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DiagnosticStudies and
Therapies
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PPD(Purified Protein Derivative
Intradermal
read 48-72 hours after injection (+) Mantoux test is in duration of 10
mm or more
for HIV positive clients, induration of 5mm is considered positive
(+) Mantoux test signifies exposure toMycobacterium tubercle bacilli
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Practice the client on how
to hold his breath and to dodeep breathing
Instruct the client toremove metals from chest
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Studies the lung and chest inmotion
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Aradiopaque medium is instilled directly into thetrachea and bronchi and the entire bronchial tree or
selected areas may be visualized Nursing interventions before bronchogram
Secure written consent
Check for allergies to sea foods or iodine or anesthesiaNPO for 6-8 hrsPre-op meds: atropine sulfate and valium, topicalanesthesia sprayed; followed by local anestheticinjected into the larynx
Have oxygen and antispasmodic agents ready Nursing interventions after bronchogram
Side-lying positionNPO until cough and gag reflexes returnCough and deep breath client
Low grade fever commom
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The direct inspection and observation of thelarynx, trachea and bronchi through flexibleor rigid bronchoscope
Diagnostic uses:To collect secretions
To determine location of pathologic processand collect specimen for biopsy
Therapeutic uses:
Remove foreign objects
Excise lesions
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Nursing interventions before bronchoscopyInformed consent/permit needed
Atropine and valium pre-procedure; topicalanesthesia sprayed followed by localanesthesia injected into the larynx
NPO for 6-8 hrsRemove dentures, prostheses, contact lenses
Nursing interventions after bronchoscopySide-lying positionCheck for the return of cough and gag reflexes
before giving fluid per oremWatch for cyanosis, hypotension, tachycardia,
arrhythmias, hemoptysis, dyspnea. Thesesigns and symptoms indicate perforation ofbronchial tree.
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Following injection of aradioisotope, scans are taken with ascintillation camera. Measure bloodperfusion through the lungs.Confirm pulmonary embolism orother blood-flow abnormalities
Remain still during the procedure
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Gross appearance
Sputum C&S
AFB staining
Cytologic examination/Papanicolaou examinationEarly morning sputum specimen is to be collected
Rinse mouth with plain water
Use sterile container
Sputum specimen for C&S is collected before thefirst dose of antimicrobial
For AFB staining, collect sputum specimen forthree consecutive mornings
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Transbronchoscopic biopsy-done during bronchoscopy
Percutaneous needle biopsy
Open lung biopsy
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Lymphnode biopsy Scalene or cervocomediastinal
To assess metastasis of lung cancer
Pulmonary Function Studies
Vital capacityThe maximum volume of air that can be
exhaled after a maximum inhalation
Reduced in COPD
Tidal volume The volume of air inhaled and exhaled with
normal quiet breathing
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Inspiratory reserve volume The maximum volume that can be inhaled
following a normal quiet inhalation
Expiratory reserve volume The volume of air that remains in the lungs
after normal, quiet exhalationFunctional residual capacity The volume of air that remains in the lungs
after normal, quiet exhalationResidual volume The volume of air that remains in the lungs
after forceful exhalation
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Purpose: to assess ventilation and acid-base balance
Radial artery is the common site for
withdrawal of blood specimen Allens test is done to assess for
adequacy of collateral circulation of thehand
10 ml pre-heparinized syringe to preventclotting of specimen
Container with ice to prevent hemolysis
of the specimen
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Aspiration of the fluid or air from thepleural space
Nursing intervention before thoracentesis
Secure consentTake initial vital signs
Position: upright leaning on over bed table
Instruct to remain still, avoid coughingduring insertion of needle
Pressure sensation is felt on insertion ofneedle
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Nursing interventions after thoracentesis:
Turn on the unaffected side to preventleakage of fluid in the thoracic cavity
Bed rest until VS is stable
Check for the expectoration of blood.Notify physician
Monitor VS
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Oxygen therapy Tracheobronchial suctioning
a. Client should be in semi-fowlers positionb. Use sterile gloves, sterile suction catheterc. Hyperventilate client with 100% oxygenbefore and after suctiond. Insert catheter with gloved hand(3-5 lengthof catheter insertion)e.Apply suction during withdrawal of catheterf. When withdrawing catheter rotate whileapplying intermittent suction
g. Suctioning should take only 10 seconds(maximum of 15 seconds)h. Evaluate: clear breath sounds onauscultation of the chest
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Bronchial Hygiene Measures
Suctioning:oropharyngeal;nasopharyngeal
Steam inhalation
Aerosol inhalation
Madimist inhalation
Chest Physiotherapy (CPT)
Postural drainage
Percussion
Vibration
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Nursing intervention in CPT
a. Verify doctors orderb. A
ssess areas of accumulation of mucussecretionsc. Position to allow expectoration of mucus
secretions by gravityd. Place client in each position for 10 to 15
minutese. Percussion and vibration done to loosen
mucus secretionsf. Change position gradually to prevent postural
hypotensiong. Procedure is best done 60 to 90 minutes before
meals or in the morning upon awakening andat bedtime
h. Provide oral care after the procedure
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Incentive Spirometry
To enhance deep inhalation Closed chest drainage
(Thoracostomy Tube)
Purpose: to remove air and/or fluidsfrom the pleural space; toreestablished negative pressure and
reexpand the lungs.
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Types:
a. one-bottle system The bottle serves as a drainage bottle and
water-seal bottle
Immerse tip of the tube in 2-3 cm ofsterile NSS to create water-seal bottle
Keep bottle at least 2-3 ft below the levelof the chest to allow drainage from the
pleura by gravity
Never raise the bottle above the level ofthe chest to prevent reflux of air or fluid
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Assess for patency of the device:-observe for fluctuation of fluid along
the tube-observe for intermittent bubbling offluid; continuous bubbling meanspresence of air-leak
In the absence of fluctuation:-suspect obstruction of the device-checkfor kinks along tubing; milk tubingtowards the bottle-if there is no obstruction, consider lungreexpansion; validated by chest x-ray
Air vent should be open to air
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b. Two-bottle system Not connected to the suction apparatus
-the first bottle is drainage bottle; the
second bottle is water-seal bottle-observe for fluctuation of fluid along thetube (water-seal bottle) and intermittentbubbling with each respiration
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Connected to suction apparatus
-the first bottle is drainage and water-seal
bottle; the second bottle is suction controlbottle
-expect continuous bubbling in the suctioncontrol bottle; intermittent bubbling and
fluctuation in the water-seal-immerse tip of the tube in the first bottle in2-3 cm of sterile NSS; immerse the tube ofthe suction control bottle in 10-20 cm ofsterile NSS to stabilize the normal negativepressure in the lungs. This protects thepleura from trauma if the suction pressureis inadvertently increased
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c. Three-bottle system
The first bottle is drainage bottle; thesecond bottle is water-seal bottle, thethird bottle is suction control bottle
Observe for intermittent bubbling andfluctuation with respiration in water-sealbottle; continuous bubbling in the
suction bottle
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The term common cold is a popular phrase for a
group of symptoms including sneezing,congestion, and mild malaise Symptoms can continue for two weeks Clinical presentation:
Sneezing
Sore throatRhinorrheaMild malaise and achinessNon-productive cough
Sinus congestionHeadacheMay include nasal mucosa edema and erythema,
nasal secretions, low-grade fever or milderythema in the larynx
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Treatment:
Decongestants are helpful to relieve
rhinorrhea, sinus congestion, andheadache
Gargling with warm salt water often
soothes a sore throat and can help clearoropharyngeal secretions
Analgesic
Nursing interventionsGood nutrition and adequate sleep
strengthen the immune system
Frequent and thorough hand washing
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A seasonal viral respiratory illness It is similar to common cold in mode
of infection and transmission, being
spread by the aerosol method orclose contact Older adults and those with chronic
illnesses are most at risk forcomplications like pneumonia,exacerbation of commorbidities, anddeath
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Clinical presentation:
ExhaustionChills
Sinus congestion
Nonproduvtive coughHeadache
Myalgias
Fever
Pharyngitis
Cervical adenopathy
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Treatment
Acetamonophen
Analgesia
Nursing interventions
RestIncrease fluid
Those too ill to maintain hydration may
need to be hospitalized. If symptoms donot resolve within 7 days, furthermedical attention is needed.
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URTI
Cigarette smokingAllergic rhinitis
Inflammation
Edema of the mucous membrane
Hypersecretion of mucus
Infection
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Assessment
Pain:
Maxillary: cheek, upper teethFrontal: above eyebrows
Ethmoid: in and around the eyes
Sphenoid: behind eye, occiput, top of the head
General malaise
Stuffy nose
Headache
Post-nasal dripPersistent cough
Fever
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Nursing interventions
Rest
Increase fluid intakeHot wet packs
Codeine, avoid ASA. It increases the risk of
developing nasal polypsAmoxicillin or other anti-infectives (acute-7
to 10 days; chronic-21 days)
Nasal decongestants e.g. Sudafed,
Dimetapp (used for 72 hrs)Irrigation of maxillary sinuses with warmNSS
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Surgery:
F
unctional Endoscopic Sinus Surgery(FESS)
Caldwell-Luc surgery (Radical AntrumSurgery)
Ethmoidectomy
Sphenoidectomy/ethmoidotomy
Osteoplastic flap surgery for frontalsinusitis
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Cigarette smokingRespiratory tract infection (RTI)
Environmental pollutants
Inflammation
Bradykinin
Histamine
Prostaglandin
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Increase capillary permeability
Fluid/cellular exudation
Edema of mucous membrane
Hypersecretion of mucus
Persistent cough
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Allergy(extrinsic)Inflammation(Intrinsic)
Histamine,bradykinin,prostaglandin,
Serotonin, Leukotrienes, ECF-A, SRS-A
(a)Bronchospasm
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Bronchoconstriction
(b) edema of mucous membrane
(c) hypersecretion of mucus
Narrowing of air ways
Increase work of breathing
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Tends to sit up,
Restlessness,
tachypnea/dyspnea,tachycardia,
Flaring of the alae nasi,
diaphoresis,Cold clammy skin,
wheezing, retractions,
Pallor-cyanosis
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Exhaustion
Slow, shallow respiration (hypoventilation)
Retention of carbon dioxide (air trapping)
Hypoxia Respiratory acidosis
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Assessment in COPD
CoughDyspnea
Chest pain
Sputum productionAdventitious breath sounds
Pursed-lip breathing
Tends to assume upright, leaning forwardposition
Alteration in LOC
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Alteration in skin color (pallor to cyanosis)
Alteration in skin temoerature (cold totouch)
Voice changes
Decreased metabolism: weakness, fatigue,anorexia, weight loss
Alteration in thoracic anatomy (barrel
chest)Clubbing of fingers
Polycythemia
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Collaborative Management
Rest to reduce oxygen demands of tissues
Increase fluid intake to liquefy mucussecretions
Good oral care to remove sputum and
prevent infection Diet: high caloric diet provides source of
energy; high protein diet helps maintainintegrity of alveolar wall; low carbohydratediet limits carbon dioxide production(natural end product),the client hasdifficulty in exhaling carbon dioxide.
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Oxygen therapy of 1 to 2 Lpm. Do notgive high concentration of oxygen. The
drive for breathing may be depressed. Avoid cigarette smoking, alcohol,
environmental pollutants. These inhibits
mucociliary function CPT- percussion, vibration, postural
drainage
Bronchial hygiene measures: steaminhalation, aerosol inhalation, medimistinhalation
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Pharmacotherapy:
>Expectorants (guaiafenessin)/mucolytic(mucomyst/mucosolval)
>Antitussive:
-Dextrometorphan, Codeine
Observe for drowsiness
Avoid activities that involve mentalalertness
Causes decrease of peristalsis therebyconstipation
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>Bronchodilators:
-Aminophylline(Theophyline),Ventolin(Slbutamol)
Observe for tachycardia
>Anti-histamine
-Benadryl(Diphenhydramine)
Observe for drowsiness
>Steroids
-Anti-inflammatory effect
>Antimicrobials
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Causes:Bacterial
Viral
Fungal
Aspiration
Chemical irritants
Inflammation of lung tissue
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Hypertrophy of mucous membrane
Increased sputum production
WheezingDyspnea
Cough
RalesRhonchi
Increase capillary permeability
Increased fluid ISC
Consolidation
Hypoxemia
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Inflammation of the pleura
Chest pain
Pleural effusion
Dullness
Decreased breath soundsDecreased vocal fremitus
Hypoventilation
Decreased chest expansionRespiratory acidosis
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Protective mechanism
Increased WBC
Increased RRFever
Nursing interventions
Rest
Fluids
Incentive spirometry
Oxygen therapy
Semi-fowlers position
Bronchial hygiene
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Oral hygiene
Humidifier
Splint chest when coughing
Monitor: sputum, chest x-ray,temperature
Pharmacotherapy: antibiotics
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Reportable, communicable,inflammatory disease that can occur
in any part of the body; mostfrequent site- pulmonary
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Classification of TB
a. Class 0: no exposure, no infectionb. Class 1: exposure, no infectio
c. Class 2: infection, no disease (+PPD
reaction but no clinical evidence ofactive TB)
d. Class 3: disease , clinically active
e. Class 4: disease, not clinically activef. Class 5: suspected disease,
diagnosis pending
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Pathophysiology
Mycobacterium tubercle bacilli
Dried droplet nuclei
Inflammation in alveoli
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Client education guide: PTB
a. TB is infectious; it may be cured or arrested
by medications
b. TB is transmitted by droplet infection
c. Cover nose and mouth when coughing,
sneezing, or laughingd. Wash hands after any contact with body
substances, masks or soiled tissues
e. Wear masks when advisedf. Take medications regularly, as prescribed
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Primary anti-TB drugs:
>Isoniazid (INH)
-may be used at any age and amongpregnant women
-side effects: peripheral neuritis,
hepatotoxicity-administer vitamin B6 (pyridoxine) toprevent peripheral neuritis
-monitor ALT (SGPT),AST(SGOT)
-used as prophylaxis for 6 months to 1 yr
>Streptomycin
-Side effects: ototxicity,nephrotoxicity
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>Rifampicin
-side effects: red orange to body
secretions, hepatoxicity,
-Nausea and vomiting,thrombocytopenia
>Ethambutol
-side effects: optic neuritis, skin rash
-opthalmologic examination at regular
basis
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NOTES: Evaluate effectiveness of anti-TBdrugs by sputum culture for acid fast
bacilli
>Anti-TB drugs must be taken in
combination to avoid bacterial resistance>drugs to be taken on empty stomach for
maximum absorption
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