PN 132Day 5

Adult Health Nursing 7th EdFoundations of Nursing 7th Ed

PNEUMONIAEtiology/Pathophysiology -Inflammation of the pulmonary tissue -interstitial spaces -alveoli -bronchioles -Other causes: -oversedation -inadequate ventilation -aspiration

PNEUMONIA

PNEUMONIA -Occurs in any season -most common during winter and early

spring. -People of any age are susceptible -more common in infants and the elderly. -defense mechanisms that are

damaged/altered -vulnerable to contracting pneumonia. -Nosocomial pneumonia

PNEUMONIA-communicable disease -the mode of transmission is dependent on the infecting organism -classified according to the offending

organism.Causes: -bacteria -viruses -fungi -chemicals -mycocplasma

PNEUMONIA -50% of cases are caused by bacteria

and viruses; -96% of bacterial cases are caused by 4 organisms: -Streptococcus pneumoniae -Hemolytic Streptococcus type A -Staphylococcus aureus -Hemophilus influenzae type B.

Aspiration pneumonia -necrotizing pneumonia -pathological changes in the lungs. -aspiration of vomitus: -altered state of consciousness -seizures -alcohol -anesthesia -shock, etc. - foreign body aspiration - toxic materials -gasoline or kerosene.

ASPIRATION PNEUMONIA

CLINICAL MANIFESTATIONS -Various physiological responses -pH of the aspirated substance. -productive and painful cough -consistency and color of the sputum varies. -severe chills, elevated temperature,

increased heart and respiratory rate -Clinical manifestations - dependent on the type of pneumonia.

ASSESSMENTSUBJECTIVE: -onset of symptoms -duration of cough. -fever -night sweats

OBJECTIVE: - Level of consciousness/mental status changes - Vital signs, especially the temperature every 2 hours or as ordered. - Sputum - color, consistency, and amount - Use of accessory muscles - Cyanosis or dyspnea. - Auscultate the lungs -crackles on inspiration/pleural rub.

SPUTUM AND SPUTUM SPECIMEN

DIAGNOSTIC TESTS -Blood and sputum cultures. -Collect the sputum BEFORE the

beginning of antibiotic therapy. -Chest x-ray. -CBC -WBC count with the differential. - ABG test. -Pulmonary function tests (PFT’s) -Pulse oximetry.

Pulse oximetry, pulmonary function test

ABG test

Medical management Medications- -antibiotics: -erythromycin -cephalosporin -tetracycline

- antibiotic depends on the causative organism. -no definitive treatment for viral pneumonia. -analgesics

-antipyretics -expectorants -bronchodilators

Expectorant, Bronchodilator

BRONCHODILATOR

Medical Management -Humidification with humidifier/nebulizer -secretions are tenacious. -Oxygen -O2 saturation is < 91%. -Venturi mask or nasal cannula is used. -Pneumonia vaccine for the most common

bacterial: -streptococcal (or also called Pneumococcal) pneumonia. -recommended for the people at risk -given again after age 65

NURSING INTERVENTIONS -Patient should conserve energy -plan strategies to allow for rest periods. -High Fowler’s position -allows for optimal air exchange. -Position the patient with the good lung down -PaO2 rises when the healthy one is dependent. -Assess the patient’s ability to cough up

secretions. -Assist with: - coughing, suctioning, positioning, liquefying secretions

NURSING INTERVENTIONS -bronchodilators, mucolytics, and expectorants: - dilate the bronchioles - remove secretions. -auscultate the lungs -every 2-4 hours -especially before and after treatments and suctioning -characteristics of the cough and the sputum. -hydration -at least 3 liters per day -oral or IV fluids.

NURSING INTERVENTIONS -at least 1500 cal. per day -small, frequent meals.

Patient and family teaching -deep breathing and coughing techniques. -Good handwashing!!!!!!! -medications -reasons - importance of taking the full course of the prescribed medications -disease process - treatment - possible complications - duration

Teaching -inform his PCP about a change in his health

status - fever despite having taken the full course of antibiotics - change in the color of his sputum - feeling more fatigued - more dyspneic, etc. -balance of exercise and rest. -availability of a Pneumococcal vaccine.

PROGNOSIS -resolves in 2-3 weeks with proper treatment. -most common cause of death from

infectious disease in North America. -Bacterial aspiration pneumonia has a poor

prognosis despite antibiotic therapy -extensive lung damage -resulting lung abscess or empyema.

PLEURISYEtiology/Pathophysiology -inflammation of the visceral and parietal

pleurae. -either a bacterial or viral infection. -occurence: -may occur spontaneously -complication of: -pneumonia -pulmonary infarction -viral infections of the intercostal muscles -pleural trauma -early stages of TB -lung tumor

PLEURISY

CLINICAL MANIFESTATIONS -Sharp, inspiratory pain, -radiating to the shoulder or abdomen of

the affected side -stretching of the inflamed pleur. -If pleural effusion develops -pain subsides -fever and dry cough occur. -Dyspnea, increased temperature

ASSESSMENT

SUBJECTIVE:

-chest pain on inspiration -increased temperature

OBJECTIVE: -assesses the nature of the inspiratory pain with its radiation pattern -vital signs, especially the temperature every 2 -4

hours. -auscultate the lungs -pleural friction rub should be heard -respiratory rate and rhythm -note any dyspnea

DIAGNOSTIC TESTS -Physical exam -presence of a pleural friction rub. -Chest x-ray -not diagnostic unless there is a pleural

effusion.

MEDICAL MANAGEMENT -Injection of an anesthetic block around the

vertebra -blocks the intercostal nerves -relieves the pain -Prescribed medications: -antibiotics -analgesics -antipyretics -oxygen

NERVE BLOCK

NURSING INTERVENTIONS -Position the on the affected side to splint

the chest -Heat or cold may be applied to the area -Effectively cough every 2 hours -Splint the affected side -Signs/symptoms of exacerbation: -purulent sputum -increase in temperature -increased pain

PLEURAL EFFUSION and EMPYEMA

Etiology/Pathophysiology - Pleural effusion -pleural lining is inflamed -fluid can accumulate in the pleural space -secondary problem -occurs when physiological pressure in the

lungs and pleurae is disturbed -alteration of pressure gradients -surface characteristics of capillaries.

Blood and/or purulent drainage in the pleurae

Empyema -pleural fluid becomes infected -may be acute or chronic. -acute empyema -inflammation of the affected area with a thin

layer of fluid -untreated (chronic) -fluid thickens - pleura becomes scarred and fibrosed, losing

its elasticity

CLINICAL MANIFESTATIONS -result of bacterial infection. -persistent fever despite taking antibiotics. -associated with other disease processes: -pancreatitis -CHF -pulmonary edema, etc.

ASSESSMENTSUBJECTIVE: -difficulty breathing, air hunger. -feelings of fear and anxiety related to

decreased levels of oxygen.

OBJECTIVE: -signs and symptoms of respiratory distress -decreased breath sounds.

DIAGNOSTIC TESTS -Chest x-ray. -Thoracentesis -obtain a specimen for C+S -remove excess fluid.

MEDICAL MANAGEMENT -Under normal conditions - intrapleural pressure is below

atmospheric pressure - if intrapleural pressure becomes equal to atmospheric pressure, the lungs will

collapse.

MEDICAL MANAGEMENT Insertion of a chest tube -continuous drainage -medication instillation -prevent the lung from collapsing -a closed system is used Chest tubes are placed in the pleural cavity -drains blood, fluid, or air -re-establishs a negative pressure.

CHEST TUBES -chest or thoracotomy tubes are attached to a

closed, water-seal drainage system.

CHEST TUBE BOTTLES, PLEUROVAC UNIT

CLOSED- SYSTEM, WATER-SEAL DRAINAGE

CHEST TUBE

-If two thoracotomy (chest) tubes are inserted

-one is placed in the anterior chest wall

-removes air from the pleural space

-second tube is inserted through a stab wound in the

posterior chest

- larger in diameter

-removes sero-sanguinous fluid/purulent exudate

from the pleural space.

NURSING INTERVENTIONS -Patient is on bed rest. -Oxygen therapy may -frequent oral care - prevents drying of the mucous membranes. -Deep breathing and coughing every 2 hours. - Auscultate the lungs every 2-4 hours; -Assess the dressing for drainage - color, odor, amount -Ensure the patency of the chest tube system. -keep straight, connections are secured and

coiled loosely.

-Position the patient on the unaffected lung side

-When able to ambulate

-chest tube must be below the level of the chest

-prevent any fluid from draining back into the

pleural cavity

-Document at the end of the shift:

-amount

-color

-consistency of the chest tube drainage

-antibiotics -explain the chest tube insertion procedure to the patient -answer any questions about the patient’s condition and treatments -allay anxiety -practice deep breathing and coughing

with the patient

ATELECTASISEtiology/Pathophysiology -All or part of the lung collapses -Causes hypoventilation -gas exchange is not adequate to meet the

metabolic needs of the body -bronchial obstruction caused by mucous accumulation. -prevents the respiratory exchange of carbon

dioxide and oxygen -common post-op complication -resulting from shallow breathing.

- Accumulation of secretions, a foreign body, or a

tenacious plug -occludes a bronchus. -Compression of lung tissue - emphysema, pneumothorax, or a tumor. -Pathophysiology depends on the site and the degree of occlusion. -Stasis pneumonia -secretions are rich in nutrients for the growth of bacteria -lung damage.

ATELECTASIS

CLINICAL MANIFESTATIONS -Dyspnic -Tachypnic -Pleural friction rub -Restless -Hypertensive -Increased temperture

ASSESSMENTSUBJECTIVE: -Dyspnea -Requires more effort to breathe -Fatigue. -Feeling of air hunger -Anxiety

OBJECTIVE: -Decreased breath sounds -Crackles on auscultation. -Hypertension will be present at first -followed by hypotension. -Respiratory rate -Amount of effort required for breathing. -Level of consciousness (LOC) - hypoxic -may exhibit an altered LOC.

DIAGNOSTIC TESTS -Serial chest x-rays -same area for comparison. -ABG’s -PaO2 may be < 80 mm. Hg. -improves within the first 24 hours. -Pulse oximetry -< 90% because of hypoventilation -Bronchoscopy -bronchial obstruction.

BRONCHOSCOPY

MEDICAL MANAGEMENT -Incentive spirometry -10 times every hour while awake. -Oxygen therapy. -Suctioning may be needed. -Prescription medications: -bronchodilators -antibiotics -mucolytics -Intubation with mechanical ventilation

NURSING INTERVENTIONS -Deep breathe, cough, and change position

every 1-2 hours (DB,C,T) -Analgesics -relieves pain -facilitates ventilatory effort -Give emotional support. -Early ambulation.

PATIENT AND FAMILY TEACHING -Effective deep breathing and coughing

techniques. -Measures for optimal gas exchange: -exercising -changing positions -Medications prescribed -side effects

PNEUMOTHORAXEtiology/Pathophysiology -Collection of air or gas in the pleural space -causes the lung to collapse. -secondary to a ruptured bleb or a severe

coughing spell. -penetrating chest injury -pleural lining is punctured -fractured rib -insertion of a sub-clavian catheter -spontaneous rupture without any obvious

cause

PNEUMOTHORAX -Pleural cavity is penetrated -air enters -normal negative pressure is

interrupted -lung collapses.

PNEUMOTHORAX -Spontaneous pneumothorax -rupture of a bleb -Open pneumothorax -opening through the chest -Tension pneumothorax -blunt chest injury -

PNEUMOTHORAX

CLINICAL MANIFESTATIONS -Recent chest injury. -Decreased breath sounds -affected side. -Sharp, sudden pleuritic chest pain -with shortness of breath. -Diaphoretic -Increased heart and respiratory rate -Lack of chest movements -affected side. -Pneumothorax is from a penetrating injury -sucking sound on inspiration.

Pneumothorax

CLINICAL MANIFESTATIONS -Mediastinum shifts to the unaffected side. -As intrathoracic increases -cardiac output decreases -venous return is decreased -compression on the great vessels

ASSESSMENTSUBJECTIVE: -Recent penetrating chest wound -Severe coughing episode -Shortness of breath (SOB) of sudden

onset. -Feelings of air hunger -Anxiety

•OBJECTIVE: -Frequent vital signs - Change in heart and respiratory rate or heart rhythm -Unequal breath sounds on the right and

left sides -diminished sounds on the affected side. -Sputum -amount, characteristics and

color

DIAGNOSTIC TESTS -Patient’s history. -Chest x-ray. -ABG test.

MEDICAL MANAGEMENT -Thoracotomy -insertion a chest tube -chest tube is then attached to a water-seal

drainage system -Heimlich valve -stopgap measure until chest tube therapy

can be started

HEIMLICH VALVE

NURSING INTERVENTIONS -Patent airway. -Adequate oxygenation. -Chest tube patent. -Chest tube drainage -color , consistency and amount of per shift. -Monitor BP. -High Fowler’s position -promote lung expansion -removal of secretions. -Pain medication -do not depress the respirations.

PATIENT AND FAMILY TEACHING -Explain the rationale for the treatments -before they are implemented -Reinforce the need for ongoing effective

breathing techniques -Limit exposure to people who have infections. -upper resp. infection, influenza -Copious fluid intake -Discourage smoking -Avoid fatigue and strenuous activity. -Report any recurrent s/s to the PCP -fever, chest pain, difficulty breathing, etc.