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NCLEX RN Preparation Program

Respiratory Disorders

Module 5, Part 3 of 3

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Chronic Airflow Limitation

Emphysema

+

Chronic Bronchitis

=

COPD

Chronic Obstructive Pulmonary Disease

Photo Source: National Heart, Lung and Blood Institute (NHLBI http://www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd_WhatIs.html

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Emphysema

Loss of lung elasticity

Hyperinflation

Air trapped in lungs

Alveoli over-stretched bullae

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Chronic Bronchitis

Recurrent inflammation Vasodilation, Congestion, Edema, Spasm

Excessive thick mucus blocks air flow Hypoxemia, CO2 retained

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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

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Signs of COPD

General Breathing Sputum Sounds Skin Finger tips

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Assess

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

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Is this an emergency?

Dyspnea scale 0-10 Oxygen saturation < 90% Peak flow < 300 ml

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Diagnostic Tests

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

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Goal: Patent Airway

Position Secretions Mucolytics Expectoration Hydration Humidifier

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Teach Effective Breathing Diaphragm Pursed-lips Controlled cough Orthopneic position

http://emphysemafoundation.org/pulhthex.jsp

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Bronchospasm

Bronchodilators Cholinergic antagonists Theophyllins

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Inflammation Infection

Inhaled steroids Systemic steroids Prevent pneumonia Influenza vaccination yearly Pneumovax q 5 years

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Conserve Energy

Schedule activities Don’t rush Supplemental oxygen Avoid arm raises

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Mealtime Strategies

Rest 4-6 small meals Bronchodilator ac Easy chewing Supplements Avoid gas-producing foods

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Stepped Therapy

1. Combivent (ipratropium + albuterol)

2. Add beta2 agonist (Albuterol)

3. Add theophyllin

4. Add Prednisone

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Control Anxiety = Dyspnea

Develop a plan Develop support network Join support group

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Complementary/Alternatives

Ask about non-prescribed methods used

Teach relaxation techniques

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Pneumonia

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

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Categories

Viral Fungal Bacterial Aspiration

Photo Source: USDS, http://www.ars.usda.gov/is/graphics/photos/sep01/k9606-20.htm]

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Classification

Causative agent (Streptococcus pneumoniae)

Anatomic location of the infection (lobar pneumonia)

By where it was acquired (community vs. hospital/nosocomial)

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Major Organisms

Community-acquired: Streptococcus pneumoniae (gram +) Staphylococcus aureus (gram +)

Nosocomial: Staphylococcus aureus (gram +) MRSA

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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

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Community Prevention

PneumovaxWash handsDon’t smokeWear mask: dusty, moldy areasAvoid crowdsEat healthy dietExercise

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Nosocomial Prevention

Prevent aspiration - How? Prevent cross-contamination Vaccinate inpatients Education Mouth care??

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Signs & Symptoms

Fever, chills Dyspnea, RR, shallow breathing Coughing, crackles, wheezing Pleuritic pain Anorexia Hypoxemia Sputum: purulent, blood-tinged, rusty

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Diagnosis

Sputum C&S Leukocytosis ABG’s Blood C&S Chest x-ray Oxygen saturation

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Goal: Improve Gas Exchange

Oxygen Antibiotics Rest Incentive spirometry Raise head of bed No smoking

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Goal: Clear Airway

Enhance cough strength Bronchodilators Rest Mucolytics Corticosteroids

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Goal: Control Pain and Fever

Pain Fever control Adequate volume

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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

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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

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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

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Diagnosis

Initial Screening – skin test Positive if >10mm induration

Chest x-ray  Sputum for AFB

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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

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Chest X-ray

To confirm positive PPD When PPD cannot be done Cavitation Caseation

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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

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How is it treated?

Initial Therapy may include: Isoniazid (INH) Rifampin Pyrazinamide (PZA) Ethambutol or Streptomycin

After two months: Isoniazid Rifampin

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Isoniazid

Precautions: Take on empty stomach, avoid antacids LFTs if liver disease

Warnings: Increases Dilantin & Tegretol levels

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Rifampin

Precautions Body secretions turn orange May ruin contact lenses

Warnings Reduces contraceptive, methadone

effect May interact with anti-retrovirals

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Rifapentine

Precautions Probably discolors body secretions

Warnings Decreased potency diabetes meds,

barbs, antibiotics, contraceptives

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Ethambutol Precautions

Decreased visual acuity Decreased red-green color discrimination

Warnings Optic toxicity is dose related Increased toxicity with renal insufficiency

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Pyrazinamide

Precautions Hepatotoxicity Nausea/vomiting Polyarthralgias Hyper-uricemia Transient rash Photo-sensitive dermatitis

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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.

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Transplant Recipients

Immune suppressed Donor organ with latent TB Reactivate pt’s latent infection Diagnosis difficult

Decreased PPD reaction

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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

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Drug Toxicity

Hx of liver disease Consuming alcohol daily Baseline + repeat LFTs Watch!

Dark urine Light stools Fatigue

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Drug Resistance

Multi-drug resistant TB (MDRTB) Second-line drugs Increased time of treatment

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Non-compliance

Failure of treatment Resistant bacilli Intermittent dosing? Arrest the patient?

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Patient/Family Teaching

Prevention Phone contact Test entire family Use precautions Follow-up sputum cultures Diet

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Acute Respiratory Failure

Dyspnea, tachycardia Progressive respiratory distress Breath sounds Mental status

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ARDS

Aspiration Sepsis Drowning Trauma

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Diagnostic Tests

pO2 < 60 mmHg

pCO2 > 50 mmHg

O2 saturation < 90% Chest x-ray – increasing

infiltrates to “white out”

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Collaborative Management

Oxygen Mechanical ventilation

Photo Source: Wikimedia Commons / Public Domain image, http://commons.wikimedia.org/wiki/Image:CPR_Dummy-Air_Force.JPG

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Intubation

Intubation tray Patient position Bed position Suction Oxygen flow meter Verify ETT placement Secure ETT

Photo Source: Centers for Disease Control (CDC) / Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Intubation.jpg

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Mechanical Ventilation

FiO2 100%

Tidal volume (Vt) 6-7 ml/kg Rate 20-28/minute

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Ventilators

Negative pressure Pressure cycled Time cycled Volume cycled

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Modes of Ventilation

CMV SIMV PSV PEEP CPAP

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Acidosis

Low pH = acidosis (normal 7.35-7.45) Low pH + low HCO3 = metabolic

acidosis (normal 21-26) Low pH + high CO2 = respiratory

acidosis (normal 35-45)

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Alkalosis

High pH = alkalosis High pH + high HCO3 = metabolic

alkalosis High pH + low CO2 = respiratory

alkalosis

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Ventilator Alarms

High pressure Low inspiratory pressure High respiratory rate Low exhaled volume

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Monitor Physiological Response

Breath sounds Breathing pattern Skin color Secretions Oxygen saturation ABGs, daily chest x-ray

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Monitor Psychological Response

Anxiety Communication Anticipate questions/needs

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Manage the Ventilator

Correct settings? Alarms on? Maintain humidity Monitor inline temperature ETT placement, cuff Tubing adjustments

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Prevent Complications

Barotrauma Stress ulcers Infection: Ventilator-assisted

pneumonia (VAP) Ventilator dependence Pressure necrosis

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Weaning from Ventilator

Awake, rested Muscle strength Heart rhythm Breath sounds ABGs Pulmonary function tests

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Weaning Methods

SIMV CPAP Pressure Support

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Extubation

Explain procedure Prepare: nasal cannula, towel, Chux Hyper-oxygenate Suction Deflate pilot balloon Suction Pull tube No talking!

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Pneumothorax

Signs and Symptoms Pleuritic chest pain SOB Tachypnea Tachycardia Asymmetrical chest wall

movement Decreased breath sounds Cyanosis Photo Source: Colorado State University,

http://www.cvmbs.colostate.edu/clinsci/wing/trauma/tension.htm

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Tension Pneumothorax

Photo Source: Lippincott, Williams, & Wilkins Connection Image Bank, http://connection.lww.com/products/smeltzer9e/imagebank.asp

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Tension Pneumothorax

Signs and Symptoms Tracheal deviation Distended neck veins Hypotension Compensatory tachycardia

& tachypnea Decreased cardiac outputMust be treated promptly

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Hemothorax

Signs and Symptoms In addition to those seen with

pneumothorax: Subcutaneous Emphysema

(crepitus) Percussion dullness over

area of hemothorax

Photo Source: http://www.chgranby.qc.ca/trauma_formation_drain.htm

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Nursing Care of the Chest Tube

Maintain closed system Assess, kinks, water seal, drainage

Maintain patency occlusive dressing, tubing, suction

Photo Source: Wikimedia Commons, GNU license, http://commons.wikimedia.org/wiki/Image:Chest_drain_-_bedside_with_fluids.jpg

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Nursing Care of the Patient

Oxygen Vital signs Chest wall movement, trachea, neck

veins Position Watch for distress

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Pulmonary Embolus

DVT Air Fat Catheter

Photo Source: National Heart, Lung and Blood Institute (NHLBI),

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Signs/Symptoms

Classic triad Common: dyspnea, tachypnea,

pleuritic pain Pleuritic chest pain + dyspnea +

predisposing factor

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Diagnosis

ABGs Chest x-ray V/Q scan Spiral CT Pulmonary angiogram

Photo Source: CDC/Wikimedia Commons, http://commons.wikimedia.org/wiki/Image:Pneumonia_x-ray.jpg

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Prevention

Early ambulation Hydration Anti-embolic stockings Sequential pumps Avoid lower extremity punctures Aspirate clotted IVs SQ heparin or LMWH

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Emergency Measures

Oxygen HOB up Support Stat ABGs, chest x-ray Prepare for code blue

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Collaborative Management

Continue oxygen Bed rest Heparin drip Coumadin Thrombolytics? Embolectomy, umbrella filter

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Teach

Bleeding precautions Avoid immobility Avoid dehydration Avoid aspirin products

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Photo Acknowledgement:Unless noted otherwise, all photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.