Nursing of AdultsWith

Medical & Surgical Conditions

Respiratory Disorders(Lower Airway)

Acute Bronchitis

• Etiology/Pathophysiology– Inflammation of the trachea and bronchial tree– Retention of secretions causes high risk of

bacterial growth– Usually secondary to upper respiratory

infection– Exposure to inhale irritants

Acute Bronchitis

• Signs & Symptoms– Productive cough– Rhonchi/wheezes– Dyspnea– Chest pain– Lowgrade temperature– Malaise– Headache

Acute Bronchitis• Treatment

– Cough suppressants• Codeine

– Antitussives• Pertussin

– Antipyretics• Tylenol

– Bronchodilators– Brethine– Antibiotics– Vaporizer– Encourage fluids

Legionnaires’ Disease

• Etiology/Pathophysiology– Legionella pneumophila– First identified in 1976 at the American Legion

convention in Philadelphia– Thrives in water reservoirs

• Air conditioners and humidifiers– Causes life-threatening pneumonia– Leads to respiratory failure, renal failure,

bacteremic shock, and ultimately death

Legionnaires’ Disease

• Signs & Symptoms– Elevated temperature

• 102 – 105 degrees– Headache– Nonproductive cough– Difficult and rapid respirations– Crackles or wheezes– Tachycardia– Signs of shock– Hematuria

Legionnaires’ Disease

• Treatment– Oxygen– Mechanical ventilation, if necessary– IV therapy– Antibiotics

• Erythromycin• Rifampin

– Antipyretics– Vasopressors

• For shock

Tuberculosis

• Etiology/Pathophysiology– Tubercle bacillus (Mycobacterium tuberculosis)– Chronic pulmonary and extrapulmonary infectious disease– Inhalation of droplet containing tubercle bacillus– Infection

• Presence of mycobacteria in the tissue of a person who has no s/s of TB

• Positive TB skin test• 10% will become active disease

– Active Disease• S/S of TB are present

– NOT easily transmitted• Most inhaled TB organisms are destroyed by the upper resp.

system

Tuberculosis

• Signs & Symptoms– Fever– Weight loss– Weakness– Productive cough– Chills– Night sweats– Hemoptysis

Tuberculosis• Diagnostic Tests

– Presumptive Diagnosis• Mantoux Tuberculin Skin Test

– Read 48 – 72 hours after given– Enduration (raised hardened tissue)– <5mm negative– >5mm positive

• Chest X-ray• Acid-fast bacilli smear x 3

– Confirmed Diagnosis• Sputum culture

– Positive for TB bacilli

Tuberculosis

• Treatment– Tuberculosis Isolation (AFB)

• Isolation room• Negative air pressure• Particulate respiration masks

– Medications• 6-9 months• First Line:

– isoniazid (INH), rifampin, rifampin and isoniazid (Rifamate), pyrazinamide, ethambutol, streptomycin

• Second Line: – Ethionamide, para-aminosalicylate sodium (PAS), cycloserine,

capreomycin, kanamycin, amikacin

Pneumonia

• Etiology/Pathophysiology– Inflammatory process of the bronchioles and the

alveolar spaces due to infection– Bacteria, viruses, mycoplasma, fungi, and parasites– Aspiration– Retained secretions become infected– Inflammation of respiratory tract occurs– Decreased oxygen/carbon dioxide exchange

Pneumonia

• Signs & Symptoms– Productive cough

• Sputum depends on cause– Severe chills– Elevated temperature– Increased heart rate– Increased respiratory rate– Dyspnea

Pneumonia• Treatment

– Oxygen– Chest percussion and postural drainage– Encourage to cough and deep breathe– Antibiotics

• Penicillin, erythromycin, cephalosporin, and tetramycin– Analgesics

• Tylenol or aspirin– Expectorants– Bronchodilators– Humidifier or nebulizer

Pleurisy

• Etiology/Pathophysiology– Inflammation of the visceral and parietal pleura– Bacterial or viral

Pleurisy

• Signs & Symptoms– Sharp inspiratory pain

• Usually radiates to the shoulder or abdomen– Dyspnea– Cough – Elevated temperature– Pleural friction rub

Pleurisy

• Treatment– Antibiotics– Analgesics

• Demerol or morphine– Antipyritics

• Tylenol– Oxygen– Anesthetic block for intercostal nerves

Pleural Effusion/Empyema• Etiology/Pathophysiology

– Pleural Effusion– Accumulation of fluid in

the pleural space– Usually secondary– Empyema

• Fluid accumulation with pleural effusion becomes infected

Pleural Effusion/Empyema

• Signs & Symptoms– Dyspnea– Air hunger– Respiratory distress

• Nasal flaring• Tachypnea• Dyspnea• Decreased breath sounds

– Fever

Pleural Effusion/Empyema• Treatment

– Thoracentesis– Chest tube with closed

water seal drainage system

• Glass bottle system• Pleur-evac• (Pg. 385 Box 9-6

Maintaining chest tubes and closed chest drainage bottles)

– Antibiotics– Cough and deep breath

                                                               

Atelectasis

• Etiology/Pathophysiology– Abnormal condition characterized by the collapse of

lung tissue– Due to occlusion of air to a portion of the lung– Postoperative complication– Secretions– Foreign body– Mucous plug– Emphysema, pneumothorax, tumor

Atelectasis

Atelectasis

• Signs & Symptoms– Dyspnea– Tachypnea– Pleural friction rub– Restlessness – Hypertension > hypotension– Elevated temperature– Decreased breath sounds– Crackles

Atelectasis• Treatment

– Cough and deep breath– Analgesia– Early ambulation– Incentive spirometery– Intermittent positive pressure breathing– Oxygen– Chest percussion and postural drainage– Bronchodilators

• Proventil

– Antibiotics– Mucolytic agents

• Mucomyst - Decrease viscosity of secretions

– Chest tube

Pneumothorax

• Etiology/Pathophysiology– A collection of air or gas in the pleural space,

causing the lung to collapse– Penetrating chest injury– Coughing– Ruptured bleb– Spontaneous

Pneuomothorax

Pneumothorax

• Signs & Symptoms– Decreased breath sounds– Sudden, sharp chest pain with dyspnea– Diaphoretic– Increased heart rate– Tachypnea– No chest movement on affected side– Sucking chest wound– Mediastinal shift

Pneumothorax

• Treatment– Chest tube to water seal drainage system– Oxygen– Analgesics– Encourage fluids

Chest Tube Placement

Chest Tube Drainage System

Lung Cancer

• Etiology/Pathophysiology– Primary tumor or metastasis– Small cell lung cancer– Non-small cell lung cancer– Squamous cell carcinoma– Large-cell carcinoma– 80% linked to smoking

Lung Cancer

• Signs & Symptoms– Hemoptysis– Dyspnea– Fever– Chills– Wheezing – Pleural effusion

Lung Cancer

• Treatment– Surgery– Most are not diagnosed early enough for curative

surgical intervention– Segmental resection– Lobectomy– Pneumonectomy– Radiation– Chemotherapy

Pulmonary Edema

• Etiology/Pathophysiology– Accumulation of serous fluid in interstitial

tissue and alveoli • Left ventricular failure• Inhalation of irritating gases• Rapid administration of IV fluids• Barbiturate or opiate overdose

Pulmonary Edema• Signs & Symptoms

– Dyspnea– Tachypnea– Tachycardia – Cyanosis – Pink or blood tinged, frothy sputum– Restlessness– Agitation– Wheezing – Crackles– Sudden weight gain– Decreased urinary output

Pulmonary Edema• Treatment

– Oxygen– Mechanical ventilation, if necessary– Diuretics

• Lasix– Narcotic analgesics

• Morphine will help decrease resp rate– Nipride

• Vasodilator that improves myocardial contraction and reduces pulmonary congestion

– Strict I&O; Daily weight– Low sodium diet

Pulmonary Embolus• Etiology/Pathophysiology

– Foreign substance in the pulmonary artery• Blood clot, fat, air, or anmiotic fluid

– High risk• Prior thrombophlebitis• Recent surgery, pregnancy, or given birth• Taking contraceptives long-term• Hx of CHF, obesity, or immobilization from

fracture

Pulmonary Embolus

• Signs & Symptoms– Sudden, unexplained dyspnea– Rapid respiratory rate– Hemoptysis– Chest pain– Elevated temperature– Increased WBC

Pulmonary Embolus

• Treatment– Oxygen– HOB up 30 degrees– Anticoagulants

• Heparin (IV)– Gradually tapered

• Coumadin (oral)– Initiated as Heparin is tapered – Continued at home for up to 1 year

– Fibrinolytic agents

Adult Respiratory Distress Syndrome(ARDS)

• Etiology/Pathophysiology– Complication of other disease processes– Direct or indirect pulmonary injury– Viral or bacterial pneumonia, chest trauma, aspiration,

shock, drug over doses, renal failure, pancreatitis, COPD, Guillain-Barre’ syndrome, and myasthenia gravis

• .increased permeability of capillary membrane• .allows fluid to leak into interstitial spaces and alveoli• .pulmonary edema and hypoxia• .alveoli lose their elasticity and collapse• .capillaries allow plasma and RBC’s to leak out, resulting in hemorrhage

Adult Respiratory Distress Syndrome(ARDS)

• Signs & Symptoms– Respiratory distress

• Dyspnea• Restlessness

– Tachycardia– Hypotension– Decreased urinary output

Adult Respiratory Distress Syndrome(ARDS)

• Treatment– Treat cause– Oxygen– Corticosteroids– Diuretics– Morphine– Lanoxin– Antibiotics

Chronic Obstructive Pulmonary Disease

• Chronic airflow limitation• Includes• Emphysema• Chronic Bronchitis• Asthma• Bronchiectasis

Emphysema

• Etiology/Pathophysiology– The bronchi, bronchioles and alveoli become

inflamed as a result of chronic irritation– Air becomes trapped in the alveoli during expiration,

causing alveolar distention, rupture, and scar tissue– Cigarette smoking is primary irritant– Complication:

• Cor pulmonale– Right-sided congestive heart failure due to pulmonary

hypertension

Emphysema

Emphysema• Signs & Symptoms

– Dyspnea on exertion– Sputum

• Initially there is very little• Eventually becomes copius

– Barrel chest• Increased anteroposterior diameter caused by

overinflation– Chronic weight loss– Emaciation– Clubbing of fingers

Barrel-Chest

Emphysema• Treatment

– Oxygen (low-flow)• 1-2 liters per NC

– Chest physiotherapy– Bronchodilators

• Theophylline or aminophylline, Isuprel, Brethine, Alupent, Proventil, Bronkosol

– Corticosteroids– Antibiotics– Diruretics– Humidifier– Pursed-lip breathing– High-protein, high-calorie diet

• Encourage fluids between meals rather than with meals

Chronic Bronchitis

• Etiology/Pathophysiology– Hypertrophy of mucous gland causes

hypersecretion and alters cilia function– Increases suseptibility to infection causing

airway scaring– Increased airway resistance causes

bronchospasm– Most common cause is cigarette smoking

Chronic Bronchitis

• Signs & Symptoms– Productive cough

• Especially in the mornings– Dyspnea– Use of accessory muscles to breath– Wheezing

Chronic Bronchitis• Treatment

– Bronchodilators• Theophylline, aminophylline, etc

– Mucolytics• Mucomyst

– Antibiotics• Erythromycin

– Oxygen (low-flow)• 1-2 liters per NC

– Pursed-lip breathing

Asthma• Etiology/Pathophysiology

– Narrowing of the airways due to various stimuli– Extrinsic

• External factors– Pollens, dust, feathers, animal dander, foods

– Intrinsic• Internal causes

– Respiratory infection

– Influenced by secondary factors• Mental or physical fatigue and emotional factors

– Antigen-antibody reaction

Asthma• Signs & Symptoms

– Mild Asthma• Dyspnea on exertion• Wheezing

– Acute Asthma Attack• Usually at night• Tachypnea• Expiratory wheezing• Use of accessory muscles• Nasal flaring• Cyanosis• Productive cough

– Status asthmaticus• Severe, unrelenting attack that fails to respond to usual treatment• Leads to exhaustion and respiratory failure

Asthma• Treatment

– Maintenance Therapy• Serevent inhalant, prophylactic• Corticosteroid inhalant

– Floevent• Avoid allergens

– Acute or Rescue Therapy• Proventil inhalant• Corticosteriod and epinephrine oral or sq• Aminophylline IV• Oxygen

– Monitor by pulse oximetry

Bronchiectasis

• Etiology/Pathophysiology– Gradual, irreversible process that involves

chronic dilation of bronchi resulting in loss of elaticity

– Repeated pulmonary infections– Secondary causes may be cystic fibrosis,

foreign body, or tumor

Bronchiectasis

Bronchiectasis• Signs & Symptoms

– Dyspnea– Cyanosis– Clubbing of fingers– Coughing

• Esp in the morning and when lying down• Copious amounts of foul-smelling sputum

– Fatigue– Weakness– Loss of appetite– Wheezes and crackles

Bronchiectasis• Treatment

– Oxygen (low-flow)• 1-2 liters per NC

– Chest physiotherapy– Hydration– Mucolytic agents

• Mucomyst– Antibiotics– Bronchdilators

• Theophylline– Cool mist vaporizer– Surgery

• Lobectomy