk of

developing nasal polypsAmoxicillin or other anti-infectives (acute-7

to 10 days; chronic-21 days)

Nasal decongestants e.g. Sudafed,

Dimetapp (used for 72 hrs)Irrigation of maxillary sinuses with warmNSS


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Surgery:

F

unctional Endoscopic Sinus Surgery(FESS)

Caldwell-Luc surgery (Radical AntrumSurgery)

Ethmoidectomy

Sphenoidectomy/ethmoidotomy

Osteoplastic flap surgery for frontalsinusitis


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Cigarette smokingRespiratory tract infection (RTI)

Environmental pollutants

Inflammation

Bradykinin

Histamine

Prostaglandin


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Increase capillary permeability

Fluid/cellular exudation

Edema of mucous membrane

Hypersecretion of mucus

Persistent cough


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Allergy(extrinsic)Inflammation(Intrinsic)

Histamine,bradykinin,prostaglandin,

Serotonin, Leukotrienes, ECF-A, SRS-A

(a)Bronchospasm


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Bronchoconstriction

(b) edema of mucous membrane

(c) hypersecretion of mucus

Narrowing of air ways

Increase work of breathing


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Tends to sit up,

Restlessness,

tachypnea/dyspnea,tachycardia,

Flaring of the alae nasi,

diaphoresis,Cold clammy skin,

wheezing, retractions,

Pallor-cyanosis


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Exhaustion

Slow, shallow respiration (hypoventilation)

Retention of carbon dioxide (air trapping)

Hypoxia Respiratory acidosis


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Assessment in COPD

CoughDyspnea

Chest pain

Sputum productionAdventitious breath sounds

Pursed-lip breathing

Tends to assume upright, leaning forwardposition

Alteration in LOC


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Alteration in skin color (pallor to cyanosis)

Alteration in skin temoerature (cold totouch)

Voice changes

Decreased metabolism: weakness, fatigue,anorexia, weight loss

Alteration in thoracic anatomy (barrel

chest)Clubbing of fingers

Polycythemia


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Collaborative Management

Rest to reduce oxygen demands of tissues

Increase fluid intake to liquefy mucussecretions

Good oral care to remove sputum and

prevent infection Diet: high caloric diet provides source of

energy; high protein diet helps maintainintegrity of alveolar wall; low carbohydratediet limits carbon dioxide production(natural end product),the client hasdifficulty in exhaling carbon dioxide.


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Oxygen therapy of 1 to 2 Lpm. Do notgive high concentration of oxygen. The

drive for breathing may be depressed. Avoid cigarette smoking, alcohol,

environmental pollutants. These inhibits

mucociliary function CPT- percussion, vibration, postural

drainage

Bronchial hygiene measures: steaminhalation, aerosol inhalation, medimistinhalation


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Pharmacotherapy:

>Expectorants (guaiafenessin)/mucolytic(mucomyst/mucosolval)

>Antitussive:

-Dextrometorphan, Codeine

Observe for drowsiness

Avoid activities that involve mentalalertness

Causes decrease of peristalsis therebyconstipation


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>Bronchodilators:

-Aminophylline(Theophyline),Ventolin(Slbutamol)

Observe for tachycardia

>Anti-histamine

-Benadryl(Diphenhydramine)

Observe for drowsiness

>Steroids

-Anti-inflammatory effect

>Antimicrobials


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Causes:Bacterial

Viral

Fungal

Aspiration

Chemical irritants

Inflammation of lung tissue


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Hypertrophy of mucous membrane

Increased sputum production

WheezingDyspnea

Cough

RalesRhonchi

Increase capillary permeability

Increased fluid ISC

Consolidation

Hypoxemia


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Inflammation of the pleura

Chest pain

Pleural effusion

Dullness

Decreased breath soundsDecreased vocal fremitus

Hypoventilation

Decreased chest expansionRespiratory acidosis


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Protective mechanism

Increased WBC

Increased RRFever


Rest

Fluids

Incentive spirometry

Oxygen therapy

Semi-fowlers position

Bronchial hygiene


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Oral hygiene

Humidifier

Splint chest when coughing

Monitor: sputum, chest x-ray,temperature

Pharmacotherapy: antibiotics


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Reportable, communicable,inflammatory disease that can occur

in any part of the body; mostfrequent site- pulmonary


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Classification of TB

a. Class 0: no exposure, no infectionb. Class 1: exposure, no infectio

c. Class 2: infection, no disease (+PPD

reaction but no clinical evidence ofactive TB)

d. Class 3: disease , clinically active

e. Class 4: disease, not clinically activef. Class 5: suspected disease,

diagnosis pending


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Pathophysiology

Mycobacterium tubercle bacilli

Dried droplet nuclei

Inflammation in alveoli


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Client education guide: PTB

a. TB is infectious; it may be cured or arrested

by medications

b. TB is transmitted by droplet infection

c. Cover nose and mouth when coughing,

sneezing, or laughingd. Wash hands after any contact with body

substances, masks or soiled tissues

e. Wear masks when advisedf. Take medications regularly, as prescribed


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Primary anti-TB drugs:

>Isoniazid (INH)

-may be used at any age and amongpregnant women

-side effects: peripheral neuritis,

hepatotoxicity-administer vitamin B6 (pyridoxine) toprevent peripheral neuritis

-monitor ALT (SGPT),AST(SGOT)

-used as prophylaxis for 6 months to 1 yr

>Streptomycin

-Side effects: ototxicity,nephrotoxicity


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>Rifampicin

-side effects: red orange to body

secretions, hepatoxicity,

-Nausea and vomiting,thrombocytopenia

>Ethambutol

-side effects: optic neuritis, skin rash

-opthalmologic examination at regular

basis


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NOTES: Evaluate effectiveness of anti-TBdrugs by sputum culture for acid fast

bacilli

>Anti-TB drugs must be taken in

combination to avoid bacterial resistance>drugs to be taken on empty stomach for

maximum absorption


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respiratory disorders in older adults

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