MedSurge Exam 2 Review

Bronchoscopy - direct visualization of larynx, trachea and bronchi through bronchosope (fiber optic)

• Pre Care
• *Assess for pregnancy and hypersensitivity to anestetic
• *Instruct - no eat for drink 8-12 hrs before
• *Vital Signs
• * Administer ordered meds

• Post Care
• *Assess for complications - laryngeal edema, bronchospasm, pneumothorax (air in thorax), cardiac dysryhthmias, bleeding
• *Look for respiratory distress - dyspnea, decreased breath sounds, low O₂ sat
• *Assess gag reflex before food or drink
• *Instruct - no smoke 6-8 hrs after

• How to obtain sample
• -early morning is best -secretions pool overnight
• -fluid before helps liquify secretions
• 1. Provide mouth care
• 2. Instruct to breath deeply several time
• 3. Cough deeply & expectorate into container
• 4. Label & send to lab

• Proper suctioning
• 1. Provide mouth care
• 2. Use sterile mucous trap - aseptic technique - attach trap between suction catheter & tubing
• 3. Preoxygenate as needed
• 4. No suction during insertion - suction for no longer than 10 seconds while withdrawing
• 5. Clear suction catheter with normal saline

Acute Rhinitis = common cold (inflammation of nasal cavity)

• URI, viral contagious, infectious disease
• Spread by airborne droplet sprays by infected person: breathing, talking, coughing, sneezing orby direct hand contact

• S/S: Red, swollen (boggy) nasal membranes with congestion or coryza (clear watery discharge)
• Low grade fever, muscle aches, HA, Sneezing / coughing

• TX: rest, fluids, warm salt water gargles
• Frequent handwashing
• Analgesics, decongestants & antihistamines

• Seasonal vs. Perennial
• S/S: nasal inflammation with coryza (perfuse nasal drainage)
• Watery eyes, itching, sneezing
• Bronchospasm, stridor/wheezes

• TX: ****Management:
• Nasal decongestant sprays are not recommended more than 5 days due to rebound effect
• Oral decongestants & antihistamines
• Nasal corticosteroids (Flonase, Beconase,Rhinocort)
• Cromolyn – mast cell stabilizer/antihistamine
• Allergen desensitization/allergy shots

• Contagious, viral respiratory disease
• short incubation 18 to 72 hours
• Most deaths occur >60 years of age with underlying disease (cardiac, plum., diabetic)
• Avian “Bird” Flu (H5N1) SE Asia
• S/S: Fatigue, malaise, muscle ache
• Fever/Chills
• Coryza discharge & sore throat
• Cough (dry then productive)
• Substernal burning

• TX: Deaths preventable if vaccination (flu shot)
• OTC analgesics (Tylenol)
• Prophylaxis Amantadine or Rimantadine up to 48 hrs.
• Antiviral agents (Relenza, Tamiflu, Ribavirin)
• Antitussives for cough
• Most common complication=pneumonia

Inflammation of sinus mucous membranes

• S/S: moving head pain- worse in morning - lessens throughout day as sinuses drain
• HA / sinus tenderness /pain cheeks or teeth
• Fever
• Nasal congestion/discharge with N/V or bad breath
• Sinus x-rays opaque instead of translucent with air

• TX: Antibiotics x 10 days
• Decongestant sprays (Pseudoephedrine)
• Mucolytics like Guaifenesin to liquefy secretions
• Steam or saline nose drops
• Surgery- NS irrigation with 16 ga. Needle
• Endoscopic sinus surgery with drainage window/antrectomy
• Sphenoethmoidectomy esp. if polyps

• Nursing Care:
• Heath Promotion
• *prevent sinusitis by promoting nasal drainage
• -encourage increased fluid intake
• -us of nasal decongestants as needed

• *patient with URI blow nose with both nares open
• *saline spray can promote drainage and reduce risk of obstriction and infection

Postop Nursing Dx:

• Pain - assess pain, use analgesics as needed
• - apply ice packs to nose
• - Fowler's or high-Fowlers for 24 to 48 hours (elevation minimizes swelling and promotes comfort)

• Imbalanced Nutrition: Less than Body Requirements
• -clear liquid diet progressing to soft foods - ensure
• -monitor I & O and weight
• -Elevate HOB during meals

70% viral; 15-20% beta-hemolyticstreptococcal (strep throat), chlamydia,or gonorrhea

• S/S: If tonsils, then red or pus & edematous
• Sore throat/unable to swallow (dysphagia)
• Fever/malaise/myalgia (muscle pain)
• Enlarged lymph nodes

• TX: Antibiotics x 10 days (PCN, erythromycin) Anti-pyretics (not ASA if surgery) & analgesics
• Warm saline gargles or ice collar
• Needle aspiration (I&D) or tonsillectomy
• Complications are rheumatic fever or acute glomerulonephritis

• Epiglottitis
• H. influenza
• S/S: red, swollen epiglottis blocks airway, dysphagia,drooling, sore throat

TX: IV antibiotics,Decadron, freq.oximeters, maintainairway, No tongueblades

Laryngitis

Viral URI or stress voice

S/S: hoarseness oraphonia, sore throat,dry cough

TX: voice rest, avoid ETOH & tobacco,steam or warm gargles, antiseptic throat lozenges

• Nose Bleed
• Anterior - most common
• Posterior
• TX:
• -anterior -pressure on septum, ice packs, vasoconstrictors,
• nasal packing -nasal tampon or 0.25 inch petroleum gauze left in for 24 to 72 hours
• -posterior- nasal packing - left in for 2 to 5 days ,balloon catheter -inserted, inflated, left in place 2 to 3 days surgery - preferred to posterior packing - cauterize the vessel

• Nursing Care for Nasal Packing
• Monitor 0₂ sat
• VS
• Inspect mouth and oropharynx
• Elevate HOB
• Deep, slow breathing thourgh mouth
• Check for blood at back of mouth and frequent swallowing
• Cold compress to nose
• rest
• adequeate oral fluid intake
• frequent oral hygiene

S/S: black eyes/periorbital ecchymosis, crepitus,epistaxis, nose deformed, rhinorrhea for CSF

TX: maintain airway,ice for swelling,rhinoplasty or septoplasty coughing, straining

• Rhinoplasty - surgical reconstruction of nose
• postop care - nasal packing left in plase for up to 72 hrs
• -temp plastic splint molded to shape of nose is removed in 3 to 5 days

• -ice packs - comfort & reduce swelling
• - Elevate HOB
• - No blow nose for 48 hrs after packing removed
• - avoid vigorous coughing or straing at stool
• - clean teeth pfrequently
• -increase fluid intake
• -bruising around eyes and nose will last for several days

• Intermittent absence of air flow thru mouth/nose during sleep (tongue & soft palate block pharynx)
• Risk factors: males>females, middle age, obesity, largeneck size, ETOH or CNS depressants

• S/S: Diagnosis by sleep study (polysomnography, EEG) Loud, cyclic snoring with periods of apnea Choking/gasping/thrashing around during sleep
• Frequent awakening, insomnia, excessive daytime sleepiness, depression or impaired intellect
• Morning headaches (hypercapnia, vasodilation)

• TX: Wt. reduction & ETOH abstinence
• nCPAP=Nasal Continuous Positive Airway Pressure;nasal mask to prevent airway collapse
• BiPAP=Bilevel Positive Airway Pressure (higher pressure on inspiration, tolerated better)
• Surgery:tonsils/adenoids, uvulopalatropharyngoplasty

Machines dry mucous membrane - use in-line humidifier or room hymidifier

Benign Polyps (papillomas) – bilat. wart-like growths on vocal cords, HPV, hoarseness or breathy tone;

TX: corticosteroids to shrink or polypectomy

• Malignant Cancer of Larynx: (squamous cell)
• Risk factors: males>females; > 50 years old,tobacco, alcohol, exposure to chemicals, African Amer.

• S/S: Early detection important
• Painless growth in mouth
• Ulcer that does not heal/change in denture fit
• Hoarseness or change in voice
• Lump in neck
• Dyspnea and/or dysphagia
• Pain is a late symptom (sometimes earache)

DX: by biopsy (TNM grading)

Glottis/vocal cords – 60%, hoarseness or change in voice, well differentiated & slow growing with late metastasis as limited lymphatic supply

Supraglottis/false vocal cords – 35%,dysphagia, lump in throat, halitosis, early metastasis as rich lymphatic supply

Subglottis/below vocal cords – 5% asymptomatic til tumor obstructs airway

• Nurse can suggest interventions to reduce side effects:
• Dry mouth (xerostomia)
• -Medication to increase production of saliva (Salagen) pilocarpine hydrochloride
• -Squirt or water bottle
• -Increase fluid intake
• -Chewing sugarless gum or candy
• -Nonalcoholic mouth rinse
• -Artificial saliva
• -Avoid commercial mouthwashes and hot or spicy foods because they are irritating

Cordectomy-superficial tumor involving one cord; voice rest

Hemilaryngectomy-removal of one vocal cord part larynx; temporary tracheostomy-voice preserved but quality is breathy and hoarse

Total laryngectomy- perm. separate trachea &esophagus so no aspiration; stoma or trach

Radical neck-+ lymph nodes but no metastasis; tissue from mandible to clavicle so deformity

• -monitor airways and respiratory status
• -Encourage deep breath & cough
• -Elevate HOB
• -Humidification of inspired gasses
• -Adequate fluid intake
• -Suction using sterile technique
• -Trach care PRN
• -Teach to protect stoma from particles in air by cover with gauze or stoma protector
• -instruct to support head when moving in bed
• -call light in reach- answer call light promptly
• -Encourage family member presence
• -Spend time with pt

• Care should be taken not to dislodge during the first few days when stoma is not mature (healed)
• Replacement tube of equal or lesser size is kept at the bedside
• Tracheostomy ties are not changed for at least 24 hours after insertion
• First tube change is performed by the physician usually no sooner than 7 days
• Accidentally dislodged-replace it immediately.

• Tube should be changed approximately once a month
• When a tracheostomy has been in place for several months, the tract will be well formed
• Teach the patient to change the tube using clean technique at home

• Washed daily
• Scarf, crocheted shield to protect
• Plastic collar when bathing
• Swimming contraindicated
• Oral intake in dry weather
• Medic Alert bracelet
• Decreased smell and taste (smoke/carbon monoxide detectors should be used in home)

• -humidifier to add humidity to inspired air
• -increase fluid intake (moist mucosa)
• -remove secretions around stoma to prevent skin breakdown

• Assess need to suction
• Explain procedure to patient
• Check suction source (neg. 80-120 mm Hg)
• Sterile technique
• Preoxygenate (100% vent. or MRB, or 3-4 deep breaths) Insert without suction on
• Withdraw catheter in rotating manner applying pressure intermittently
• Limit suctioning to 10 seconds
• Re-oxygenate, repeat suctioning if needed

Acute inflammation of bronchi (v. COPD)

• S/S: paroxysms of cough (dry then productive)
• Pleuritic substernal chest pain
• Moderate fever
• General malaise

• TX: Broad spectrum antibiotic (50% bacterial)
• Increase fluids to thin secretions
• Antipyretics (ASA, Tylenol); analgesics
• Antitussive (Robitussin) esp. at night for rest
• Smoking cessation

• Acute inflammation of lung parenchyma (functioning part of the lung)
• Caused by:
• Bacteria
• Viruses
• Mycoplasma
• Fungi
• Parasites
• Chemicals (irritating gases or aspiration of gastric contents)

• The normal protective mechanisms of the respiratory system are unable to adequately protect against the affecting agent
• Antigen-antibody response with organisms releasing endotoxins that damage bronchial & alveolar membranes resulting in inflammation & edema

• ↓ Decreased Consciousness (depresses cough & epiglottal reflexes)
• Intubation(interferes with cough & normal mucus production)
• Air pollution / Smoking
• Viral URI (influenza, cytomegalovirus, adenovirus)
• Changes of Aging
• Chronic Diseases(leukemia, alcoholism, DM, COPD) Altered Oro-Pharyngeal Flora(secondary to antibiotic therapy)

• infectous
• noninfectous
• community acquired
• hospital acquired
• opportunistic

• Streptococcus Pneumoniae (#1) - 66% gram +
• Haemophilus Influenzae (#2)
• Mycoplasma Pneumoniae - "walking pneumonia"
• Respiratory viruses (Influenza)
• Chlamydia Pneumoniae
• Legionella Pneumophila

• Staphylococcus Aureus G(+)
• Pseudomonas Aeruginosa G(-) difficult to get out
• Klebsiella G(-)
• Escherichia coli (E-Coli) enteric G(-)

G(-) tend to be more damaging to lung fields due to acidotic pH

• Opportunistic Pneumonia due to altered immune system esp. HIV/AIDS
• Pneumocystis carinii
• Mycobacterium tuberculosis
• Cytomegalovirus (CMV)
• Fungi

• Lobar pneumonia - entire lobe- exudate in alveoli -consolidation of lung tissue occurs
• Bronchopneumonia - patchy consolodation- exudate in bronchi & bronchioles
• Interstitial pneumonia - inflammatory response in interstitum (CT)

Miliary pneumonia -immunocomprimised - inflammatory lesions as pathogen spreads to lungs via bloodstream

• Sudden onset
• Chills/fever
• Tachycardia & tachypnea
• Productive cough (purulent or rust-colored)
• Pleuritic chest pain (worse with coughing &deep resp.) Pulmonary consolidation
• Dullness of percussion
• ↑ fremitus
• Bronchial breath sounds - (abnormal in LL)
• Crackles/Rhonchi
• Elderly with fever, tachypnea &altered mentation (agitation)

• Mycoplasma Pneumoniae or Viral; “Walking” Pneumonia)
• -community acquired
• More gradual onset
• Dry hacking nonproductive cough
• Headache
• Myalgia (muscle aches)
• Sore throat (pharyngitis)
• Lack of alveolar exudate & consolidation

• Legionella Pneumophila
• Gradual onset (2-10 days after exposure)
• Fever/chills
• Dry cough
• Dyspnea
• Headache
• Muscle aches (myalgias & arthralgias)
• Anorexia & diarrhea
• VERY sick (high mortality)

• Aspiration of gastric contents into lung resulting in chemical & bacterial pneumonia
• Acid pH causes severe inflammatory response
• Pulmonary edema
• Respiratory failure
• Lung abscess/gangrene

• Sputum
• Gram Stain
• Culture & Sensitivity
• CBC (leukocytosis & shift left, immature)
• ABG’s with paO2 < 70 – 80% (hypoxemia)
• Pulse Oximeter < 95%
• Chest x-ray (fluid, atelectasis, consolidation)
• Bronchoscopy to remove sputum

• Atelectasis - collapsed or nonfunctioning portion
• Lung abscess/empyema - puss is lung
• Pleurisy/pleural effusion - pleural inflammation
• Pericarditis/endocarditis - inflammation of smooth muscle
• Meningitis - bacterial infection of meningies (covers brain)
• Peritonitis - inflammation of peritoneum
• Respiratory failure or ARDS

• vaccination recommended for
• -over age 65
• -those with cardiac, respiratory conditions, diabetes mellitus, alcoholism, other chronic diseases
• -immunocompromised

• Antibiotics
• Antipyretics
• Bronchodilators
• Steroids
• Oxygen therapy
• Chest physiotherapy - percussion & vibraton
• Fluids (3L/day)
• Expectorants/Mucomyst
• Immunizations for pneumococcal &influenza

• Push Fluids/monitor IV’s
• Monitor VS esp. respirations
• Provide humidified O2
• Postural Drainage - positioning to promote drainage
• Suction PRN
• Encourage Rest
• Administer Meds (antibiotics,bronchodilators)
• High Fowlers to present aspiration
• Check gag reflex
• Do not overmedicate with Narcotics

• Client Education
• Teach prevention
• Emphasize need to finish all meds
• Adequate rest
• Encourage vaccine
• Deep breathing exercises(X 6 wk after Hosp. Discharge)
• Return to M.D. if fever, SOB,dyspnea, sleepiness, confusion

uses gravity to facilitate removal of secretions from a particular lung segment

pt is positioned with the segment to be drained superior to or above th trachea or mainstream bronchus

required various positions

Broncodilators adminsitered prior to postural drainage

-perform before meals to avoid nausea & vomiting

• Broad spectrum antibiotic
• -macrolides
• -PCN
• -Cephalosporin (2nd or 3rd gen)
• -fluoroquinolone

• Bronchodilators
• -sympathomimetic drugs - albuterol
• -metaproterenol - alupent
• -methylxanthines - theophylline (needs blood test for toxicity)

• Liquify Secretions
• -acetylcysteine -Mucomyst
• -potassium iodide
• -guaifenesin (mucinex)

Chronic pulmonary and extrapulmonary infectious disease acquired by inhalation of a dried-droplet nucleus containing a tuberclebacillus

• Airborne - from a person who expels the organism while:talking,coughing,singing,sneezing
• TB Pathophysiology:
• Macrophages Tubercle
• granulomas Caseation
• necrosis Calcification
• fibrosisReactivation

Private room & HEPA filtered respirator

• Close contact
• IV drug users
• Alcoholics
• Living in crowded,substandard housing
• Immigrants from areas with high incidence
• Medically underserved
• Institutionalized
• Health care workers
• Immunocompromised
• Preexisting medicalconditions:diabetes, chronic renal failure, silicosis,malnourishment

• low grade fever
• fatigue
• anorexia
• weight loss
• night sweats
• chest pain
• persistent cough(purulent to bloodtinged/rusty)

PPD - purified protein derivitive of tuberculin - attracts macrophages to area - inflammatory response

results read in 48 to 72 hours & recorded as diameter of induration (raised area, not erythema)

<5mm Negative Response

• 5-9mm Negative for most people but pos for ppl
• - - in close contact with infective TB
• - - abnormal CXR
• - - HIV
• - - organ transplant

• 10 - 15mm Negative for most - pos for ppl
• - -birth in high-incidence country
• - - African Am, Hispanic, Asian
• - - Injected drug use
• - - residence of care facilities

> 15mm - positive for all ppl

• (MIN. 6 MONS.)
• Prophilactic - INH can be used alone (min 6 mo)
• Active infection - concurrent use of at least to antibiotics

• INH/Isoniazid - used prophilactally -use vit B₆ & monitor liver function
• -peripheral neuropathy
• -hepatitis
• Rifampin - dont skip doses - contact lenses should not be worn (will be discolored)
• -heptitis
• -color body fluids orange-red

• Pyrazinamide (PZA) - monitor uric acid levels & avoid other hepatotoxins ASA & ETOH
• -Hyperuricemia
• -Hepatotoxicity

• Ethambutol (EMB) - monitor visual acuity
• -optic neuritis

• Streptomycin - autiometric examination & monitor renal function (BUN & CRE)
• -ototoxicity, vertigo
• -nephrotoxicity
• Calmette-Guerin (BCG) vaccine =3rd world countries to reduce symptoms of TB - PPD will be positive - CXR to rule out

• Smoking
• *80-90% of lung CA due to smoking
• *Causes changes in bronchial epithelium
• *More men then women
• *More African Americans/Blacks
• *Cigs contain 43 known carcinogens
• *Dose response relationship

• Age > 50 years
• Ionizing Radiation
• Inhaled Irritants (asbestos, radon, nickel,iron, uranium, hydrocarbons, arsenic, &air pollution)
• Genetic predisposition

• Early Signs & Symptoms
• Usually non-specific & occur late after metastasis Chronic cough
• Chest pain
• SOB
• Wheezing
• Hemoptysis

• Later S & S
• Anorexia
• Wt. loss
• Fatigue
• N & V
• Hoarseness
• Dysphagia

• Very Late S & S
• Mediastinal involvement
• Bone metastasis
• Brain metastasis
• Liver metastasis
• Neuromuscular

• Ineffective breathing pattern R/T hypo or hyperventilation.
• Ineffective Airway Clearance R/T accumulation of secretions.
• Impaired Gas Exchange
• Altered Tissue Perfusion R/T Hypoxemia
• Activity Intolerance/Fatigue R/T Hypoxemia, COPD
• Acute pain R/T Inflammation or Chronic Pain R/T Lung Cancer
• Risk for Infection R/T Spread of TB
• Knowledge Deficit R/T TB Medications
• Fear/Anxiety R/T Suffocation and Inability to Breath
• Ineffective Therapeutic Regimen Management R/T TB Medications
• Decisional Conflict R/T Smoking
• Hyperthermia R/T Pneumonia
• Anticipatory Grieving R/T Cancer DX.
• Compromised Individual or Family Coping R/T Role Relationship Changes
• Imbalanced Nutrition, Less than Required
• Low self esteem R/T Interstitial Pulmonary

• closed drainage system
• -monitor q hour, then q 2 to 4 or 8 hrs as indicated

Notify healthcare porvider if chest tube output exceeds 70 mL / hour or is bright red, warm, and free flowing (indicates intrathoradcic hemorrhage)

• Chemotherapy (combination chemo esp. small cell due to rapid growth of lung CA & dissemination)
• Radiation (cure vs. palliative)
• Surgical Intervention (small cell usually metastasized – no surgery) - non-small cell - surgery only real chance for cure
• Pain management

• Chronic inflammatory disorder with obstruction of airways and episodes of wheezing, SOB, tight chest, & coughing
• 11 million asthma attacks per yr. in US
• Increased since 1980s & now stable

• ANA controls smooth muscles of airway
• Parasympathetic/cholinergic-bronchoconstrict Sympathetic/beta adrenergic-bronchodilate

• Early Phase: stimulus/trigger causes release of chemical mediators (histamine, prostaglandins,& leukotrienes) Increase parasympathetic system causing bronchoconstriction & spasm
• Increase capillary permeability with edema & mucusproduction

Late Phase: 4-12 hrs. after trigger, basophils & eosinophils activated with increased bronchoconstriction, air trapping and decreased oxygen exchange resulting in resp. alkalosis

• Chest tightness
• Wheezing,
• Dyspnea
• Cough / cough-variant asthma
• Nasal flaring
• Tachypnea with prolonged expiration
• Tachycardia
• Use of accessory muscles & intercostal retractions Restless, anxiety/feeling of suffocation

Signs of Impending Respiratory Failure

Decreased Breath Sounds Decreased wheezing

• Pulmonary Function Tests before & after bronchodilator therapy
• Increased residual volume (RV)
• Decreased vital capacity (VC)

Bronchial Provocation

• ABG’s –Early resp. alkalosis due to hyperventilation & use of accessory muscles
• Later resp. acidosis due to exhaustion & hypoventilation

Skin Testing to ID specific allergens

• Peak Expiratory Flow Rate (PEFR) meter
• green 80-100%
• Yellow 50 -80 %
• Red <50 %

• Bronchodilators (used for acute asthma - stimulate sympathetic receptor & cause smooth mucle relaxation)
• Sympathomimetics
• *Epinephrine; Isuprel
• *Metered-Dose Inhalers (Salmeterol, Albuterol) *Terbutaline (Brethine)
• Xanthine Derivatives
• *Aminophylline IV
• *Theophylline PO
• Anticholinergics (Atropine, Combivent)

• Anti-inflammatory agents (prevent & treat acute episodes- decrease release of inflammatory mediators so decrease inflammatory response and airway edema)
• Corticosteroids (Decadron, Azmacort, AeroBid)
• Mast cell stabilizers (Nasalcrom/Cromolyn &Nedocromil)

• Leukotriene modifiers (blocks effects leukotrienes (bronchoconstrictors) which participate in inflammatory respnse )
• (Accolate, Zyflo, Singulair)maintenance & not acute attack; hepatotoxic