Respiratory Part 2

Medical Surgical Nursing

Influenza• AKA– Flu

• Highly contagious• Pathogen– Viral

• Epidemic– Rapid and extensive spreading infection and

affecting many individuals in an area or a population at the same time

FYI

• Influenza & its complications (primarily bacterial pneumonia) are the 8th leading cause of death in the US.

• @60,000 year

H1N1

• Newly identified stain• Pandemic–(World-wide

epidemic)

Mode of transmission

• Airborne droplet• Direct contact

Influenza Statistics

• Incubation period–Short

• Onset–Rapid

• Duration–Up to a week

Influenza: S&S (local)

• Runny nose• Sore throat• Cough–Dry–Non-productive

productive– Substernal burning

Influenza: S&S (systemic)

• Chills & fever• H/A• Malaise• Muscle aches• Fatigue &

weakness

Older adults

• Higher risk of–Complications•Pneumonia•Death

Why are older adult more susceptible to complications of influenza?

• Cilia– i

• Chest muscle strength– i

• Chest wall– Stiffer

• Cough– Less effective

Assessment

• S&S• Vital Signs

IDT

• “Most URI’s are self-limiting”

IDT

• Self-care• Symptomatic relief• Prevent

complications• Prevent spread

Dx test

• Throat swab– R/O streptococci

• CBC– WBC normal • Vial

– WBC increased• Bacterial

• Chest x-ray– R/O pneumonia

Flu Vaccine: Is it effective?

• Polyvalent influenza virus vaccine

• 85% effective

Flu Vaccine: Who should get it?

• Age >50 years• Nursing home residents• Pg women• Chronically ill• Immunosuppressed• Resp. conditions• Healthcare workers• Fam. members of those

at risk

Flu Vaccine: Who should not get it?

• Allergic to eggs

Small Group Questions

1. What pathogen is assoc. with flu?2. Identify 5 S&S of the flu3. What type of isolation would you use for a

client with the flu4. Mary asks you if she should get the flu

vaccine, how do you respond?5. What priority nursing diagnosis would you

give for a person with the flu?

Which of the following nursing interventions is appropriate after a

client has had a bronchoscopy?A. Report abnormal lab valuesB. Lay flat for 8 hours with a sand bag

to the puncture siteC. NPO until gag reflex returnsD. Push fluids

Tuberculosis

• AKA–TB

Tuberculosis - FYI

• Causes more death than any other disease. 2 billion world wide, 15 million in the US

Tuberculosis - FYI

• When treated, about 90% of those with active TB survive!

Tuberculosis

• Pathophysiology– Mycrobacterium

tuberculosis– Tubercle bacillus

Tuberculosis

Pathophysiology• Mode of transmission– Air-borne

• alveoli• Multiplies in alveoli

Tuberculosis

• Immune response phase–Macrophages attack TB– TB has waxy cell wall that protects it from

macrophages– Immune system surrounds the infected

macrophages– Forms a Lesion–Called a Tubercle

Tuberculosis• Dormant phase–Contagious?• No

– Symptomatic?• No

–PPD?• positive

– chest x-ray?• Negative

Tuberculosis

• Active phase–If an infected person has a weakened

immune system, –the TB escapes and infects the body

Tuberculosis• 5-10% become active• Only contagious when

active• Primarily affect lungs

but…– Kidneys– Liver– Brain– Bone

TuberculosisEtiology• Assoc. w/– Poverty– Malnutrition– Overcrowding– Substandard housing– Inadequate health care

• Elderly• HIV• Prison

Tuberculosis: S&S (active phase)• NOC sweats• Low grade fever• Wt loss• Chronic productive cough–Rust colored & thick

• Hemoptysis • SOB

Tuberculosis: Dx test• PPD –Mantoux skin test–> 10mm in diameter– induration – Indicates: • Latent TB

–Read• 48-72 after

– Intradermal: • 15-degrees

Tuberculosis

• Diagnostic tests– X-ray– Symptoms– Acid Fast Bacillus

Tuberculosis: Tx / Rx

• INH– isonicotinyl hydrazine – Isoniazid – Toxic to the liver

• Rifampin– Turns urine red

Tuberculosis: Prevention

• Clean well ventilated living areas• Resp. isolation –Negative pressure room

• If exposed take–INH

Tuberculosis: complication• Malnutrition• S/E of Rx treatment• Multi-drug resistance• Spread of TB infection

Small Group Questions

1. What type of pathogen is TB?2. What is the mode of transmission?3. What are the classic S&S of TB ?4. How to administer and read a PPD?5. If a pt is PPD +, what does that mean?

Small Group Questions

6. What is the standard screening method of TB?

7. That medications are used to treat TB, what are their side effects?

8. Where in the US is TB most prevalent? Why?

COPD - overview

COPD?– Chronic Obstructive Pulmonary

Disease– Broad classifications of diseases

COPDCharacteristics

• Airflow limitation • Irreversible• Dyspnea on exertion• Progressive• Abn. inflammatory response of the lungs

to noxious particles or gases

Pathophysiology

• Noxious particles of gas • Inflammatory response • Narrowing of airway

Pathophysiology

• Inflammation • Thickening of the wall of the

pulmonary capillaries

COPD

• Includes–Emphysema–Chronic bronchitis

• Does not include–Asthma

COPD - FYI

• COPD 4th leading cause of death in the US• 12th leading cause of disability• Death from COPD is on the rise while death

from heart disease is going down

COPD: Risk Factors

• Smoking• Passive smoking• Occupational

exposure• Air pollution

COPD risk factors

• #1– Smoking

• Why is smoking so bad??–↓ phagocytes–↓ cilia function–↑ mucus production

Chronic Bronchitis

• Disease of the airway• Definition:– cough + sputum production – > 3 months

Chronic Bronchitis

Pathophysiology• Pollutant irritates airway • Inflammation• h secretion of mucus • Bronchial walls thicken – Lumen narrows–plugs

Chronic Bronchitis

• Alveoli/bronchioles become damaged• ↑ susceptibility to LRI

Emphysema: Pathophysiology

• Affects alveolar membrane–Destruction of alveolar wall–Loss of elastic recoil–Over distended alveoli

Emphysema

Pathophysiology• Over distended alveoli–Damage to adjacent pulmonary

capillaries–Impaired passive expiration

Emphysema

• Damaged pulmonary capillary bed– h pulmonary pressure – h work load for right ventricle – Right side heart failure

Emphysema

• Nursing Diagnosis–Impaired gas exchange

COPD Compare and contrast

• Chronic Bronchitis is a disease of the ___________?–Airway

• Emphysema is a disease affecting the ___________?–Alveoli

C.O.P.D.

• Risk factors, S&S, treatment, Dx, Rx - same for Chronic Bronchitis & Emphysema

C.O.P.D.

Clinical Manifestation (primary)

1. Cough2. Sputum production3. Dyspnea on exertion(Secondary)• Wt. loss• Resp. infections• Barrel chest

C.O.P.D.Nrs. Assessment

• Risk factors• Past Hx / Family Hx• Pattern of development• Presence of comobidities• Current Tx• Impact

Dx tests

• ABG’s–Baseline PaO2

• Rule out other diseases–CT scan–X-ray

C.O.P.D. Medical Management

• Risk reduction– Smoking cessation!• (The only thing that slows down the

progression of the disease!)

C.O.P.D. Rx. therapy

Primary• Bronchodilators• CorticosteriodsSecondary• Antibiotics• Mucolytic agents• Anti-tussive agents

Bronchodilators• Action:–h the size of the lumen–Relieve bronchospasms–Reduce airway obstruction–↑ ventilation

Bronchodilators

• Examples–Albuterol (Proventil, Ventolin, Volmax)–Metaproterenol (Alupent)–Ipratropium bromide (Atrovent)–Theophylline (Theo-Dur)*

Glucocorticoids

• Action–Potent anti-inflammatory agent

Corticsteriods

• S/E–Na+ & H20 retention–Never D/C abruptly

Glucocorticoids

• Examples–Prednisone–Methyprednisone–Beclovent

C.O.P.D. Medical Management

• Treatment–O2• 2 L/min

–Pulmonary rehab• Breathing exercises• Pulmonary hygiene

Small Group Questions

1. What 2 diseases are assoc. with COPD?2. Describe the pathophysiology of COPD.3. What effect does smoking have on the resp.

system?4. Differentiate between chronic bronchitis and

emphysema.5. What are the 3 main S&S of COPD?6. What 2 classifications of meds are used to treat

clients with COPD (what are their actions)?

Pneumonia

Pathophysiology• An inflammatory process in which there

is consolidation –In the alveolar spaces.

• Gas exchange cannot take place in consolidated area

PneumoniaCausative agents• Viral pneumonia• Bacterial Pneumonia

– Streptococcus pneumoniae– Pneumocystis Pneumonia

• Fungal pneumonia• Radiation pneumonia• Chemical pneumonitis• Aspiration pneumonia• Hypostatis pneumonia

Pneumonia FYI

• Most common cause of death from infectious agents• 66,000 deaths / year• $$$

Pneumonia: Progression of events• Inflammation • h Exudate • i movement of O2 and CO2 • WBC migrate into the alveoli

• Fill air-containing spaces• i ventilation – i Oxygen saturation

Pneumonia: Risk factors

• Immunosuppressant• Smoking• Prolonged immobility• Depressed cough reflex• NPO• ETOH intoxication• Gen. anesthetic or opiod• Advanced age

Pneumonia: S&S TYPICAL

• Onset– Acute

• Shaking• Chills• Fever• Cough

– Productive• Sputum

– Rust-colored – Purulent

Pneumonia: S&S TYPICAL

• Chest pain– Sharp– Localized

• Breath sounds– Diminished– Crackles – Respiratory distress

Pneumonia: S&S ATYPICAL

• “Walking pneumonia”• Milder symptoms• Fever• H/A• Muscle aches• Malaise

Pneumonia: S&S ATYPICAL

• Cough–Hacking–Non-productive

• Self limited

S&S Elderly

• General deterioration• Weak• Abd. Symptoms–Anorexia

• Confusion• Tachycardia• Tachypnea

• Do Not C/O–Cough–Pain–Fever –Sputum

Pneumonia: Dx

• Sputum C&S• CBC / WBC–h• Bacteria

–i• Viral

• ABG’s• Pulse oximetry• Chest x-ray

Pneumonia: Medications

• Primary– Antibiotics– Bronchodilators– Expectorant

Antibiotics

• Action–Attacks pathogens

• Nursing consideration– Educate to take all –Not contagious after 24 hours on meds

Bronchodilators

• Dilate bronchi• Reduce bronchospasms• Improve ventilation

Expectorants

• Break up mucus–i viscosity

• Liquefies mucus • Easier to expectorate• Take with lots of water!

Pneumonia: Medications

• Secondary–Antibiotics–Antipyretic–Analgesic

Pneumonia: Nursing

• Fluids– 2,500 – 3,000 mL/day– Humidifier

• Chest physiotherapy– TCDB– I.S.

• Assess respiratory status• Position

– HOB • Rest

Pneumonia – Nursing Interventions

• O2 per order• Maintaining nutrition–Gatorade– Ensure

• Promoting the patients knowledge

Pneumonia

Prevention• Vaccine– Pneumonia– Flu

• Treat URI• Avoid irritants

Pneumonia: Small Group Questions

1. Describe the pathophysiology of pneumonia.2. What is the difference btw typical and atypical

pneumonia?3. What causes pneumocystis carinii?4. What lab values are associated with bacterial

pneumonia? / viral pneumonia?

Pneumonia: Small Group Questions

5. What is Nosocomial pneumonia6. Identify 5 risk factors for developing pneumonia7. What medications might be administered to treat a

pt. with pneumonia?8. What nursing education would you give to a patient

with pneumonia?9. What are the gerontological considerations of caring

for the elderly in regards to pneumonia?

Lung Cancer

Pathophysiology• Carcinogen binds to

the DNA and changes it

• Abnormal growth• Usually develops on

the wall of the bronchial tree

FYI

• Lung Cancer is the number one cancer killer in the US

Lung CancerEtiology/Contributing factors• #1

– Tobacco Smoke (85%)– Second hand smoke

• Carcinogens– Asbestos– Uranium– Arsenic– Nickel– Iron oxide– Radon– Coal dust

Lung Cancer

Clinical manifestations: early• Insidious and

asymptomatic • until late stages

FYI

– 70% of lung CA have metastasized by the time of diagnosis

Lung Cancer

S&S: Early• Objective symptoms

– #1: • Cough

– #2 • Repeated respiratory

tract infection– Wheezing– Dyspnea

Lung Cancer

S&S: Late• Hemoptysis • Chest pain• Wt loss• Anemia• Anorexia

Lung Cancer

Dx exams/procedures• X-ray• CT scan• Biopsy via

Bronchoscopy– cytology

Lung Cancer

Treatment• Surgery– Removal

• Chemotherapy – Metastasis

• Radiation – To shrink or reduce

symptoms

Lung CA

• Priority Nrs Dx– Ineffective

breathing– Ineffective Airway

clearance– Ineffective Gas

exchange

Assessment

• Resp assessment• Smoking hx• Lab values• S&S of

complications

Assessment

• S&S of complications– Edema– H/A– Dizziness– Vision changes– Difficulty breathing– C/O pain

Interventions

• Assess q4hrs• HOB • Pulmonary hygiene– TCDB– IS

• O2 per order• Suction PRN• Emotional support

Secondary Nrs Dx

• Activity intolerance• Pain• Grieving

Activity intolerance

• Document response to activity– Pulse– Resp. status– Fatigue

• Planned rest periods• Increase activities

gradually• Enc to remain as active as

possible

• Allow fam. To provide assist PRN

• Keep frequently used objects nearby

Pain

• Assess pain• Administer

analgesics PRN

PAIN & CANCER

• “For cancer pain, maintain a continuous medication schedule using opiates, NSAIDs and other drugs as ordered”– Addiction is not a concern for the terminal cancer

client; adequate pain relief that does not allow “breakthrough” pain is vital.

Pain

• Assess pain• Administer analgesics

PRN• Alternative pain relief– Massage– Positioning– Distraction– Relaxation techniques

Pain

• Provide diversion activities– TV– Reading– Social events

• Allow family to remain

Grieving

• Spend time with client & family

• Answer questions honestly

• Enc. Pt to express feelings (fear, anxiety, concerns)

• Assist to understand the grief process

Grieving

• Enc other support systems– Spiritual– Social groups– Social services– Hospice

• Discuss advanced directives– Living will

Lung Cancer

Preventative measures• Stop smoking

Small Group Questions

• What is the number one carcinogen of lung cancer?

• What are the early S&S of lung cancer?• Who is Lung Cancer diagnosed?• How is lung cancer usually treated?• What is one priority nursing diagnosis for a

client with lung cancer? Identify 3 nursing interventions for this diagnosis