1 Care of Patients with Disorders of the Lower Respiratory SystemChapter 14 Care of Patients with Disorders of the Lower Respiratory System Copyright © 2017, Elsevier Inc. All rights reserved.
2 Theory Objectives Compare and contrast commonalities and differences in nursing care for patients with bronchitis, influenza, pneumonia, emphysema, and pleurisy. List nursing interventions appropriate for care of patients with nursing diagnoses of Ineffective airway clearance, Ineffective breathing pattern, Impaired gas exchange, and Fatigue related to hypoxia.
3 Theory Objectives (Cont.)Analyze ways a nurse can contribute to prevention and prompt treatment of tuberculosis (TB). Summarize the pathophysiologic changes that occur during an asthma attack.
4 Theory Objectives (Cont.)Evaluate problems that occur with aging that may cause a restrictive pulmonary disorder. Describe the specifics of nursing care for the patient who has had thoracic surgery and has chest tubes in place.
5 Clinical Practice ObjectivesComplete a nursing care plan, including home care, for the patient with chronic obstructive pulmonary disease. Review nursing interventions for the tracheostomy patient on oxygen therapy. Teach a patient how to use a peak flowmeter. Observe a respiratory therapist (RT) who is responsible for a patient on a mechanical ventilator and identify how RTs and nurses work together to deliver safe care.
6 Acute Bronchitis An extension of an upper respiratory infection involving the trachea Usually viral in origin Early symptoms are similar to those of the common cold – cough producing some sputum, sore throat, headache, muscle aches Treatment includes humidification with warm or cool moist air, cough mixtures, or bronchodilators.
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8 Influenza An acute, highly infectious disease of the upper and lower respiratory tracts. Caused by three major types (A, B, and C) and numerous subtypes of influenza viruses Spread by direct and indirect contact – coughing, sneezing, contaminated hands to objects Between 25 and 50 million cases resulting in more than 200,000 hospitalizations and between 30,000 and 40,000 deaths occur each year.
9 Signs and Symptoms Appear 2 to 3 days after exposureHeadache, fever ( ), chills, and muscle aches Sore throat, hacking cough, runny nose, and nasal congestion Chest radiographs/auscultations are usually normal. Virus is usually shed for 1 to two 2 before the onset of symptoms.
10 Treatment and Nursing ManagementAntiviral medications may be used in specific patient populations. Uncomplicated influenza usually is managed more effectively by nursing intervention than by drugs or other forms of medical treatment. – see list on page 291 Antibiotics are given only if there is evidence of bacterial infection secondary to the viral infection Antibiotics are not effective against viral illness and are contraindicated. Antiviral drugs must be started within 48 hours of the start of symptoms.
11 Health Promotion: ImmunizationThe Advisory Committee on Immunization Practices (2009) recommends annual influenza vaccination for People at high risk for influenza-related complications and severe disease, including children ages 6 to 59 months, pregnant women, people older than 50 years, and people of any age with certain chronic medical conditions People who live with or care for persons at high risk, including household contacts who have frequent contact with people at high risk and who can transmit influenza to those individuals, and health care workers
12 Complementary and Alternative Therapy for the “Flu”Elderberry juice has been used for centuries as a treatment to ease symptoms of the flu, colds, and sinus infections. Seems to prevent the virus from attaching to cells Antioxidants in the purple elderberry fruit have an anti-inflammatory effect comparable to aspirin. May explain why the juice produces symptom improvement
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14 Pneumonia An extensive inflammation of the lung with either consolidation of the lung tissue as it fills with exudate or interstitial inflammation and edema. Bacteria or viruses may cause pneumonia. Viral pneumona does not produce exudate – it causes interstitial inflammation See concept map 14-1 page 292 Pneumonia is classified as community acquired or hospital acquired. Viral pneumonia does not produce exudate; it causes interstitial inflammation, and it tends to be less severe than bacterial pneumonia. Concept Map 14-1, p. 292.
15 Pneumonia Chemical pneumonia- inhalation of irritating gasesAspiration pneumonia – accidental aspiration of foods or liquids Hypostatic pneumonia – lying in bed for extended periods – inadequate aeration of the lungs HAP – Hospital Acquired VAP – Ventilator Acquired
16 Signs, Symptoms, and DiagnosisUsually a high fever accompanied by chills A cough that produces rusty or blood-flecked sputum Sweating and chest pain that is made worse by respiratory movement A general feeling of malaise and aching muscles Diagnosis is confirmed by chest radiography, which reveals densities in the affected lung.
17 Prevention of pneumoniaAvoiding infection – cleanliness - asepsis for debilitated patients Frequent turning, coughing, deep breathing for postop patients Maintain head elevation for patients at risk for aspiration Encourage pneumonia vaccine for those at risk Encourage immunization against influenza
18 Complementary and Alternative Therapy for Pneumonia pg 293Barberry root bark is used against bacteria, fungi, and viruses as well as other organisms and is an alternative treatment for pneumonia. It has antimicrobial action against both gram-positive and gram-negative bacteria. It should not be used during pregnancy because it can cause spontaneous abortion.
19 Cultural Considerations: Pneumococcal Vaccine page 292Routine use of pneumococcal polysaccharide vaccine is not recommended for persons of Alaskan Native or American Indian heritage unless they have underlying medical conditions such as chronic lung, liver, or renal disease. Local public health authorities may consider recommending the vaccine for occurrences of increased risk.
20 Nursing Management of Pneumonia pg 293Promote oxygenation. Control elevated temperature. Maintain nutritional and fluid intake. Provide adequate rest. Monitor vital signs and respiratory status. Relieve pain and discomfort. Provide good oral hygiene. Prevent irritation of the lungs by smoke and other irritants. Avoid secondary bacterial infections.
21 Clinical Cues The first signs of decreasing oxygenation may be restlessness or confusion. The patient may want to sit upright to allow for better chest excursion. The respiratory rate will increase, and later there will be flaring of the nares and then retraction of respiratory muscles if the condition worsens. Cyanosis is a very late sign.
22 Older Adult Care Points pg 294Older adults are more at risk for influenza and pneumonia because of a less efficient immune system, decreased action of cilia, and decreased elasticity and muscle tone. Confusion often is the most obvious sign of atypical pneumonia in older adults. It may take 6 to 12 weeks after a bout of pneumonia for the older person to be able to resume normal activities without undue fatigue.
23 Older Adult Care Points (Cont.)Very old patients may never quite regain the former level of wellness after a serious episode of pneumonia. Teach older adults to seek medical attention quickly if symptoms of pneumonia occur.
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25 Atelectasis An incomplete expansion, or collapse, of alveoliMay occur from compression of the lungs from outside, a decrease in surfactant, or bronchial obstruction Breath sounds are diminished when the airways are collapsed, and oxygen saturation (Sao2) will decrease. Treatment consists of expelling secretions by coughing. Deep breathing and use of an incentive spirometer help to keep the alveoli open and functional.
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27 Fungal Infections Fungal infections are caused by the inhalation of the fungus or spores or by overgrowth of organisms found normally in the body. The most common fungal lung infections are coccidioidomycosis and histoplasmosis. Fever, fatigue, cough, dyspnea and weight loss over 1 to 2 months
28 Tuberculosis page 294 TB is an infectious disease of the lung characterized by lesions within the lung tissue. The lesions may continue to degenerate and become necrotic, or they may heal by fibrosis and calcification. The causative organism is the true tubercle bacillus Mycobacterium tuberculosis.
29 Tuberculosis Tuberculosis is spread through airborne particles that carry the TB bacilli and are inhaled. Diagnosis Tuberculin skin testing – requires 2 visits Radiographs and sputum cultures 2 blood tests – QFT-GIT and T-SPOT measure the immune system reaction to TB
30 Signs and Symptoms Cough, low-grade fever in the afternoon, anorexia, loss of weight, fatigue, night sweats, and sometimes hemoptysis (blood in sputum) Tight or dull chest pain and mucopurulent sputum may occur as the disease progresses.
31 Treatment Treatment of active TB consists of at least four drugs for an extended period of time. See list page 296 –Bactericidal agents Isoniazid, Ethambutol, Rifampin Pyrazinamide
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33 Latent Tuberculosis InfectionLatent TB infection (LTBI) is the current terminology for an infection with Mycobacterium tuberculosis but no current active disease. LTBI may develop into active TB if the immune system is weakened by a serious illness such as HIV or when the system is less efficient, as with advanced age.
34 Cultural ConsiderationsAmerican Indian, Alaska Natives, Asian/Pacific Islanders, black non-Hispanics, and Hispanics have a high incidence of TB. The disease is most prevalent in people older than 65 years of age in these groups. For the first few years of residence in the United States, new immigrants from areas where TB is prevalent have incidence rates similar to those of their former countries.
35 Directly Observed TherapyBecause of an increase in the incidence of multidrug-resistant TB, directly observed therapy (DOT) is recommended for patients who are known to be at risk of noncompliance with therapy. Visual observation of the ingestion of each required dose of medication for the entire course of treatment Often a public health nurse administers the medication at a clinic site. Follow-up visits are necessary for 12 months after completion of therapy to monitor for the presence of resistant strains.
36 Legal and Ethical ConsiderationWhen someone is found to have TB and the person is non-compliant with treatment, is it legal or ethical to compel the person to come for treatment? What would happen if the person is allowed to remain in the community without treatment?
37 Complementary and Alternative Therapy for TuberculosisVitamin D has been found to be successful in the prevention and treatment of TB. White blood cells convert vitamin D into an active form that helps make a protein that kills TB bacteria. Perhaps this is why moving to a sunny climate and a solarium environment helped people with TB years ago.
38 Nursing Management of TuberculosisNursing diagnoses Ineffective breathing pattern related to decreased lung capacity Noncompliance related to lack of knowledge of disease process and long-term requirements for treatment Activity intolerance related to fatigue, febrile status, and poor nutritional status Imbalanced nutrition: less than body requirements related to anorexia, fatigue, and productive cough
39 Extrapulmonary TuberculosisIt is possible for the tubercle bacillus to attack and damage parts of the body other than the lungs. Areas most frequently affected are the bones, meninges, urinary system, and reproductive system. TB of the spine, called Pott’s disease, is now quite rare in the United States. The deformity most commonly seen in Pott’s disease is kyphosis, or “hunchback.”
40 Occupational Lung DisordersCoal dust; dust from hemp, flax, and cotton processing; and exposure to silica in the air all can cause work-related lung disorders. Asbestos exposure may cause a rare cancer of the chest lining called mesothelioma.
41 Restrictive Pulmonary Disorders
42 Restrictive Pulmonary DisordersCaused by decreased elasticity or compliance of the lungs or decreased ability of the chest wall to expand Disorders of the central nervous system or of the neuromuscular system can cause a restrictive lung disorder.
43 Restrictive Pulmonary Disorders (Cont.)Myasthenia gravis and arthritis are examples of extrapulmonary causes of a restrictive disorder Kyphosis of the spine or severe scoliosis may also hamper lung expansion, although in these muscular and skeletal disorders, the lung tissue remains normal.
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45 Sarcoidosis A lung disease characterized by granulomasIt causes fibrotic changes in the lung tissue over time, and the cause is unknown. It affects other tissues in the body as well. A cellular immune response seems to be responsible for the tissue changes.
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47 Pulmonary Fibrosis Occurs from severe infection, repeated infection, or inflammation that causes scarring of the lung tissue The scarring decreases functional lung tissue.
48 Pleurisy An inflammation of the pleuraTB, pneumonia, neoplasm, and pulmonary infarction all can cause pleurisy. Pleurisy pain is sharp and abrupt in onset and is most evident on inspiration. Pain causes shallow breathing. Pleural friction rub may sometimes be heard.
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50 Pleural Effusion A collection of fluid in the pleural spaceTransudative Occurs in noninflammatory conditions Often a result of congestive heart failure, chronic liver failure, or renal disease Transudate is a thin fluid containing no protein that passes from cells into interstitial spaces or through a membrane.
51 Pleural Effusion (Cont.)Exudative Thicker, contains cells and other substances, and is slowly discharged from cells into a body space or to the outside of the body. Exudative pleural effusion occurs in an area of inflammation caused by the increased capillary permeability characteristic of the inflammatory reaction. Occurs with lung cancer, pulmonary embolism, pancreatic disease, and pulmonary infections
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53 Empyema Occurs when fluid in the pleural cavity becomes infected – exudate becomes thick and purulent – staph or streptococci Tx – chest tube to remove fluid – sent to lab to test for sensitivity and choice of antibiotic therapy
54 Obstructive Pulmonary DisordersProblems with moving the air out of the lungs Exhalation is difficult
55 Bronchiectasis Chronic respiratory disorder in which one or more bronchi are permanently dilated Thought to occur as a result of frequent respiratory infections in childhood
56 Cystic Fibrosis A genetic disease in which there is excessive mucus production because of exocrine gland dysfunction It occurs most often in whites. The lungs, intestines, sinuses, reproductive tract, sweat glands, and pancreas are all affected. It is diagnosed by history, physical examination, and a positive sweat test result.
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58 Chronic Obstructive Pulmonary Disease
59 Obstructive Pulmonary DisordersCharacterized by problems with moving air into and out of the lungs Narrowing of the openings in the tracheobronchial tree increases resistance to the flow of air, making it difficult for oxygen to enter, and contributes to air trapping because exhalation also is difficult. Chronic bronchitis Asthma Emphysema Atelectasis
60 Chronic Obstructive Pulmonary DiseaseEtiology and diagnosis Emphysema Chronic bronchitis Treatment Bronchodilators and anti-inflammatory agents Smoking cessation Respiratory rehabilitation programs Nutrition Complementary and alternative therapies
61 Complementary and Alternative Therapy for EmphysemaGinger and cinnamon are aromatic digestives that provide benefit for emphysema patients. Very small doses of Capsicum annum (chili) or garlic can be useful as mucolytic agents.
62 Complications of Chronic Obstructive Pulmonary Disease page 300Cor pulmonale- enlarged right side of heart Acute respiratory failure Peptic ulcer and gastroesophageal reflux disease
63 Emphysema Destruction of alveolar/alveolar capillary wallsNarrowed airways Permanently inflated airways Lung elasticity decreases
64 Emphysema Signs and SymptomsDyspnea – early symptom Diaphragm flattened – ribs flare outward Barrel chest Whites – skin is pink in tone Excess CO2 Hemoglobin and hematocrit levels are elevated – attempt by the body to compensate for chronic hypoxia
65 Emphysema PathophysiologyExcess mucus that decreases ciliary function Airways become edematous and narrowed Respiration infection occur frequently because thick mucus provides a growth medium for bacteria
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67 Comparison Emphysema and Chronic BronchitisTable 14-2 Page 301 Comparison Emphysema and Chronic Bronchitis
68 Asthma Chronic lung disease characterized by reversible airway obstruction, airway edema or swelling from inflammation. See Figure 14-3 –Allergen or stimulus Respiratory distress without a wheeze is an ominous sign for the asthma patient; this suggests further constriction with very little air movement. ACE inhibitors (can cause cough) – asthma patient must report a cough – may trigger attack
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70 Goals of Medical TreatmentMinimize irritation of the air passages and relieve obstruction by secretions, edema, or bronchospasm. Prevent or control infection and allergy. Increase the patient’s tolerance for activity. Determine the best drug combination in the least amount that will control symptoms.
71 Metered Dose Inhaler Dry powder inhaler-Patient should hold 1 to 2 inches in front of the mouth Slow deep breath – depress activator Do not put mouth around mouthpiece – this only for liquid not powder inhalers
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73 Peak Flowmeter used by asthma patientsThe peak flowmeter helps determine the drug dosage needed to control the asthma, predict the effectiveness of therapy, and detect airflow obstruction buildup before it becomes serious and requires hospitalization. See “using a peak flowmeter” page 306
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75 Patient Teaching Know your “green zone” (when airflow is normal), your “yellow zone” (when usual airflow has decreased and routine medications should be increased), and your “red zone” (when you need to use rescue medications and call your health care provider).
76 The Step System of Asthma Treatment – see Table 14-3 page 303I. Mild intermittent II. Mild persistent III. Moderate persistent IVa. Severe persistent IVb. Severe persistent, not responsive to the previous step
77 Asthma Nursing management Smoking cessation Psychosocial carePatient and family teaching How to avoid bronchial irritation and infection
78 Audience Response Question 1On initial admission assessment of a patient with acute exacerbation of chronic obstructive pulmonary disease (COPD), the nurse is likely to expect which sign(s) and symptom(s)? (Select all that apply.) Tensing of the shoulder muscles Inability to tolerate sitting up Flaring of the nostrils Completes sentences with no effort Sternal retraction Correct Answer: 1, 3, and 5
79 Respiratory Distress see page 306 Clinical CuesApply high-flow oxygen and monitor the saturation level with a pulse oximeter. Observe and monitor continuously. Immediately alert the RN and the physician. If there is a history of COPD, the oxygen rate should be changed, as ordered, to a lower flow of 1 to 3 L per nasal cannula after the respiratory crisis has been resolved.
80 COPD – Patient Teaching pg 306Drink 2 to 3 quarts water daily Report changes in sputum Exhale on exertion 3 to 4 balanced meals per day Daily breathing exercises Avoid crowds during cold and flu season No OTC unless directed by physician Don’t smoke
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82 Lung Cancer page 307 Cigarette smoking primary cause Air pollutionTB and COPD Often not detected until at advanced stage
83 Lung Cancer - PathophysiologyChronic irritation of the epithelial tissue in the lung Changes in cell structure This makes tissue more vulnerable to carcinogens and irritants Dysplasia develops and tumor grows Common metastases – brain, bone and liver
84 Two types of Lung CancerNon-small cell lung cancer (NSCLC) 85% of all lung cancers- located near a major bronchus –– slow growth- tend to metastasize Small cell lung cancer (SCLC) 15% - grow rapidly – found in lung periphery
85 Lung Cancer – Signs and SymptomsSome cough – wheezing Tumor grows – patient may have pain or discomfort Blood streaked sputum Fatigue, anorexia and weight loss – lung cancer is usually advanced when discovered
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87 Pulmonary Vascular Disorders
88 Pulmonary Vascular DisordersPulmonary embolism – pulmonary vessel is plugged with a mass or a clot. Page 308 s/s depends on size and location of the clot – respiratory distress, dyspnea, chest pain, cough. D-dimer testing of plasma, CTA, ABGs, ECG Tx- heparin IV, Xarelto, Thrombolytic therapy – oxygen to decrease hypoxia Prevention is the best intervention
89 Pulmonary Vascular Disorders page 309Primary pulmonary hypertension – elevated pressure in the pulmonary artery. s/s – dyspnea, fatigue, chest pain with exertion, dizziness, syncope. Eventually leads to right-sided heart enlargement (cor pulmonale) Tx- drug therapies, calcium channel blockers, anticoagulants Lung transplantation
90 Pulmonary Vascular DisordersLung transplantation - option for end-stage lung disease Normal wait for organ is one year Most common cause of death is infection Immunosuppressive therapy is lifelong to prevent organ rejection
91 Chest Injuries – page 309 Fractured ribs Flail chestPenetrating wounds Pneumothorax and hemothorax Spontaneous pneumothorax Tension pneumothorax
92 Major Concerns for Patients with Chest InjuriesMaintenance of an airway Assurance of adequate ventilation Treatment of circulatory problems to ensure circulation of oxygenated blood Pneumothorax (air in the pleural cavity) and hemothorax (blood in the pleural cavity) often occur as a result of a blunt or penetrating injury to the chest wall.
93 Pneumothorax treatmentAdministration of oxygen and rest Air in pleural space may be aspirated with a large bore needle If larger amount of air present – thoracostomy
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95 Lung Disorders page 310 Pulmonary edema – abnormal collection of fluid in the interstitial spaces of the lung and inside the alveoli. Adult (acute) respiratory distress syndrome – result of sepsis, major trauma- alveoli fill with fluid and the oxygen and carbon dioxide cannot cross the membrane Respiratory failure – insufficient oxygen or excessive carbon dioxide.
96 Common Therapeutic MeasuresIntrathoracic surgery Preoperative care Postoperative care Medication administration Humidification Pulmonary hygiene Oxygen therapy
97 Chest Tubes and Closed DrainagePurposes Provide for drainage of air and blood from within the pleural cavity. Allow for gradual re-expansion of the lung. Major assessments The respiratory status of the patient The site at which the tube is inserted into the chest and the length of the tube (for kinks) The amount and character of the drainage in the collection chamber
98 Location of Sites for Insertion of Chest TubesSee Figure 14-6 on p. 313.
99 Disposable Water-Seal Drainage SystemSee Figure 14-7 on p. 313.
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101 Various Oxygen Delivery Devices see p 320See Figure 14-9 on p. 320. See Table 14-5 on p. 320 for advantages and disadvantages of each type.
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103 Mechanical VentilationMechanical Ventilation is needed when the patient cannot maintain adequate ventilation due to respiratory, neurologic or neuromuscular problems or trauma
104 Mechanical Ventilation (cont) page 322Modes of ventilation – pressure cycled and volume cycled Controlled mode – fixed number of breaths per minute at a set volume Assist-mode – when patient takes a breath, the machine delivers a set tidal volume Pressure support ventilation – adjunct to standard ventilator modes pg 323 Continuous positive airway pressure -CPAP Noninvasive positive ventilation
105 Dangers of Mechanical Ventilation page 324Barotrauma Oxygen toxicity Impaired cardiac output Infection Fluid retention Gastric distention Gastrointestinal bleeding See Table 14-6 on p. 324.
106 Preventing Ventilator-Acquired PneumoniaThe Centers for Disease Control and Prevention recommends Elevation of the head of the bed to 30 to 45 degrees Continuous removal of subglottic secretions Change of ventilator circuit no more often than every 48 hours and washing hands before and after contact with every patient
107 Preventing Ventilator-Acquired Pneumonia (Cont.)In addition, facility bundle policy may include Checking the residual volume in the nasogastric tube Providing oral care with chlorhexidine Deep vein thrombosis prophylaxis Peptic ulcer prophylaxis
108 Mechanical VentilationWhen caring for a patient on mechanical ventilation, the nurse should Check the physician’s order each shift and then check the ventilator for the proper settings. Check alarms to see that they are turned on. Keep tubing clear of pooled water; empty the water into an appropriate receptacle as needed.
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