The System: Respi
The System: Respi
The System: Respi
RESPIRATORY DISORDERS
PATHOPHYSIOLO GY Allergen
Degranulation of mast cells Basophils Release histamine, bradykinin, Prostaglandin, leukotrienes Vascular permeability
bronchoconstriction
Airway edema
Non-specific irritants
bronchoconstricti on
bronchoconstricti on
Diagnostics: 1. CBC with WBC differential increased eosinophil 2. ABG - dec. O2, dec. pH, inc. CO2 3. Sputum exam increased eosinophils 4. Skin testing identify specific antigen 5. Pulmonary Function test- residual volume, expiratory volume 6. Curshmann spirals 7. Charcot Leyden crystals
Medical Mgt: 1. Reverse airway spasm B2-Agonist, anticholinergics Salbutamol, Ipratropium bromide,
Theophylline
Supplemental oxygen (O2) 1. Control inflammation Inhaled corticosteroids Leukotriene inhibitors Mast cell stabilizers
Nrsg Mgnt: 1. Monitor vital signs 2. Place client in High-Fowlers position 3. Administer O2 as ordered 4. Administer medications as ordered 5. Provide humidification/ hydration to loosen secretions. 6. Monitor for respiratory distress.
1. Status Asthmaticus
- Subcutaneous epinephrine
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) A disease state characterized by the presence of airflow obstruction that is generally progressive
CHRONIC OBSTRUCTIVE BRONCHITIS inflammation of the bronchi resulting to increased mucus production and cough
Etiology and Risk Fx. 1. Cigarette smoking 2. Chronic respiratory infections 3. Irritants 4. Hereditary predisposition
Thicker mucus
Chronic infection
Airway obstruction
Airway collapse
Air trapped in distal portion of the lung hypoxi a Cyanosis, DOB, polycythemia Cor pulmonale CHF acidosis
Manifestations: 1. Productive cough Lasting 3 months or more in 2 consecutive year With copious amount of thick, tenacious sputum 1. Cyanosis 2. Distended neck vein 3. Edema 4. Wheezing and rhonchi upon auscultation
Laboratory and Dx Test: 1. CBC with WBC differential - RBC and hematocrit, WBC if infection is present. 2. ABG hypoxemia, hypercapnia, decreased pH 3. Pulmonary Function test- residual volume, expiratory volume
EMPHYSEMA A disorder in which the alveolar walls are destroyed, leading to permanent over distention of air spaces
Etiology and Risk Fx. 1. Cigarette smoking 2. Aging 3. -1 anti-trypsin deficiency 4. Chronic respiratory infections 5. Irritants 6. Hereditary predisposition
Types: 1. Centrilobular (Centriacinar) Most common type of emphysema Destruction in the respiratory bronchioles common in the upper lung regions 2. Paraseptal (Panacinar) Destruction of entire acinus (respiratory bronchioles and alveolar walls) Due to -1 antitrypsin deficiency
Manifestations: 1. Dyspnea 2. Cough 3. Thin 4. Tachypnea 5. Barrel chest 6. Use of accessory muscles 7. Diminished breath sounds 8. Hyperresonant sound on percussion
Manifestations: 9. Pursed lip breathing 10. Tends to assume an upright position 11. Alteration in LOC, skin color (pallor to cyanosis), skin temp (cold to touch) 12. Weakness , fatigue, anorexia, weight loss 13. Clubbing of fingers 14. Polycythemia
BARREL CHEST
Laboratory and Dx Test: 1. CBC with WBC differential - RBC and hematocrit, WBC if infection is present. 2. Serum -1 antitrypsin - deficient 3. ABG hypoxemia, hypercapnia, decreased pH 4. Pulmonary Function test- residual volume, expiratory volume 5. Chest X-ray flattened diaphragm due to hyper-inflated lungs
BLUE BLOATER
PINK PUFFER
Resp.
3. Polycythemia 4. Spontaneous pneumothorax Collaborative Management: 1. Medications - flu vaccine, pneumovax - bronchodilators - antihistamines - steroids - antibiotics - AAT replacement tx -expectorants /antitussives - O2 replacement tx (caution in bronchitis) - mast cell stabilizers
2. Pulmonary hygiene - nebulized bronchodilators - positive-pressure airflow - positive end-expiratory pressure (PEEP) - postural drainage - chest physiotherapy 3. Exercises - does not improve lung function - enhance CV fitness & train skeletal muscles to function more effectively - walking - breathing (diaphragmatic)
4. Controlling complications * edema & cor pulmonale diuretics - digitalis * polycythemia phlebotomy - > 60% hct * continuous O2 inhalation 1-3 LPM (2 is safest) 5. Avoiding irritants - stop smoking - avoid high altitudes
6. Psychological support 7. Rest 8. Good oral care 9. Increase oral fluids if without edema 10. Dietary management - frequent small feedings - increase calorie for energy - increase protein maintain integrity of alveolar walls - low carbohydrate limits carbon dioxide production
BRONCHIECTASIS an extreme form of bronchitis it causes permanent abnormal dilation and distortion of bronchi and bronchioles
Incidence and Etiology: 1. Recurrent inflammation of the airway 2. Exposure to toxic gases 3. Abnormal lung or immunologic defenses 4. Localized airway obstruction
Manifestations: 1. Cough 2. Muco-purulent sputum 3. Fever 4. Hemoptysis 5. Nasal stuffiness Diagnostic: Chest X-ray and CT Scan - dilated bronchioles
Classifications: 1. Re-absorption atelectasis Gases that normally keeps the alveoli open become reabsorbed, leading to collapse of the lung unit Any condition that promotes supine positioning, immobility, decreased depth of respiratory excursion and decreased cough can cause re-absorption atelectasis
Etiology: 1. Airway obstruction by mucus, tumor, foreign body, airway edema 2. Chest wall disorders (e.g., scoliosis, flail chest) 3. Impaired diaphragmatic movement (e.g., obesity, ascites) 4. Central nervous system dysfunction (e.g., coma, neuromuscular disorders, over sedation) 5. Oxygen toxicity
2. Compression atelectasis
Secondary to space occupying processes that cause crowding of the tissue and prevents normal expansion Etiology: 1. Pneumothorax 2. Pleural effusion 3. Pleural tumor
3. Contraction atelectasis
Localized or generalized fibrotic changes in the lung or pleura that prevents the lung from expanding fully Etiology: 1. Interstitial fibrosis 2. Decreased surfactant (e.g., ARDS, inhalation anesthesia)
Physical assessment: 1. Tracheal shift toward affected side 2. Decreased tactile fremitus over affected area 3. Dull percussion note 4. Decreased chest movement on involved side 5. Decreased breath sounds 6. Crackles upon auscultation
Diagnostic procedures: 1. Chest x-ray- patchy or consolidated area 2. Pulse oximetry hypoxemia PaO2 < 90% 3. V/Q scan shunt type of V/Q mismatch
Medical Management: 1. Treatment of underlying cause 2. Keep airways open 3. Maintain adequate respiratory function 4. Prevent respiratory failure
Nursing Care: 1. Preventing atelectasis 2. Encourage frequent position changes 3. Encourage early ambulation 4. Perform deep breathing and coughing exercise 5. Use of incentive spirometry
Management: 1. Remove secretions by coughing, chest physiotherapy and suctioning 2. Assess respiratory status 3. Watch for signs of respiratory failure 4. Administer nebulization or bronchodilators as ordered 5. Provide supplemental O2 6. Assist in thoracentesis 7. Provide nursing care for patient on mechanical ventilators
INFECTIOUS DISORDERS
Pneumonia inflammation of the lung parenchyma
Classifications: Affected area 1. Lobar- involvement of an entire lobe 2. Lobular- involving part of a lobe 3. Bronchopneumonia-involving distal airways and alveoli 4. Alveolar/ acinar pneumonia involving distal air spaces 5. Interstitial/ reticular pneumonia involving lung tissues surrounding air spaces & vascular structure rather than the air passages themselves
Cause: 1. Noninfectious causes Aspiration pneumonia aspiration of food or gastric acid Hydrocarbons Foreign bodies Hypersensitivity reactions Drug or radiation induced
2. Microbial causes
Streptococcus pneumoniae most common cause of community acquired pneumonia Kleibsella pneumoniae most common gram negative microorganism in the hospital Staphylococcus aureus Most common causative agent of nosocomial pneumonia Haemophilus influenzae common cause of pneumonia in children
Onset: Community acquired pneumonia (CAP) - occurring in the community setting or 48 hours after hospitalization Nosocomial pneumonia (hospital acquired) development of pneumonia 48 hours after admission to a health facility
Pneumonia
bloodstream
Lung capillaries
- Cough w/ : Tachypnea RR > 20 per minute Tachycardia CR >100 per minute Fever - Temp >37.8 C Diminished breath sounds Rhonchi Crackles Wheeze
Pathophysiology: 4 stages: 1. Congestion Local inflammation Bacteria laden fluid fills alveoli Edema in the alveoli Edema may thicken alveolar walls
2. Red hepatization
Occurs 2 -3 days after initial infection Polymorphonuclear neutrophils (PMNs) rush to area Lung tissues appear dry, granular and dark reddish-brown resembling the liver
3. Gray hepatization
Last 2 days or more after red hepatization Macrophages replace PMNs and ingest debris Alveoli is relatively bloodless due to the fibrin
4. Resolution
Exudate is removed Fibrin is removed or becomes a dense scar
Clinical Manifestations: 1. Dyspnea 2. High fever 3. Sudden onset of shaking chills 4. Productive cough with rusty brown or blood streaked purulent sputum 5. Stabbing pleuritic chest pain aggravated by respiration and coughing 6. Tachypnea
Elderly patients - may not present w/ dyspnea or fever - altered mental status - volume depletion
Physical Assessment: 1. Crackles upon auscultation 2. Increased bronchophony 3. Increased egophony 4. Increased whispered pectoriloquy 5. Increased tactile fremitus
Laboratory and Diagnostic Test: 1. Chest x-ray presence of infiltrates 2. WBC - increased 3. Sputum culture Confirmatory test Reveal inflammatory and bacterial cells 1. Bronchoscopy- allows collection of specimen to identify specific infectious organism 2. ABG to assess need for supplemental oxygen
Nursing Management Assessment Ask: 1. Contact w/ other clients experiencing similar symptoms 2. Hx. of TB or exposure 3. Exposure to birds
Problem I : Ineffective airway clearance related to inflammation & secretions. Intervention: 1. fluid intake 1. Effective coughing 2. Deep breathing 3. Frequent turning at least q hr or 2 hrs 4. Chest physiotherapy 5. Suctioning
Problem II: Ineffective Breathing Pattern Intervention 1. Position for comfort & to facilitate breathing. Semi fowlers position. 2. Splint chest during coughing episodes 3. Administer prescribed meds. - expectorants - analgesics - antibiotics - bronchodilators 4. Monitor ABGs
Problem III: Activity intolerance related to depleted energy reserves & impaired O2 / CO2 transport. Intervention 1. Schedule activity after treatment or meds 2. Avoid smoking, temperature extremes, stress 3. Encourage purse lip breathing & diaphragmatic breathing.
Elderly Patients - high index of suspicion - assess for heart failure, CAL - usually bacteria from the GI tract
Pulmonary Tuberculosis Causative Agent: Mycobacterium tuberculosis Reservoir Lungs of infected individual Portal of Exit: Mouth and nose of infected individuals Mode of Transmission: Droplet sneezes, cough, and talk Indirect e.g contaminated objects, systemic infection Portal of Entry: Mouth and nose Wounds
Risk Factors: 1. Close contact with someone with active PTB 2. Immunocompromised status e.g. HIV infxn 3. Substance abuse (drug users and alcoholics) 4. Anyone without adequate health care (homeless, impoverished, minorities, children below 15 and young adults bet 15-44) 5. Preexisting medical condition and medical treatment (DM, CRF, malnourishment, selected malignancies, organ transplant, gastrectomy)
prevalence. 7.Institutionalization (long term facilities, psych institution , prisons) 8.Living in overcrowded substandard housing 9.Being with health care provider performing high risk activities (medication administration, O2 administration, suctioning)
Incubation Period: 2 10 weeks Pathophysiology: Stages: Primary Infection Progressive primary tuberculosis Secondary tuberculosis
Clinical manifestations: 1. productive or nonproductive cough 2. low-grade fever in the afternoon 3. night chills and sweat 4. anorexia and weight loss 5. fatigue 6. dyspnea 7. hemoptysis 8. dull or pleuritic chest pain 9. chest tightness
Class II (TB infection) - (+/-) exposure - (+) Mantoux test - (-) signs & symptoms - (-) chest Xray - preclinical state of TB - risk of developing TB is 5 15% during 1st 10 yrs after 1 infection
Class III (TB disease) At least 3 or more of the ff: 1. Exposure 2. (+)Mantoux test / (+) sputum AFB x3 3. (+) signs & symptoms 4. Abnormal CXR 5. Lab findings suggestive of TB sputum culture: gold standard
May present w/ : Cough > 2 weeks Fever > 2 weeks Painless cervical or other lymphadenopathy Weight loss/ loss of appetite Failure to respond to appropriate therapy Failure to make a quick return to normal health after an infection
Class IV (TB inactive) - (+/-) hx of previous TB - (+/-) previous chemotherapy - (+) radiologic evidence of healed/ calcified TB - (+) Mantoux test - (-) s/sx - (-) smear
Identifying TB Symptomatics One smear (+) case will infect 10-20 persons/year, if left undiagnosed half of them will die within two years One smear (-) case may infect 1-2 persons/year
Types of TB Patients (based on case definitions as outlined by WHO and National TB Program) New - A patient who has never had treatment for TB - Or, has taken anti-TB less than one month Relapse - A patient previously treated for TB, has been declared cured or TX completed, and is diagnosed positive for smear/culture
Treatment Failure -A patient while on treatment, is sputum smear positive at 5th month or later during the course of treatment Transfer-In - A patient who has been transferred from another facility adopting NTP policies with proper referral slip to continue treatment
Return After Default (RAD) -A patient who returns to treatment with positive smear/culture following interruption of treatment > 2 months Other Positive - A patient who was initially registered as new smear negative case and turned out to be smear positive during treatment
Other Negative - A patient who interrupted treatment for >2 months and remained or became smear negative upon return to treatment
Lab and Dx Test: 1. Tuberculin Skin Testing a 5 units or 0.1 ml of PPD is injected intradermally and will be checked for induration after 48 72 hours. 2. Acid Fast Bacillus Smear - sputum is obtained for 3 consecutive days and analyzed under the microscope to determine nature of microorganism. 3. Chest X-ray presence of cavities 4. Sputum Culture usually takes 7 days before microorganism grows Confirmatory test
Nursing Responsibilities 1. Administer medications as ordered 2. Prevent transmission. Strict isolation not required if client/significant others adhere to special respiratory precautions for tuberculosis. Client should be in a well-ventilated private room, with the door kept closed at all times.
All visitors and staff should wear masks when in contact with the client and should discard the used masks before leaving the room; client should wear a mask when leaving the room for tests. Hand washing is required after direct contact with the client or contaminated articles.
planning concerning Medication regimen: prepare a sheet with each drug name, dosage, time due, and major side effects; stress importance of following medication schedule for prescribed period of time (usually 6 months); include significant others
Transmission prevention: client should cover mouth when coughing, expectorate into a tissue and place it in a paper bag; client should also wash hands after coughing or sneezing; stress importance of plenty of fresh air; include significant others Importance of notifying physician at the first sign of persistent cough, fever, or hemoptysis (may indicate recurrence) Need for follow-up care including physical exam, sputum cultures, and chest x-rays
Medical Management: 1ST LINE MEDS R-ifampicin E-thambutol S-treptomycin P-yrazinamide I- soniazid (INH)
All anti Kochs Meds are hepatotoxic!
MINOR SIDE EFFECTS Side Effects Gastro-Intestinal Intolerance Mild Skin Reactions Orange/Red colored urine Pain at injection site Drug Rifampicin/INH Any kind Rifampicin Streptomycin What to do? Give medication at bedtime Or give small meals Give Anti-histamines Reassure patient Apply warm compress Rotate sites of Injection Vitamin B6 100-200mg daily for TX 10mg daily for prevention ASA or NSAID or Allopurinol (do uric acid determination and manage accordingly) Give Antipyretics
Pyrazinamide
Flu-like symptoms
Rifampicin
MAJOR SIDE EFFECTS Side Effects Severe skin rash due to hypersensitivity Jaundice due to Hepatitis Oliguria or Albuminuria Due to renal disorder Impairment of visual acuity and color vision due to Optic Neuritis Psychosis and convulsion Drug All (especially Streptomycin) INH/RIF/PZA Streptomycin Rifampicin Ethambutol What to do
Isoniazid
Hearing impairment, Streptomycin tinnitus, dizziness due to damage CN VIII Thrombocytopenia, Anemia, shock Rifampicin
Class II - HR x 4 months
- HE x 6 months
Things to remember: 1. If patient cannot complete tx, better not start tx. 2. Instill in patients mind the need to complete 6 months tx.
- DOTS - give meds 1 hr before meals or R 1 hr before breakfast E - 1 hr before lunch Z 1 hr before supper
3. Allowance for non-compliance is 2 wks. 4. Follow up monthly 5. If symptomatic after 6 months continue meds but rpt AFB. - assess if patient has MDRTB 6. If asymptomatic x 2 yrs long term cure 7. Not infective after 2 wks of meds
Guidelines for sputum collection a. First interview with the patient (Day 1) Collect spot specimen, then the patient is given a cup and instruct to collect early morning specimen. b. Second interview with the patient (day 2) Patient returns with early sputum specimen. Collect 2nd spot specimen.
Instructions to produce good sputum specimen Breathe deeply two times, hold breathe for few seconds after each inhalation then exhale slowly. Repeat entire sequence twice. After inhaling deeply for the third time, at the height of deep inspiration, instruct the patient to cough forcefully and spit the sputum in the proper container.
Sputum should be collected in open air or designated sputum collection area. Ideal appearance of good quality sputum specimen: purulent, yellowish, cheesy-like material, 3-5 ml (1/2 to 1 teaspoon).
Types of fluid: Transudate Fluids that have pass through a membrane or tissue surface Usually clear serous fluid Exudate Fluids that have escaped the blood vessel
Types of exudative pleural effusion: 1. Hemothorax Accumulation of blood in the pleural space If <300 ml of blood no intervention is required 1. Empyema Accumulation of pus in the pleural space Undrained pus may become thick and almost solidified or contain cavities
3. Chylothorax
Chyle accumulation in the pleural space Chyle is a cloudy liquid product of digestion consisting mainly of emulsified fats 4. Pleural effusion with cloudy serous fluid
Clinical Manifestations: 1. signs and symptoms of underlying cause e.g. if caused by pneumonia expect increased temperature and chest pain 1. dyspnea 2. tachypnea 3. pleural pain 4. dry or productive cough
Assessment Findings: 1. Diminished breath sounds over affected lung 2. Asymmetric chest expansion 3. Decreased tactile fremitus 4. Dull percussion note 5. Tracheal deviation if mediastinal shift is present
Diagnostic Findings: 1. Thoracentesis identify fluid type 2. Pleural fluid analysis identify fluid composition 3. Chest X-ray positive if more than 250 ml 4. CT scan 5. Pulmonary Function Test assess degree of respiratory impairment 6. ABG reveal decrease O2 and increased carbon dioxide levels
Medical Management: 1. Treat underlying cause 2. Thoracentesis: Remove excess fluid to allow lung expansion 1. Drug therapy Antibiotics: either systemic or directly into pleural space Fibrinolytic enzymes: trypsin, streptokinase to decrease thickness of pus and dissolves fibrin clots 1. Closed chest drainage
Thoracentesis Thoracentesis, also known as pleural fluid aspiration, aspiration of pleural fluid for diagnostic and therapeutic purpose Indications: obtain a sample of pleural fluid for analysis relieve lung compression obtain a lung tissue biopsy specimen.
Thoracentesis Significance Pleural fluid may contain blood, chyle, or pus and necrotic tissue. A high percentage of neutrophils suggest septic inflammation. Pleural fluid glucose levels that are 30 to 40 mg/dl (SI, 1.5 to 2 mmol/L) lower than blood glucose levels may indicate cancer, bacterial infection, nonseptic inflammation, or metastasis.
Nursing considerations
Obtain an informed consent Explain procedure to the client Ensure that chest x-ray examination is done
before and after the procedure Assist in and support the client in a sitting position Set up a sterile field for the physician Assess pulse and respirations before, during, and after the procedure
Nursing considerations
procedure to prevent trauma to the lungs After the procedure, label and send specimens for laboratory tests Note and record the amount, color, and clarity of the fluid withdrawn Place the client on the unaffected side with the head of the bed elevated 45 degrees Monitor for respiratory distress, pneumothorax
Surgical Management: 1. Pleurectomy (Pleural stripping) Surgical stripping of the parietal pleura away from the visceral pleura, which produces an intense inflammatory reaction that promotes adhesion formation between the 2 layers during healing.
Nursing Responsibilities: 1. Providing respiratory support Place on high Fowlers position 1. Assessment of respiratory status 2. Alleviating pain Proper positioning Administration of analgesic 1. Assist in thoracentesis 2. Provide care of client in chest tube 3. Post operative management
Pleurisy Pleurisy refers to inflammation of both layers of pleura Etiology Pleurisy develops in combination with disease states in the lungs characterized by infection and inflammation e.g. pneumonia, TB, chest trauma, pulmonary emboli, lung cancer, thoracotomy
Clinical Manifestations 1. Sharp, knife-like chest pain aggravated by breathing, coughing and sneezing. May be minimally absent when holding breath. May be localized or radiating to shoulder or abdomen 2. Slow shallow breathing 3. Dyspnea 4. Symptoms of underlying cause
Physical assessment and Diagnostic findings: 1. Pericardial friction rub low pitched grating sound made by the 2 pleural lining rubbing against each other 2. Chest X-ray 3. Sputum examination 4. Thoracentesis
Management: 1. Treatment of underlying cause 2. Non steroidal anti-inflammatory drugs 3. Intercostal nerve block
Nursing Responsibilities: 1. Monitor extent of dyspnea 2. Assessed characteristic of pain 3. Administer analgesics as prescribed 4. Teach splinting of chest wall during coughing 5. Assist client in assuming comfortable position 6. Provide topical applications of heat and cold over affected area
Adult Respiratory Distress Syndrome (ARDS) Progressive form of respiratory failure characterize by severe dyspnea, hypoxemia and diffuse bilateral infiltrates.
Etiologies and Risk factors: 1. Aspiration 2. Drug ingestion and overdose 3. Hematologic disorder 4. Oxygen toxicity 5. Localized infection
5. Metabolic
4 criteria: 1. Sudden onset 2. PaO2 / FiO2 ratio < 200 3. PCWP < 18 mmHg or no clinical evidence of LHD 4. Bilateral pulmonary infiltrates
Collaborative Management: 1. Respiratory Support Hooked to mechanical ventilators Administer nitric oxide which dilates the capillary bed of the lungs High concentrations of supplemental O2 (810LPM) If on PEEP administer morphine/ativan or Pavulon METICULOUS EYE CARE for patients on Pavulon because they inhibit the blink reflex 1. Maintenance of hemodynamic stability Administer diuretics Fluid restriction Administer inotropic drugs
CHEST TRAUMA Pneumothorax life threatening situation wherein air enters the pleural cavity causing a lung to collapse partially or completely on the affected side, resulting in a reduction in tidal volume and gas
Types: 1. Spontaneous Most common type of closed pneumothorax Air accumulates within the pleural space without an obvious cause. Rupture of a small bleb on the visceral pleura most frequently produces this type of pneumothorax
2. Traumatic
Open Pneumothorax: Laceration in the parietal pleura that allows atmospheric air to enter inside. Closed Pneumothorax- Laceration in the visceral pleura that allows air in the lung to enter the pleural space.
3. Tension Pneumothorax Air enters the pleural space with each inspiration but cannot escape Causes increased intrathoracic pressure and shifting of the mediastinal contents to the unaffected side (mediastinal shift)
Etiology/ Classification: 1. Penetrating common cause of open pneumothorax 2. Blunt chest trauma- common cause of close pneumothorax 3. Rupture of alveoli 4. Medical procedure
Manifestatons: 1. tachypnea 2. dyspnea 3. sudden sharp pain 4. asymetrical chest expansion 5. diminished breath sound on affected side 6. hyperresonance 7. acute respiratory distress 8. anxiety 9. increased use of accessory muscles
Lab. And Dx. Test: Chest x-ray Med. Mgt. Closed Chest Drainage
Chest Tube
Use of tubes and suction to return negative pressure to the intrapleural space and to drain air from the intrapleural space, To maintain negative pressure, the chest tube is placed in the second or third intercostal space To drain blood or fluid, the catheter would be placed at a lower site, usually the eighth or ninth intercostal space Also called closed thoracotomy tube (CTT), chest tube drainage
Types of drainage:
One-chamber system one bottle serves both as a water seal and drainage bottle
Types of drainage:
Two-chamber system 1st bottle is for drainage 2nd bottle is a water seal
Types of drainage:
Three-chamber system 1st bottle is for drainage 2nd bottle is a water seal 3rd bottle is for suction
Types of drainage:
Commercially prepared plastic unit e.g. Pleur-Evac Combines the features of the other systems and may or may not be attached to suction
Nursing Responsibilities:
Collection chamber
Monitor drainage, report if greater than 100ml per hour or if bright red or increases suddenly Mark chest tube drainage at 1-4 hour intervals using a tape
Water seal
Monitor for fluctuation of the fluid level in the water seal chamber Fluctuation stops in obstruction, looping, suction no working properly or if the lung has expanded
In pneumothorax patients intermittent bubbling in the water seal chamber is expected but continuous bubbling indicates an air leak in the system Assess respiratory status and lung sounds Keep drainage below the level of the chest and the tubes free of kinks or obstructions
Encourage coughing and deep breathing Do not strip or milk a chest tube unless directed by a physician Keep a clamp and sterile occlusive dressing at bedside at all times Never clamp a chest tube without written orders from the physician
If the drainage system cracks or breaks, insert the chest tube into a bottle of sterile water, remove the cracked or broken system and replace it If the chest tube is pulled out accidentally pinch the skin opening together, apply an occlusive sterile dressing, cover the dressing with overlapping pieces of tape and call the physician
When the chest tube is removed , the client is asked to take a deep breath and hold it and the tube is removed; a dry sterile dressing, petroleum gauze dressing is taped in place During removal of tube, deep breath , exhale and bear down
Virchows triad: 1. Venous stasis 2. Hypercoagulable state 3. Vessel injury Etiology: Sites of thrombus formation: 1. Iliofemoral venous system most common 2. Prostatic veins 3. Pelvic veins
Precipitating factors: 1. Exercise 2. Straining on defecation Other sources of emboli: 1. Tumors 2. Air 3. Fat 4. Bone marrow 5. Amniotic fluid 6. Septic thrombi 7. Vegetations on heart valves
Risk factors: 1. Previous surgery on the pelvis / legs. 2. Trauma of long bones. 3. Immobility early ambulation leg exercises weight loss dont massage calf
DV T
Pathophysiolog y
IVC obstruction
RV
Pulmonary arteries
V/Q Mismatch
Clinical manifestations: 1. Dyspnea at rest 2. Chest pain similar to MI 3. Pleuritic chest pain when pulmonary infarction occurs 4. Syncope w/ CO 5. Tachypnea, tachycardia, low grade fever 1. breath sounds, dullness, cyanosis
Diagnosis: 1. Chest X Ray - usually normal - wedge-shaped density 2. ECG - diff. Between MI & PE - sinus tachycardia: most common - peaked P waves 3. ABGs - PO2 : hypoxia - PCO2: hyperventilation - PCO2 pH : mild acute respiratory alkalosis.
Perfusion scanning - most specific for PE - blood is labeled w/ radioactive tracer Xenon ventilation scan patient inhales tracer Pulmonary angiography gold standard
Medical Management: 1. Anticoagulants - heparin: DOC - PTT at 2 2.5x the normal value - coumadin: begin 3 days before heparin is stopped to provide a transition - warfarin x 3 6 months 2. O2 inhalation 3. Bed rest
4. Thrombolytic agents - used when occlusion has produced RHF 5. Surgery - inferior vena caval ligation - clipping, plication - umbrella/Greenfield filter - embolectomy
Nursing Management 1. Monitor for hypoxemia and respiratory compromise. 2. Monitor for manifestations of right sided heart failure. 3. Facilitate breathing by elevation of head and administration of supplemental O2 as ordered 4. Elevate leg slowly and avoid severe flexure of hips 5. Administer analgesics for pain (Morphine) 6. Watch out for adverse reaction of anticoagulant
Obstruction of Upper Airway Acute Airway Obstruction 1. Acute laryngeal edema - associated w/ inflammation, injury or anaphylaxis - hoarseness or DOB - ET tube - epinephrine : anaphylaxis
2. Laryngospasm - anesthetics - repeated intubation - foreign substances - hypocalcemia - Give 100% O2 - Neuromuscular blocker: succinylcholine - emergency cricothyroidotomy or tracheotomy
Epistaxis - irritation, trauma, infection, tumors - systemic diseases (HPN, blood dyscrasias - most common cause: nose picking - most common site: Kiesselbachs plexus - pinch nose for 5 10 mins - lean forward - apply ice - nasal packing w/ antimicrobial ointment x 48 72 hrs
- Avoid petrolatum gauze - posterior plugs for post. Epistaxis (for 5 days) - arterial ligation: internal maxillary or ethmoid artery ligation. - avoid strenuous activity, blowing nose, sneezing, stooping, lifting.
RHINITIS inflammation of nasal cavities Types: Acute Rhinitis- inflammation of the nasal cavities as a result of a viral infection, most frequently in conjunction with coryza (common cold) Chronic Rhinitis chronic inflammation of the mucous membrane caused by repeated acute infections, by an allergy, or vasomotor rhinitis
Acute Rhinitis
1. Mucoid nasal discharge 2. Sneezing 3. Sore throat 4. Headache 5. Malaise 6. Cough 7. Decreased sense of smell and taste
Acute Rhinitis Diagnostics: 1. Patient history and physical findings 2. WBC 3. Throat, nose/nasopharynx culture
Allergic
1. Nasal congestion 2. Watery thin discharge 3. Sneezing 4. Allergic shiners 5. Swollen eyelids 6. Reddened conjunctiva
Diagnostics: Patient history Nasal smear Radioallergosorbent test (RAST) Skin test
Chronic Rhinitis 1. Careful medical follow-up is indicated. 2. When nasal obstruction persists, surgery may be necessary to remove the polyps (polypectomy) or to remove tissue obstruction (septoplasty). 3. If nasal passages are dry, a nasal spray of normal saline can be purchased in a drug store or it can be made by mixing 1 tsp of salt in 1 quart of water. Homemade solution should be made fresh daily. The solution is best administered from a spray bottle with both nostrils open
Allergic Rhinitis
Eustachian tube function decongestants (sympathomimetic amines) e.g., Afrin 0.05% (oxymetazolin) and Otrivin 0.1% (xylometazoline).
Nursing Management: 1. Obtain additional rest. 2. Drink at least 2 3 L of fluid daily. 3. Medications: Use nasal spray or nose drops 2 to 3 times/day as ordered 4. Prevent further infection: Blow nose with both nostrils open to prevent infected matter from being forced into Eustachian tube,
Cover mouth with disposable tissues when coughing and sneezing to prevent droplet nuclei from contaminating the air, Avoid exposure when possible (e.g., avoid crowds, people with colds, specific allergens). Disposed used tissues properly. Wash hands frequently and especially after coughing, sneezing, and so on. Seek medical attention if the following is present:
a. High fever, severe chest pain, earache b. Symptoms lasting longer than 2 weeks c. Recurrent colds
SINUSITIS- inflammation of the mucous membranes of one or more of the sinuses. A. Acute Sinusitis condition that block the nasal ostia and impede sinus drainage which contribute to stasis of secretions and subsequent infection - complication of the common cold B. Chronic Sinusitis- develops when mucosal disease in sinuses produces irreversible epithelial changes.
Predisposing Conditions: 1. Anatomic obstruction of the nasal passages e.g nasal septal deviation 2. Foreign bodies e.g. nasal packing, nasogastric intubation 3. Inflammation of the nasal mucosa e.g. rhinitis 4. Impairment of ciliary function e.g. exposure to tobacco smoke/ air pollution
Clinical Assessment and findings A. Acute 1. Nasal congestion 2. Pressure sensation over paranasal sinus area 3. Throbbing head and face pain 4. Headache exacerbated by bending, stooping or straining 5. Thick yellow/ green nasal discharge 6. Fever and chills 7. Body malaise
B. Chronic 1. Persistent nasal discharge 2. Nasal obstruction 3. Diminished sense of smell 4. Purulent secretions with unpleasant order 5. Halitosis 6. Red, swollen mucosa
Medical Mgnt 1. Pharmacology Broad-spectrum antibiotics Oral/topical decongestant Antihistamines Saline nose drops/ spray Mucolytics
Surgery: 1. Antral Irrigation-Also known as sinus lavage. A trocar is inserted through an opening (ostium) in the inner wall of the nose to the affected. Saline solution is then injected to rinse the sinus
2. Functional Endoscopic Sinus Surgery (FESS) an endoscope is inserted through the nasal cavity to the sinus, allowing visualization, removal of diseased tissues, and widening of the sinus opening
3. Caldwell-Luc Procedure
4. External Sphenoethmoidectomy procedure performed to removed diseased tissues, from the ethmoid or sphenoid sinuses.
Nursing Management: Health Teachings for Non-Surgical Patients with Sinusitis: 1. Avoid factors that contribute to sinusitis. Avoid chilling and cold, damp atmospheres Avoid air conditioning when outside air is warm and moist, if this precipitates sinus irritation. Avoid smoking and being around smokers Avoid fatigue
Postoperative Care for Patients with Sinus Surgery: 1. After general anesthesia, position patient well onto the side to prevent swallowing or aspiration of bloody drainage. 2. Administer cool mist via face tent or collar, or provide humidifier 3. When the patient is awake, remind him or her to expectorate secretions and not swallow them. 4. Encourage Fowlers position when fully awake to promote drainage and decrease edema. 5. Apply ice compresses over nose (or ice bag over maxillary or frontal sinuses) in the early postoperative period.
8. Change nasal pad when it is soiled. 9. Encourage liberal fluid itake 10.Teach patient to:
Avoid blowing nose for at least 48 hours after packing is removed to prevent bleeding. Avoid sneezing; if patient must sneeze, he or she should keep mouth open. Avoid lifting heavy objects. Report signs of infection to surgeon Expect tarry stools from swallowed blood for a few days. Avoid constipating because straining can increase on postoperative site. Take prophylactic antibiotics as prescribed
PHARYNGITIS general term for any inflammation of the pharynx sore throat Etiology: 1. Infection with viruses, bacteria, fungi most common is Beta hemolytic streptococcus 1. Irritation 2. Neoplasms
Manifestations: 1. Scratchy or mild sore throat 2. Malaise 3. Headache 4. Odynophagia 5. Fever 6. Local tenderness
Medical management: 1. Oral antibiotics. 2. Intramuscular penicillin 3. IV fluids 4. Lozenges containing a mild anesthetic may help relieve the local soreness. 5. For adults, aspirin administered orally as a gargle
Nursing Management: 1. Warm saline gargle. 2. Ice collar may make the person feel more comfortable. 3. Moist inhalations may help relieve the dryness of the throat. 4. Liquids (Fluids of at least 2 3 L/ day; soft bland diet)
drying of the lips, refreshes the mouth Encourage bed rest when febrile. Symptoms of recurrence requiring medical attention: fever, excessive pain, pus, dysphagia. Explain the importance of adherence to the antibiotic regimen
TONSILITIS ETIOLOGY: Usually streptococcus microorganisms Types 1. Acute Tonsilitis inflammation of any tonsils Manifestations: 1. Throat pain 2. Dysphagia 3. Odynophagia 4. Otalgia 5. Malaise
Medical and Nursing Management: 1. Encourage rest. 2. Increase oral fluid intake 3. May have warm saline throat irrigation. 4. Antibiotics for streptococcal tonsillitis 5. Acetaminophen (Tylenol) may be given for pain 6. Ice collar may relive discomfort
Laryngitis Inflammation of the larynx Etiology: Viral/ bacterial infection Vocal abuse
A. Acute Laryngitis
Manifestations: 1. Hoarseness 2. Throat pain 3. Fever 4. Malaise 5. Dysphagia 6. Laryngeal edema Diagnostics: Laryngoscopy
Treatment: 1. Voice rest 2. Rest in humidified room 3. Warm saline gargle 4. Throat lozenges
Nursing Management: 1. Provide other means of non-verbal communication. 2. Follow prescribed antibiotic regimen 3. Advise patient to quit smoking 4. Referral to support group wanting to quit smoking 5. Increase fluid intake