Nursing Interventions for Patients with Respiratory Needsuserfiles/pdfs/course-materials/Nursing... · Nursing Interventions for Patients with Respiratory Needs Debra Mercer BSN,

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Nursing Interventions forNursing Interventions forPatients with RespiratoryPatients with Respiratory

NeedsNeedsDebra Mercer BSN, RN, RRTDebra Mercer BSN, RN, RRT

UPPER AIRWAYUPPER AIRWAYDISORDERSDISORDERS

EpistaxisEpistaxisSinusitisSinusitisPharyngitisPharyngitis/Tonsillitis/TonsillitisRhinitisRhinitisSinusitis Sinusitis vsvs Allergic Rhinitis Allergic RhinitisLaryngitisLaryngitis

EpistaxisEpistaxis Causes Causes

CausesCausesIrritationIrritationTraumaTraumaInfectionInfectionForeign BodyForeign BodyTumorTumorSystemic diseaseSystemic diseaseHypertensionHypertensionBlood Blood DyscrasiasDyscrasias

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EpistaxisEpistaxis continued continued

90% anterior bleeds90% anterior bleeds10% posterior bleeds10% posterior bleedsMay require nasal packingMay require nasal packingSurgery for severe bleedSurgery for severe bleed

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Nursing ManagementNursing ManagementEpistaxisEpistaxis

Nursing managementNursing managementMonitor closely for hypoxia andMonitor closely for hypoxia andairway obstructionairway obstructionMonitor for further bleedingMonitor for further bleedingPack remains in place for 5 daysPack remains in place for 5 daysComfort measuresComfort measures

EpistaxisEpistaxis (Surgery) (Surgery)

Packing remains in place for 24Packing remains in place for 24hourshoursWatch for further:Watch for further:

BleedingBleedingInfectionInfectionHypertensionHypertensionHypotensionHypotension

Minimize activity for 10 daysMinimize activity for 10 days

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SinusitisSinusitis

EtiologyEtiologyBacterialBacterialViralViralFungalFungalImpaired Impaired ciliaryciliary action actionAccumulation or mucousAccumulation or mucous

Acute or ChronicAcute or Chronic

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Sinusitis ContinuedSinusitis Continued

AssessmentAssessment

DiagnosisDiagnosis

Medical ManagementMedical Management

Nursing ManagementNursing ManagementSinusitisSinusitis

Hot packsHot packsAvoid antihistaminesAvoid antihistaminesSaline nasal spraySaline nasal sprayAdequate restAdequate restIncrease fluid intakeIncrease fluid intakeNotify provider if symptomsNotify provider if symptomsincrease or fail to resolveincrease or fail to resolve

Sinusitis SurgicalSinusitis SurgicalManagementManagement

Purpose is to allow ventilationPurpose is to allow ventilationand drainage of mucousand drainage of mucousPotential complicationsPotential complicationsAssessmentAssessment

Pre-opPre-opAssess for bleeding tendenciesAssess for bleeding tendencies

Post-opPost-opAssess for bleeding, respiratoryAssess for bleeding, respiratorydistress, bruising and/or facial edemadistress, bruising and/or facial edema

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Nursing Management ofNursing Management ofSurgical SinusitisSurgical Sinusitis

InterventionsInterventionsPreoperativelyPreoperativelyPostoperativelyPostoperatively

PharyngitisPharyngitis/Tonsillitis/Tonsillitis

Generally viral infectionsGenerally viral infectionsTreat viral infectionsTreat viral infectionssymptomaticallysymptomaticallyAntibiotics only in the presenceAntibiotics only in the presenceof documented bacterialof documented bacterialinfectioninfectionTonsillectomy reserved forTonsillectomy reserved forrecurrent tonsillitisrecurrent tonsillitis

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RhinitisRhinitis

Acute Rhinitis (Common Cold)Acute Rhinitis (Common Cold)Allergic RhinitisAllergic RhinitisVasomotor RhinitisVasomotor RhinitisSymptomsSymptomsEffectsEffects

Management of RhinitisManagement of Rhinitis

AvoidanceAvoidanceSteroid Nasal SpraySteroid Nasal SprayAntihistamineAntihistamineDesensitizationDesensitization

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Differentiation of SinusitisDifferentiation of Sinusitisand Allergic Rhinitisand Allergic Rhinitis

SinusitisSinusitisRed and inflamed mucosaRed and inflamed mucosaDiscolored drainageDiscolored drainage

Allergic RhinitisAllergic RhinitisPale, boggy nasal mucosaPale, boggy nasal mucosaClear drainageClear drainageItching of face, nose, palate withItching of face, nose, palate withsneezing and nasal creasesneezing and nasal crease

LaryngitisLaryngitis

CausesCausesInflammationInflammationVocal AbuseVocal AbuseRefluxRefluxVirusVirusBacteriaBacteria

TreatmentTreatmentAntibioticsAntibioticsSteroidsSteroidsIncreaseIncreaseHumidityHumidityVoice RestVoice RestTreat RefluxTreat Reflux

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LOWER AIRWAYLOWER AIRWAYDISORDERSDISORDERS

AsthmaAsthmaStatus Status AsthmaticusAsthmaticusCOPDCOPDChronic BronchitisChronic BronchitisEmphysemaEmphysemaTracheobronchitisTracheobronchitisBronchiectasisBronchiectasisAtelectasisAtelectasis InfluenzaInfluenza

LOWER AIRWAYLOWER AIRWAYDISORDERSDISORDERS

PneumoniaPneumoniaPulmonary TuberculosisPulmonary TuberculosisSARSSARSMalignant Malignant NeoplasmsNeoplasmsOccupational Lung DiseaseOccupational Lung DiseaseCystic FibrosisCystic FibrosisLung TransplantLung TransplantSarcoidosisSarcoidosisPleural Pain and Pleural EffusionPleural Pain and Pleural EffusionAvian FluAvian Flu

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AsthmaAsthma

Also called RADAlso called RADEtiologyEtiologyPathophysiologyPathophysiologyEarly Phase ReactionEarly Phase ReactionLate Phase ReactionLate Phase Reaction

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Asthma TriggersAsthma Triggers

StressStressAllergens in extrinsic asthmaAllergens in extrinsic asthmaCold or hot airCold or hot airDry AirDry AirExerciseExerciseASA/NSAIDS or beta blockersASA/NSAIDS or beta blockersFoods containing MSGFoods containing MSGURI, GERD, Sinusitis, PNDURI, GERD, Sinusitis, PNDAnything that irritates the airwayAnything that irritates the airway

Hairspray or cologneHairspray or cologneHousehold cleaners especially with bleachHousehold cleaners especially with bleachAir freshener (Aerosols)Air freshener (Aerosols)

Asthma ClassificationsAsthma Classifications

Mild IntermittentMild IntermittentMild PersistentMild PersistentModerate PersistentModerate PersistentSevere PersistentSevere Persistent

Daily high dose inhaled corticosteroid + long acting Daily high dose inhaled corticosteroid + long acting ββ2 agonist2 agonistand leukotriene modifierand leukotriene modifierShort acting Short acting ββ2 agonist as needed2 agonist as needed

Severe persistentSevere persistentasthmaasthma

Daily medium to high dose inhaled corticosteroid + long actingDaily medium to high dose inhaled corticosteroid + long actingββ2 agonist2 agonistAlso consider adding leukotriene modifierAlso consider adding leukotriene modifierShort acting Short acting ββ2 agonist as needed2 agonist as needed

Moderate persistentModerate persistentasthmaasthma

Daily anti-inflammatory mediation like cromolyn or a low doseDaily anti-inflammatory mediation like cromolyn or a low doseinhaled corticosteroidinhaled corticosteroidMay consider a leukotriene modifier insteadMay consider a leukotriene modifier insteadShort acting Short acting ββ2 agonist as needed2 agonist as needed

Mild persistent asthmaMild persistent asthma

No daily medications; Short acting No daily medications; Short acting ββ2 agonist as needed2 agonist as needed(should not be needed daily)(should not be needed daily)

Mild intermittentMild intermittentasthmaasthma

Medication RegimenMedication RegimenSeveritySeverity

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AsthmaAsthma

Chronic inflammation leads toChronic inflammation leads tohyperresponsivenesshyperresponsivenessHyperactivity of bronchi andHyperactivity of bronchi andairway edema decreaseairway edema decreasediameter of lumendiameter of lumenMucous further reducesMucous further reducesdiameterdiameterAirflow is limitedAirflow is limited

Asthma SymptomsAsthma Symptoms

WheezingWheezingDyspneaDyspneaCoughCoughIncreased respiratory effortIncreased respiratory effortNasal flaringNasal flaringPursed lip breathingPursed lip breathingAccessory Muscle useAccessory Muscle use¤¤ Cyanosis is LATE signCyanosis is LATE sign¤¤ Inability to Inability to auscultateauscultate wheezing wheezing

may be an ominous sign may be an ominous sign

Emergency Signs of AsthmaEmergency Signs of Asthma

CyanosisCyanosisPeak expiratory flow of <50 ofPeak expiratory flow of <50 oftheir usual valuetheir usual valueAbsence of wheezing in anAbsence of wheezing in anasthmatic patient withasthmatic patient withrespiratory distress requiresrespiratory distress requiresimmediateimmediate treatment treatment

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Diagnosing AsthmaDiagnosing Asthma

Clinical symptomsClinical symptomsPFT’sPFT’s//SpirometrySpirometryResponse to treatmentResponse to treatmentABG’sABG’sAllergy testingAllergy testing

Medical Goals for AsthmaMedical Goals for Asthma

Prevent chronic asthmaPrevent chronic asthmaexacerbationsexacerbationsMaintain normal activity levelsMaintain normal activity levelsMaintain normal lung functionMaintain normal lung functionMinimize side effects of therapyMinimize side effects of therapyPartner with patient to meetPartner with patient to meetexpectations and satisfactionexpectations and satisfaction**Teach step by step instructions for**Teach step by step instructions formonitoring and adjusting therapy atmonitoring and adjusting therapy athome** p.1817home** p.1817

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Asthma MedicalAsthma MedicalManagementManagement

Treat infectionsTreat infectionsTreat GERDTreat GERDRule out other medicalRule out other medicaldiagnosis such as CHFdiagnosis such as CHFReverse Airway SpasmReverse Airway SpasmControl InflammationControl InflammationTreatment is based onTreatment is based onclassification of severityclassification of severity

Asthma Treatment ProtocolAsthma Treatment Protocolp.1815p.1815

www.nhlbi.nih.gov/about/naeppwww.nhlbi.nih.gov/about/naeppClick on health providerClick on health providerinformationinformationHas treatment protocol forHas treatment protocol forchildren < 5 years of age andchildren < 5 years of age andchildren and adults > 5 years ofchildren and adults > 5 years ofage including all medicationsage including all medicationscurrently being used in thecurrently being used in thetreatment of asthma.treatment of asthma.

Asthma ExacerbationsAsthma Exacerbations

Treated withTreated withSubcutaneous EpinephrineSubcutaneous EpinephrineOxygenOxygenNebulizedNebulized ?? 2 Agonist2 AgonistIV CorticosteroidsIV CorticosteroidsPossible AntibioticsPossible Antibiotics

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Asthma MedicationsAsthma Medications

BronchodilatorsBronchodilators?? 2 Agonist2 AgonistTheophyllineTheophylline//aminophyllineaminophyllineAnticholinergicsAnticholinergicsCombinationCombinationAnti-inflammatoryAnti-inflammatoryLeukotrieneLeukotriene Modifiers Modifiers

Asthma Nursing ProcessAsthma Nursing Process

AssessmentAssessmentControl airway distressControl airway distressPrecipitating factorsPrecipitating factorsComplete Respiratory AssessmentComplete Respiratory AssessmentMonitor for deteriorating or improvingMonitor for deteriorating or improvingsymptomssymptomsAssess family support and teachAssess family support and teachhow stress may exacerbatehow stress may exacerbatesymptomssymptoms

Status Status AsthmaticusAsthmaticus

Life threatening conditionLife threatening conditionAcute Acute bronchospasmbronchospasm that continues that continuesdespite aggressive treatment ordespite aggressive treatment orrecurs as the medication wears offrecurs as the medication wears offWork of breathing is increasedWork of breathing is increased

5-10 x 5-10 xCan lead to severe air trapping, CO2Can lead to severe air trapping, CO2retention, obstruction of venousretention, obstruction of venousreturn, severe return, severe pulsuspulsus paradoxusparadoxus and andcorcor pulmonalepulmonale, death, death

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Status Status AsthmaticusAsthmaticusTreatmentTreatment

Treat with:Treat with:SubcutaneousSubcutaneous Epinephrine Epinephrine1:1000 (0.3ml)1:1000 (0.3ml)**Oxygen ****Oxygen **NebulizedNebulized ?? 2 Agonist2 AgonistIV CorticosteroidsIV CorticosteroidsIntubation may be requiredIntubation may be required

Asthma Nursing DiagnosisAsthma Nursing Diagnosis

Ineffective Breathing PatternIneffective Breathing PatternIneffective Airway ClearanceIneffective Airway ClearanceImpaired Gas ExchangeImpaired Gas ExchangeAnxietyAnxietyActivity IntoleranceActivity IntoleranceImbalanced NutritionImbalanced NutritionDisturbed Sleep PatternDisturbed Sleep PatternInfectionInfectionKnowledge DeficitKnowledge Deficit

Asthma and the NursingAsthma and the NursingProcessProcess

EvaluateRespiratory status and oxygenationKnowledge of treatment planAbility to identify triggers and measuresto avoid themAbility to use inhaler correctlyAbility to use peak flow meterKnowledge of signs of distress and whatto do when they occur

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Asthma Self CareAsthma Self Care

Patient should keep diary ofPatient should keep diary ofsymptomssymptomsPatient should assess peak flowPatient should assess peak flowBID before any medicationsBID before any medicationsMedications are adjusted basedMedications are adjusted basedon peak flow readingson peak flow readingsPatient should know triggersPatient should know triggersand attempt to avoid themand attempt to avoid them

Chronic ObstructiveChronic ObstructivePulmonary Disease (COPD)Pulmonary Disease (COPD)Refers to several disorders thatRefers to several disorders thataffect movement of air in andaffect movement of air in andout of lungsout of lungsAmerican Thoracic SocietyAmerican Thoracic Societydefines it as a disease state thatdefines it as a disease state thatis characterized by airflowis characterized by airflowobstruction resulting formobstruction resulting formobstructive bronchitis orobstructive bronchitis oremphysema.emphysema.

COPDCOPD

EtiologyEtiologySmoking is leading risk factorSmoking is leading risk factorAgingAgingHeredity and genetic predispositionHeredity and genetic predisposition

PathophysiologyPathophysiology Hallmarks HallmarksDestruction of lung parenchyma-Destruction of lung parenchyma-emphysemaemphysemaInflammation of central airways-chronicInflammation of central airways-chronicbronchitisbronchitis

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Chronic BronchitisChronic Bronchitis

Defined as:Defined as:Presence of productive cough forPresence of productive cough for3 months in 2 successive years3 months in 2 successive years

Other causes must be ruled outOther causes must be ruled outbefore diagnosis is madebefore diagnosis is madePathophysiologyPathophysiologyManifestationsManifestations

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Chronic BronchitisChronic Bronchitis involves an inflammation of the involves an inflammation of the bronchibronchi(the large airway passages, or bronchioles, connecting each(the large airway passages, or bronchioles, connecting eachlung to the trachea)lung to the trachea), and excessive production of , and excessive production of sputumsputum(mucus)(mucus). The inflammation makes it very difficult to get rid of. The inflammation makes it very difficult to get rid ofsputum, and the airways become progressively blocked.sputum, and the airways become progressively blocked.

EmphysemaEmphysema

PathophysiologyPathophysiologyHallmarksHallmarksClassificationsClassificationsManifestationsManifestations

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1. Healthy alveolus2. Alveolus with emphysema

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Medical Management ofMedical Management ofCOPDCOPD

Improve ventilationImprove ventilationRemove bronchial secretionsRemove bronchial secretionsPromote ExercisePromote ExercisePrevent complicationsPrevent complicationsSlow progression of manifestationsSlow progression of manifestationsPromote health maintenance andPromote health maintenance andclient management of diseaseclient management of disease

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Common Medications ofCommon Medications ofCOPDCOPD

?? 2 Agonist and 2 Agonist and AnticholinergicsAnticholinergicsSteroidsSteroidsMethylxanthines Methylxanthines (Rare)(Rare)MucolyticsMucolytics (Controversial) (Controversial)DiureticsDiureticsAntiarrhythmicsAntiarrhythmics, , InotropicsInotropicsAntibioticsAntibioticsAlpha I Alpha I AntitrypsinAntitrypsinAntidepressantsAntidepressantsAnxiolyticsAnxiolytics

Nursing Management ofNursing Management ofCOPDCOPD

Health historyHealth historyDetails regarding onset andDetails regarding onset andduration of symptomsduration of symptomsComplete physical assessmentComplete physical assessmentVital SignsVital SignsSpecific Pulmonary AssessmentSpecific Pulmonary AssessmentLabsLabs

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COPD Nursing DiagnosisCOPD Nursing Diagnosis

Impaired gas exchangeImpaired gas exchangeActivity IntoleranceActivity IntoleranceAnxietyAnxietyIneffective Breathing PatternIneffective Breathing PatternAltered Nutrition: less than bodyAltered Nutrition: less than bodyrequirementsrequirementsKnowledge deficit: self careKnowledge deficit: self careSleep pattern disturbanceSleep pattern disturbanceIneffective individual or family copingIneffective individual or family copingAltered family processAltered family process

Surgical Management ofSurgical Management ofCOPDCOPD

Lung TransplantLung Transplant

Lung Volume Reduction SurgeryLung Volume Reduction Surgery

BullectomyBullectomy

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Nursing Management of theNursing Management of theSurgical PatientSurgical Patient

Frequent AssessmentsFrequent AssessmentsGood pulmonary Good pulmonary hygeinehygeinePain controlPain controlMonitor oxygenation andMonitor oxygenation andventilation after dischargeventilation after discharge(SaO2)(SaO2)Refer to pulmonary rehabilitationRefer to pulmonary rehabilitationprogramprogram

Considerations for ElderlyConsiderations for ElderlyPatientsPatients

Coexisting health problemsCoexisting health problemsDecreased exercise toleranceDecreased exercise toleranceImpaired nutritionImpaired nutritionLong standing smoking habitsLong standing smoking habitsIncreased risk of drugIncreased risk of druginteractionsinteractions

TracheobronchitisTracheobronchitis

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BronchiectasisBronchiectasis

Extreme form of bronchitisExtreme form of bronchitisPermanent, abnormal dilationPermanent, abnormal dilationand distortion of the bronchi andand distortion of the bronchi andbronchiolesbronchiolesBronchial walls are weakenedBronchial walls are weakenedby chronic inflammatoryby chronic inflammatorychangeschangesUsually localized to one lobe orUsually localized to one lobe orone lung segmentone lung segment

More mucous can accumulate in pouches and crevices inthe baggy, soft, bronchial tube walls; During coughs, the bronchial tube wall tends to collapse, trapping mucous inside,rather than acting as a rigid tube through which mucous can beexpelled. This leads to more mucous accumulating in the bronchial tubes, producing a vicious cycle, where increasingAmounts of infected mucous produce further damage andsoftening of the bronchial tube walls, leading to the accumulation of more mucous. The presence of soft,dilated bronchial tubes is called Bronchiectasis.

BronchiectasisBronchiectasis

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AtelectasisAtelectasis

Definition: Collapse of lungDefinition: Collapse of lungtissue at any structural level.tissue at any structural level.Develops when there are factorsDevelops when there are factorsthat interfere with lungthat interfere with lungexpansion.expansion.EtiologyEtiologyManifestationsManifestationsNursing ManagementNursing Management


Goal is to prevent occurrenceGoal is to prevent occurrencewith frequent position changeswith frequent position changesand early ambulation.and early ambulation.Deep breathing and coughingDeep breathing and coughingenhance lung expansionenhance lung expansionMay require oxygen, posturalMay require oxygen, posturaldrainage, chest PT and trachealdrainage, chest PT and trachealsuctioningsuctioning


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InfluenzaInfluenza

Definition: Viral infection of theDefinition: Viral infection of therespiratory tractrespiratory tractEtiologyEtiologyManifestationsManifestationsNursing ManagementNursing Management

Prevention through vaccinationPrevention through vaccinationAdminister anti-viral agents within 24Administer anti-viral agents within 24hours of onset of symptomshours of onset of symptomsPrevent spread of infection to othersPrevent spread of infection to othersSymptomatic treatmentSymptomatic treatment

PneumoniaPneumonia

Definition: Inflammatory processDefinition: Inflammatory processin lung parenchyma associatedin lung parenchyma associatedwith increase in interstitial andwith increase in interstitial andalveolar fluid.alveolar fluid.EtiologyEtiologyPathophysiologyPathophysiology

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Pneumonia Risk FactorsPneumonia Risk Factors

AgeAgeHistory URIHistory URISmokingSmokingMalnutritionMalnutritionDehydrationDehydrationChronic DiseaseChronic DiseaseTracheal IntubationTracheal IntubationProlonged ImmobilityProlonged ImmobilityImmunosuppressive TherapyImmunosuppressive TherapyNon functioning immune systemNon functioning immune system

Pneumonia ManifestationsPneumonia Manifestations

Fever and chillsFever and chillsPleuriticPleuritic chest pain chest painCough, sputum and Cough, sputum and hemoptysishemoptysisDyspneaDyspneaHeadacheHeadacheFatigueFatigue** Elderly patients frequently present** Elderly patients frequently presentwith altered LOC and dehydrationwith altered LOC and dehydration****AfebrileAfebrile****

PneumoniaPneumonia

Assessment FindingsAssessment FindingsMedical Management:Medical Management:

Depends on type of pneumoniaDepends on type of pneumonia

Nursing ManagementNursing ManagementFrequent respiratory assessmentsFrequent respiratory assessmentsMonitor oxygen therapy and Monitor oxygen therapy and ABG’sABG’sAdditional pertinent informationAdditional pertinent informationEvaluationEvaluation

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Pneumonia NursingPneumonia NursingDiagnosisDiagnosis

Ineffective Airway ClearanceIneffective Airway ClearanceIneffective Breathing PatternIneffective Breathing PatternActivity IntoleranceActivity IntoleranceFluid Volume DeficitFluid Volume DeficitAltered NutritionAltered NutritionPainPainAltered Oral Mucous MembranesAltered Oral Mucous MembranesKnowledge DeficitKnowledge Deficit

Pulmonary TuberculosisPulmonary Tuberculosis

Kills more people than any otherKills more people than any otherinfectious disease in the worldinfectious disease in the worldCaused by mycobacteriumCaused by mycobacteriumtuberculosistuberculosisMost commonly occurs inMost commonly occurs inpeople who have repeated closepeople who have repeated closecontact with an infected personcontact with an infected personwho has not been diagnosedwho has not been diagnosed


Risk FactorsRisk Factors

Factors that influenceFactors that influencedevelopment of active TBdevelopment of active TB

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PathophysiologyPathophysiologyPrimary InfectionPrimary InfectionSecondary InfectionSecondary Infection

Pulmonary TBPulmonary TBManifestationsManifestations

ManifestationsManifestationsOften unrecognized becauseOften unrecognized becausepatients are relativelypatients are relativelyasymptomaticasymptomaticOnly signs may be + skin test andOnly signs may be + skin test andX-ray findingX-ray finding

Pulmonary TB Skin TestingPulmonary TB Skin Testing

TB skin testingTB skin testing0.1ml given 0.1ml given intradermalintradermal in left forearm in left forearmRead in 48-72 hoursRead in 48-72 hoursNote the presence of Note the presence of indurationinduration, not , not erythemaerythema

Positive results arePositive results are>5mm in known or suspected HIV infection, IV>5mm in known or suspected HIV infection, IVdrug users, those with close contact with knowndrug users, those with close contact with knownTB infection and those with X-rays suggestive ofTB infection and those with X-rays suggestive ofprevious TB infectionprevious TB infection>10mm for all other high risk groups (US)>10mm for all other high risk groups (US)>15mm for patients in low risk groups>15mm for patients in low risk groups

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Measuring a TB Skin TestMeasuring a TB Skin Test

Induration created by the Mantoux SkinTest. The size of a positive test resultdepends on the exposure history and

health status of theindividual and a measure of the actualinduration rather than the erythema

produced:

Pulmonary TB DiagnosisPulmonary TB Diagnosis

If confirmed with Sputum culture forIf confirmed with Sputum culture forAFBAFB

3 separate specimens collected on 33 separate specimens collected on 3consecutive morningsconsecutive morningsSmears are not extremely sensitiveSmears are not extremely sensitiveCulture is definitive but may take 2-12Culture is definitive but may take 2-12weeksweeks

Respiratory isolation until cultureRespiratory isolation until cultureresults are knownresults are knownOther Other mycobacterialmycobacterial diseases will have diseases will havea positive smear for AFBa positive smear for AFB

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Treatment of Pulmonary TBTreatment of Pulmonary TB

Rarely hospitalizedRarely hospitalizedOnly if acutely ill, living in a high risk situation,Only if acutely ill, living in a high risk situation,non-compliant with therapy, has a history ofnon-compliant with therapy, has a history ofprevious disease with non-compliance orprevious disease with non-compliance orhighly resistant organismshighly resistant organisms

Treatment is long term and shouldTreatment is long term and shouldbe started ASAPbe started ASAPPatients usually receive 2-3Patients usually receive 2-3medications to ensure elimination ofmedications to ensure elimination ofresistant organismsresistant organisms

Treatment of Pulmonary TBTreatment of Pulmonary TB

CDC recommends a 2 phaseCDC recommends a 2 phaseapproachapproach

11stst: intensive phase with 2-3 drugs: intensive phase with 2-3 drugsaimed at destruction of large numbers ofaimed at destruction of large numbers ofrapidly multiplying organisms, lastsrapidly multiplying organisms, lastsabout 2 monthsabout 2 months22ndnd: maintenance phase of usually 2: maintenance phase of usually 2drugs, lasts another 4+ months untildrugs, lasts another 4+ months untilcultures are clearcultures are clearIf no response in 1If no response in 1stst phase, 2 additional phase, 2 additionalagents will be addedagents will be added

Pulmonary TB NursingPulmonary TB NursingDiagnosisDiagnosis

AnxietyAnxietyIneffective airway clearanceIneffective airway clearanceImpaired gas exchangeImpaired gas exchangePainPainAltered nutrition: less than bodyAltered nutrition: less than bodyrequirementsrequirementsIneffective individual and/or familyIneffective individual and/or familycopingcopingAltered health maintenanceAltered health maintenanceKnowledge deficitKnowledge deficitSleep pattern disturbanceSleep pattern disturbance

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Prevention of TransmissionPrevention of Transmissionof Pulmonary TBof Pulmonary TB

Preventative Therapy forPreventative Therapy forPulmonary TBPulmonary TB

May prevent infection in thoseMay prevent infection in thosewho are exposed and keepwho are exposed and keeppeople with dormant TB frompeople with dormant TB fromdeveloping active TBdeveloping active TBINH is used for preventiveINH is used for preventivetherapy for 6-12 monthstherapy for 6-12 months

Self Care Pulmonary TBSelf Care Pulmonary TB

Teach patient about disease, itsTeach patient about disease, itstransmission and how to prevent ittransmission and how to prevent itTeach patient regarding treatmentTeach patient regarding treatmentTeach patient about need toTeach patient about need tocontinue therapy & keep follow-upcontinue therapy & keep follow-upappointmentsappointmentsTeach regarding medication sideTeach regarding medication sideeffects and interactionseffects and interactions

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Evaluate Pulmonary TBEvaluate Pulmonary TB

Medication complianceMedication complianceUnderstanding of action ofUnderstanding of action ofmedicationsmedicationsSide effectsSide effectsFuture sputum specimensFuture sputum specimensFollow up x-ray resultsFollow up x-ray resultsImprovement or worsening ofImprovement or worsening ofconditioncondition

ExtrapulmonaryExtrapulmonaryTuberculosisTuberculosis

TB occurring outside lungsTB occurring outside lungsHighly aerobic sites such as renalHighly aerobic sites such as renalcortex, growth plates and cortex, growth plates and meningesmeningesOften difficult to detect withOften difficult to detect withnondistinctnondistinct findings, weight loss, findings, weight loss,fatigue , malaise, fever and nightfatigue , malaise, fever and nightsweats may or may not be presentsweats may or may not be presentTreatment may be longer and moreTreatment may be longer and moremedications may be requiredmedications may be required

SARSSARS

Severe acute respiratory syndromeSevere acute respiratory syndromeAge 25-70Age 25-70Most victims were previously healthyMost victims were previously healthyIncubation 2-7 daysIncubation 2-7 daysProdromalProdromal period of fever, period of fever,sometimes associated with chills,sometimes associated with chills,rigors, headache, diarrhea, malaiserigors, headache, diarrhea, malaiseand and myalgiamyalgiaOccasionally, respiratoryOccasionally, respiratorymanifestations are notedmanifestations are noted

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SARSSARS

After 3-7 days, lower respiratory phaseAfter 3-7 days, lower respiratory phasebeginsbeginsDry, nonproductive and Dry, nonproductive and dyspneadyspneaprogressing to hypoxemiaprogressing to hypoxemiaFatality rate is about 3%Fatality rate is about 3%Ranges from mild illness to deathRanges from mild illness to deathA few close contacts have become ill butA few close contacts have become ill butmost remain wellmost remain wellEffective treatment regimen remainsEffective treatment regimen remainsunknownunknownWith progressive illness, interstitialWith progressive illness, interstitialinfiltrates and consolidation show on x-rayinfiltrates and consolidation show on x-rayLeukopeniaLeukopenia and thrombocytopenia and thrombocytopenia

Malignant Malignant NeoplasmsNeoplasms

Malignancy of epithelium ofMalignancy of epithelium ofrespiratory tractrespiratory tract

Most common typesMost common typesSmall cell (oat cell) carcinomaSmall cell (oat cell) carcinomaSquamousSquamous cell carcinoma cell carcinomaAdenocarcinomaAdenocarcinomaLarge cell carcinomaLarge cell carcinomaAre many other typesAre many other types

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Risk FactorsRisk Factors

PathophysiologyPathophysiologySmall cellSmall cellNon-small cellNon-small cell


ManifestationsManifestationsMimics other pulmonary conditionsMimics other pulmonary conditionsSpecific findings vary with type of tumor,Specific findings vary with type of tumor,location and pre-existing pulmonarylocation and pre-existing pulmonaryhealthhealthPulmonary symptomsPulmonary symptomsChest, shoulder, arm and back painChest, shoulder, arm and back painHemoptysisHemoptysisPericardial effusion or Pericardial effusion or tamponadetamponadeCardiac Cardiac dysrhythmiasdysrhythmias


Warning signsWarning signsChanges in respiratory statusChanges in respiratory statusPersistent coughPersistent coughBlood streaked sputum or frankBlood streaked sputum or frankhemoptysishemoptysisRust colored or purulent sputumRust colored or purulent sputumWeight lossWeight lossChest, shoulder, back or arm painChest, shoulder, back or arm painUnexplained Unexplained dyspneadyspneaRecurrent episodes of pleural effusion,Recurrent episodes of pleural effusion,pneumonia or bronchitispneumonia or bronchitis

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DiagnosisDiagnosisBronchoscopyBronchoscopySputum cytologySputum cytologyCTCTMRIMRIBiopsy confirms diagnosisBiopsy confirms diagnosisRadio Nucleotide ScansRadio Nucleotide Scans


Diagnostic stagingDiagnostic stagingTumor-node-metastasis (TNM)Tumor-node-metastasis (TNM)scheme used (p1854)scheme used (p1854)Uses size of tumor and degree ofUses size of tumor and degree ofpulmonary involvement along withpulmonary involvement along withevaluation of metastasis to lymphevaluation of metastasis to lymphnodes and distant metastasis tonodes and distant metastasis tostagestageExample: T1-N0-M0Example: T1-N0-M0


MetastasisMetastasisSpreads either by direct extension orSpreads either by direct extension ormetastasismetastasis

ManagementManagementEarly detectionEarly detectionRadiationRadiationChemotherapyChemotherapySurgerySurgery

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Surgical ProceduresSurgical ProceduresLaser surgery done forLaser surgery done foresophageal obstructions that areesophageal obstructions that arenot not resectableresectablePulmonary resectionPulmonary resectionLobectomyLobectomy – removal of entire – removal of entirelobe of one lunglobe of one lungPneumonectomyPneumonectomy – removal of – removal ofentire lungentire lung


Surgical management (cont)Surgical management (cont)Usually 2 chest tubes are placedUsually 2 chest tubes are placedfollowing following resectionalresectional surgery surgeryUpper tube anterior at 2Upper tube anterior at 2ndnd

intercostalintercostal space allows drainage space allows drainageof air from pleural spaceof air from pleural spaceLower tube posterior 8Lower tube posterior 8thth intercostalintercostalor 9or 9thth midaxillarymidaxillary intercostalintercostal is isusually larger to allow drainage ofusually larger to allow drainage ofserosanguineousserosanguineous fluid fluid


Nursing ManagementNursing ManagementDiagnostic PhaseDiagnostic PhaseMedical TreatmentMedical TreatmentPreoperativePreoperativePostoperativePostoperative

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Postoperative nursingPostoperative nursingmanagementmanagement

When to clamp a chest tubeWhen to clamp a chest tubeUsually contraindicated because itUsually contraindicated because itmay precipitate a tensionmay precipitate a tensionpneumothoraxpneumothoraxClamp in the following casesClamp in the following cases

Persistent air leakPersistent air leakChanging drainage systemChanging drainage systemEvaluating readiness for removalEvaluating readiness for removal


Potential complications (p1858)Potential complications (p1858)Monitor for respiratory failure,Monitor for respiratory failure,tension tension pneumothoraxpneumothorax, pulmonary, pulmonaryembolism, pulmonary edema,embolism, pulmonary edema,thrombophlebitisthrombophlebitis, , hypovolemiahypovolemia,,infection, subcutaneousinfection, subcutaneousemphysema,emphysema,Monitor IV flow rateMonitor IV flow rateMonitor cardiac rhythmMonitor cardiac rhythm

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Nursing DiagnosisNursing DiagnosisIneffective airway clearanceIneffective airway clearancePainPainImpaired physical mobilityImpaired physical mobilityRisk for ineffective individualRisk for ineffective individualcopingcopingDeficient knowledge r/t self careDeficient knowledge r/t self careafter dischargeafter discharge

Occupational Lung DiseaseOccupational Lung Disease

Caused by inhalation of dust,Caused by inhalation of dust,chemicals, and other particleschemicals, and other particlespresent in the work environmentpresent in the work environmentHarmful effects depend onHarmful effects depend on

Nature of exposureNature of exposureDuration and intensity of exposureDuration and intensity of exposureParticle size and water solubilityParticle size and water solubility

Occupational Lung DiseaseOccupational Lung Disease

Acute respiratory irritation resultsAcute respiratory irritation resultsfrom exposure to chemicals likefrom exposure to chemicals likeammonia and chlorine in the form ofammonia and chlorine in the form ofgases, aerosols or particulate mattergases, aerosols or particulate matterIf irritants reach lower airway,If irritants reach lower airway,alveolar damage and pulmonaryalveolar damage and pulmonaryedema may resultedema may resultEffects are usually short livedEffects are usually short livedalthough may cause chronic damagealthough may cause chronic damageTreatment is avoidance andTreatment is avoidance andrespiratory supportrespiratory support

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Cystic FibrosisCystic FibrosisPathophysiologyPathophysiology

Cystic FibrosisCystic FibrosisDiagnosisDiagnosis

People with cystic fibrosis have between 2People with cystic fibrosis have between 2and 5 times the normal amount of salt inand 5 times the normal amount of salt intheir sweat. Thus, doctors can use a sweattheir sweat. Thus, doctors can use a sweattest to measure the amount of salt (sodiumtest to measure the amount of salt (sodiumchloride) in a person's sweat. Sweat ischloride) in a person's sweat. Sweat iscollected from the person's arm or leg andcollected from the person's arm or leg andtaken to a laboratory to be analyzed.taken to a laboratory to be analyzed.In newborns, doctors can measure theIn newborns, doctors can measure theamount of a protein called amount of a protein called trypsinogentrypsinogen in the in theblood. The level of this protein is higher thanblood. The level of this protein is higher thannormal in people with cystic fibrosis.normal in people with cystic fibrosis.Finally, genetic tests can identify a faultyFinally, genetic tests can identify a faultyCFTR gene using a sample of the patient'sCFTR gene using a sample of the patient'sblood.blood.

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Cystic FibrosisCystic Fibrosis

ManifestationsManifestationsEarliest signs are cough that isEarliest signs are cough that isintermittent, becomes daily and isintermittent, becomes daily and isworse at night in early morningworse at night in early morningCough becomes productive, thenCough becomes productive, thenparoxysmal and is associated withparoxysmal and is associated withgagging and emesisgagging and emesisSputum is tenacious, purulent andSputum is tenacious, purulent andoften greenoften green

Cystic FibrosisCystic Fibrosis

ManagementManagementClear secretionsClear secretions

Ensure hydrationEnsure hydrationMucolyticMucolytic and bronchodilator aerosols and bronchodilator aerosolsTeach effective coughing techniquesTeach effective coughing techniquesPostural drainage and percussion at leastPostural drainage and percussion at leastBIDBID

Enhance aerationEnhance aerationEffective cough to clear airwaysEffective cough to clear airwaysHigh Fowler’s positionHigh Fowler’s positionOxygen is hypoxia is presentOxygen is hypoxia is presentExercise to improve pulmonary functionExercise to improve pulmonary function


Done for end stage lung diseaseDone for end stage lung diseaseInvolves replacement of one orInvolves replacement of one orboth lungsboth lungsWidely accepted treatment forWidely accepted treatment formany lung diseasesmany lung diseasesPreoperative CarePreoperative CarePostoperative CarePostoperative Care

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Signs of rejection: Signs of rejection: dyspneadyspnea,,development of infiltrates on x-ray,development of infiltrates on x-ray,need for need for ventilatoryventilatory support, fatigue support, fatiguePatient may experience alterations inPatient may experience alterations inself concept related toself concept related to

Changes in appearance due to sideChanges in appearance due to sideeffects of medication for rejectioneffects of medication for rejection(steroids and (steroids and immunosuppressantsimmunosuppressants))LifestyleLifestyleWork abilityWork ability


Self careSelf careTeach about medsTeach about medsStress need for daily medicationStress need for daily medicationdespite lack of manifestationsdespite lack of manifestationsTeach to report fever, cough,Teach to report fever, cough,dyspneadyspnea, sputum, pain, reduced, sputum, pain, reducedexercise tolerance, weight gain orexercise tolerance, weight gain orfatiguefatigue

SarcoidosisSarcoidosis

EtiologyEtiology

PathophysiololgyPathophysiololgy

ManifestationsManifestations

ManagementManagement

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Pleural PainPleural Pain

Indicates presence of inflammationIndicates presence of inflammationOften accompanied by pleural friction rubOften accompanied by pleural friction rubOften develops abruptly and is severeOften develops abruptly and is severeenough for the patient to seek medical careenough for the patient to seek medical careUsually unilateral and worsened byUsually unilateral and worsened bybreathing or coughingbreathing or coughingMay restrict normal respiratory efforts andMay restrict normal respiratory efforts andlead to problems with gas exchangelead to problems with gas exchangeAnalgesicsAnalgesicsIntercostalIntercostal nerve block nerve block


Accumulation of fluid in pleuralAccumulation of fluid in pleuralspacespaceManifestations depend on amount ofManifestations depend on amount offluid present and the severity of lungfluid present and the severity of lungcompressioncompression250 250 mLmL or less may only be seen on or less may only be seen onx-rayx-rayLarge effusions may restrict lungLarge effusions may restrict lungexpansion leading to expansion leading to dyspneadyspnea esp. esp.on exertion, and a dry non-on exertion, and a dry non-productive coughproductive cough

Pleural EffusionPleural Effusion

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ThoracentesisThoracentesis


ThoracentesisThoracentesis is used to remove is used to removeexcess fluidexcess fluidFluid is analyzed to helpFluid is analyzed to helpdetermine cause of effusiondetermine cause of effusionAfter After thoracentesisthoracentesis, a closed, a closedchest drainage unit to suction ischest drainage unit to suction isused to re-expand the lungused to re-expand the lung

Avian (Bird) InfluenzaAvian (Bird) InfluenzaPandemic is a global disease outbreak. APandemic is a global disease outbreak. Aflu pandemic occurs when a new influenzaflu pandemic occurs when a new influenzavirus emerges for which people have littlevirus emerges for which people have littleor no immunity, and for which there is noor no immunity, and for which there is novaccine. The disease spreads easilyvaccine. The disease spreads easilyperson-to-person, causes serious illness,person-to-person, causes serious illness,and can sweep across the country andand can sweep across the country andaround the world in very short time.around the world in very short time.

It is especially virulentIt is especially virulentIt is being spread by migratory birdsIt is being spread by migratory birdsIt can be transmitted from birds to mammals and inIt can be transmitted from birds to mammals and insome limited circumstances to humans, andsome limited circumstances to humans, andLike other influenza viruses, it continues to evolve.Like other influenza viruses, it continues to evolve.

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Avian InfluenzaAvian Influenza

Symptoms in humans have rangedSymptoms in humans have rangedfrom:from:

typical human influenza-like symptomstypical human influenza-like symptoms(e.g., fever, cough, sore throat, and(e.g., fever, cough, sore throat, andmuscle achesmuscle acheseye infectionseye infectionsPneumoniaPneumoniasevere respiratory diseases (such assevere respiratory diseases (such asacute respiratory distress)acute respiratory distress)and other severe and life-threateningand other severe and life-threateningcomplications.complications.

Pulmonary EmbolusPulmonary Embolus

DefinitionDefinition

EtiologyEtiology

PathophysiologyPathophysiology

Clinical ManifestationsClinical Manifestations

DiagnosisDiagnosis

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Pulmonary EmbolusPulmonary Embolus

Medical ManagementMedical ManagementStabilizing CardiopulmonaryStabilizing CardiopulmonarySystemSystemAnticoagulant TherapyAnticoagulant TherapyFibronoyliticFibronoylitic Therapy TherapySurgical ManagementSurgical Management

Nursing Management for PENursing Management for PE

Monitor FrequentlyMonitor FrequentlyMonitor Monitor ABG’sABG’s and Pulse Ox and Pulse OxMonitor for Right-sided Heart FailureMonitor for Right-sided Heart FailureElevate HOBElevate HOBOxygenOxygenCarefully elevate legsCarefully elevate legsAnalgesia (Morphine)Analgesia (Morphine)Carefully monitor for excessCarefully monitor for excessanticoagulationanticoagulation

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PneumothoraxPneumothorax

Presence of air in the pleuralPresence of air in the pleuralspace that prohibits lungspace that prohibits lungexpansion.expansion.OpenOpenClosedClosedSpontaneousSpontaneousTraumaticTraumatic

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Nursing Interventions for Patients with Respiratory Needsuserfiles/pdfs/course-materials/Nursing... · Nursing Interventions for Patients with Respiratory Needs Debra Mercer BSN,