Mod 1. Lect 3. Lower Respiratory Disorders: Atelectasis Pneumonia Tuberculosis Smoking Cessation
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**Structures of the Lower Respiratory System
-Trachea biforcates into the lungs, 2 lobes on LEFT and 3 on RIght b/c of <3-Most common intubation misplacement is going into the right lung (little bit straighter), should stop at fork of trachea.
Collapse or airless condition of the alveoli: Caused by decreased respiratory effort (they just got out of surgery, sedatives on board), decreased surfactant (material that allows lung to expand more), bronchial obstruction, or external pulmonary pressure (around the lungs-pneumothorax in pleural region)
=>Risk Factors: Surgery, anesthesia, immobility, advanced age, lung disease, obesity
=>Clinical Manifestations: Decreased or absent breath sounds, cough, s/s hypoxia
=>Diagnosis by CXR (white, or little infiltrates, opageness is positive for atelectasis and increased secretions that shouldn't be in the lungs.)
**Prevention and Treatment of Atelectasis
- 1.Frequent turning, Early mobilization afater surgery especially
- 2. Strategies to improve ventilation
- -Deep-breathing exercises at least every 2 hours
- -Incentive spirometer
- -Pain control (with prevention of respiratory depression)-splinting pillow gives extra support to alow them to cough and take deep breaths.
- 3. Strategies to remove secretions
- -Coughing exercises
- -Aerosol therapy: mucolytics (medications that break down mucous) or brochodilators ( given by RT)
- -Chest physiotherapy: basically mechanical way to drive secretions up and out of lungs (later in lecture)
Device ensures that a volume of air is inhaled and the patient takes moderately slow, deep breaths. Used to prevent or treat atelectasis-TCDB while using IS is most efficient
=>Nursing considerationsPosition patient properlyProvide teaching Record results
**Additional Treatment Options
PEEP/CPAP: pressure to keep the alveoli open.
Peep: be careful! can rupture the alveoli with too much pressure.
- -both use positive pressure.
- -CPAP trial with mechanical ventillator (uses spontaneous breathing + extra pressure at the end of their breath to keep atelectis from forming)
- -Can be applied mostly through ET tube or sometimes nasal cannula
- =>Bronchoscopy: done to remove secretions/obstructions
- Oxygen therapy to keep SaO2> 90% (to prevent hypoxia)
**Nursing Considerations: Bronchoscopy
- NPO 4-6 hours priorAssess for allergies
- IV site
- Informed consent obtained
- Baseline VS, respiratory assessment
- Address anxiety, knowledge deficit
- Monitor VS, comfort, respiratory status
- High Fowler’s position
- O2 therapy as needed
- Keep NPO until anesthesia has worn off
- Monitor for complications: bleeding, pneumothorax.
Your patient is post op day #2 for Total Hip Replacement. The morning SaO2 was 90%, on RA. What is your first intervention?
1. Place the patient in high fowlers and recheck the pulse ox.
2. Have the patient use the IS and record level.
3. Have the patient cough and deep breath 2-4 times.
4. Immediately start O2 at 2L via NC.
3. Have the patient cough and deep breath 2-4 times. (THIS. First intervention if they're already in High Fowler's.)
-ways organisms reach the lungs
- Acute inflammation of lung tissue-can be bacterial or viral. People under 4 yrs and OVER 65: highest incidence of death from pneumonia.
- More likely to occur when defense mechanisms are incompetent or overwhelmed; Risk factors include Alt LOC, aging, pollution, immobility, chronic diseases, immunosuppression, enteral feedings (due to aspiration risk), malnutrition, smoking, tracheal intubation, SNF (skilled nursing facility) residency
- -aids: opportunistic pneumonia.
- =>Organisms reach lung by one of three methods
- Aspiration-normal flora in oro/nasopharynix, and if they swalloed that bacteria, the could get pneumonia (many organisms that cause pneumonia are normal inhabitants of the pharynx in healthy adults)
- Inhalation- just microbes in the air, people coughing.
- Hematogenous spread-wound gone septic-> bacteria in bloodstream -> goes into the lungs /:
Diagnostics for Pneumonia
History Physical examinationChest x-rayGram stain of sputumSputum culture and sensitivity Pulse oximetry or ABGsCBC, differential, chemistriesBlood cultures
CAP (community acquired pneumonia)
- -acute infection of the lung occuring in pts who have NOT been hospitalized or resided in a LTC within 14 days of the onset of symptoms.
- -Empiric antibiotic therapy (initiation of treatment before a definite diagnosis)
- -sixth leading cause of death for people over 65 years or older. ):
- Onset in the community or within 2 days of hospitalization (so you know it started not while they were in the hospital)
- Pneumococcal most common
- 1/3 cases viral
HAP (hospital acquired)
Onset 48 hours AFTER hospitalization
Pseudomonas, enterobacter, e. coli, Staph (b/c most prevalent in hospitals)
-ventilator associated pneumonia (48 hrs after ET intubation)
HCAP (Hospital and Community acquired pneumonia)
Previous hospitalization( people in long term care, previous antibiotics maybe developed resistiances--worried about MRSA or VRE), SNF, previous IV ABX, chemo, wound care
MDR concern (multiple drug resistance b/c they've had previous antibiotics)
- -New onset pneumonia in a ation who
- (1) was hospitalized in an acute care hospital for 2 days or longer within 90 days of the infection;
- (2) resided in a LTC facitiy,
- (3) Reveived IV antibiotic therapy/chemo/wound care w/in 30 days of current infecion or
- (4) attended a hospital or hemodialysis cliinic.
-occurs from abnormal entry of material from mouth or stomach into the trachea and lungs
-decreased LOC (seizure, stroke, alcohol intake), difficulty swalowing, NG tube increae risk due to decreased gag/cough reflexes
-aspirtated material triggers an imflammatory response; prmiary bacterial infection
-aspiration of acidic gastric contents causes chemical (noninfectious pneumonitis which may not require antiboitc theraypy BUT secondary bacterial infection can occur 48-72 hours later.
Due to food, water, vomitus, oral content
In immunocomprosed patients (HIV, chemotherapy also)
-PCP (pneumo cytis pneumonia)- P. Jiroveci pneumonia rarely occurs in health; HIV mostly; chest xray shows consolidations; treatment: trimethoprim/sulfamethoaxazo.e (bactrim/spetra)
-CMV (cytomegavirus--extremely common in population but dangerous if you're immunosuppressed)-herpes virus can cause viral pneumonia
-Transplant pts that take immunosuppresants.
**Prevention of Pneumonia
- Good hygiene and infection control
- Adequate rest, nutrition, and hydration
- Avoidance of tobacco
- Pneumococcal and influenza vaccines (especially for pts over 65, must be revaccinated Q5Years)
=> Atelectasis prevention and treatment (because atelectasis may Lead to pneumonia)
- Early mobilization TCDB at least every 2 hours
- Pain control
- => Aspiration prevention
- HOB 30 degrees for all patients. (unless contraindicated-orthopedics spinal cautions)
- Oral care at least q2 hours (important for intubated pts in ICU, tend to get all those secretions in their mouth so they have antimicrobial swab Q2H)
- Check gastric residuals (if too much, then they're not digesting they're feedings and it'll build up), placement w/ enteral feedings
- => More aggressive collaborative prevention measures as necessary
- Suctioning Aerosol therapy
- Chest physiotherapy
**Pathophysiology of Pneumonia (FOUR STAGES)
1. Congestion: inflammatory response secondary to organisms. Fluid in lungs impairs gas exchange.
2. Red hepatization: capillary dilation occurs and alveoli fill with organisms, WBCs, RBCs, fibrin. (body's reaction to get all the cells their to combat infection)
3. Gray hepatization: blood flow decreases and consolidation occurs. (decreased circulation; typical of bacterial pneumonia, occurs when normally air filled alveoli become filled with fluid and debri); mucous production
4. Resolution: exudate is lysed and normal lung tissue restored. (Macrophages in alveoli ingest and remove debris, Normal lung tissue restored, gas exchange returns to normal)
**Pneumonia: Clinical Manifestations
- Fever, chills, shaking, SOB, productive or not cough, pleuritic chest pain
- S/S of hypoxia (irritability or alt LOC)
- Decreased breath sounds, crackles, dullness to percussion
- Physical Examination findings: Dullness to percussion, Increased Fremitus, Bronchial Breath Sounds, Crackles, Hypoxemia
- Atypically with a more gradual onset , dry cough, extrapulmonary manifestations
- Consolidation or pulmonary infiltrates on CXR (whites on xray)
Leukocytosis (high WBC count)-sputum or gram stains: ideal but not typically done unless someone's not responding to therapy (can appear green, yellow or even rust colored)
- FOR ACUTELY ILL: Get Blood cultures, ABGs, serial CBC's-complications: pleurisy, (relatively common), atelectasis (collapsed alveoli), Becteremia (infecion in blood), Lung abscess, Pericarditis (Infected pleura), Meningitis, Sepsis, Acute Respiratory Failure and Pnemothorax (air collects in the pleura space resulting in collapse. )
**During the assessment of a patient with pneumonia, the nurse suspects the development of a pleural effusion upon finding:
A barrel chest
hyperresonance on percussion
localized absence of breath sounds
A barrel chest
hyperresonance on percussion (this is normal, when tapping over air filled space-which is good!)
localized absence of breath sounds (THIS!- may be due to consolidation so decreased air moving through pneumonia area, or inflammation)
**Pneumonia: Collaborative Care
Outpatient vs. inpatient treatment (hospital vs community acquired)
=> Discharge Teaching
- =>Empiric Antibiotic therapy
- A. CAP
- Outpatient- macrolide or doxycycline; respiratory fluoroquionolone (Levoquin); beta lactams plus macrolide'
- Inpatient- respiratory fluroquinolone or beta lactam plus macrolide-Azithromycin/Erythromycin (these are macrolides) if no resp disease or recent antibiotics, and Doxycliclin IF allergic to macrolides :)
- B. HAP/HCAP
- Depends on likely organisms and pattern of drug resistance (need to get cultures, look at residence, age, other medical conditions, alt LOC, dehydrdation, resp distress, fluid in pleural spaces)-if hospitalized: three days of IV antibiotics -> orals to go home to finish therapy.*antibiotic selection is what Joint Cmmision looks at when treating pneumonia.
- => Collaborative Care Supportive
- Oxygen Adjunct medications: medications that SUPRRESS cough reflex (robutussin) is BAD idea because you want to assist to cough the secretions OUT.
- -O2 therapy for hypoxia, analgesics (chest pain), antipyrecitcs like aspirin/tylenol for temp.
- -Mucinex maybe to break out mucus.
- -antihistamines must used with caution: can thicken mucous and diff to cough upIS, TCDB
- -pt mobility improved diaphragm movement, chest expansion.
- -NO definifitive treatment for viral pneumonias. Generally supportive care.
- => Discharge Teaching
- Drink plenty of liquids
- OTC meds for pain, fever
- Finish entire course of antibiotics
- Avoid tobacco productscool mis humidifier or warm bathsfollw up chest xray in 6-8 weeks.
Complications of Pneumonia:
Acute Respiratory Failure
Pleurisy: Inflammation of the pleura
Pleural Effusion: Fluid in the pleural space,can occur. In most cases the effusion is sterile and is reabsorbed in 1-2 weeks. Occasionally, effusions require aspiration by thoracentesis
Atelectasis: Collapsed, airless alveoli. One or part of one lobe may occur. These areas usually clear with effective TCDB
Bacteremia: Bacterial infection in the blood. More likely to occur in infections with streptococcus pneumoniae and Haemophilus influenzae
Lung Abscess: not common complication of penumonia, but caused by S. aureus and gram negative organizms.
Emphyema: the accumulation of purulent exudate in the pleural cavity. Occurs in less than 5% of cases and requires antibiotic therapy and drainage of the exdate by a chest tube or open surgical drainage.
Pericarditis: Results from spread of the infecting organsim from infected pleura or via a hematogenous route to the pericardium
Meningitis: Can be caused by S. Pneumoniae. THe patient with pneumonia who is disoriented, confused or drowsy may have a lumbar puncture to evaluate the possiblity of meningitis.
Sepsis: Can occur when bacteria within alveoli enter the bloodstream. Severe sepsis can lead to shock and multisystem organ dysfunction syndrome (MODS)
Acute Respiratory Failure: one of the leading causes of death in patients with severe pneumonia. Failure occurs withen pneumonia damages the lung's ability to exchange oxygen for carbon dioxide.
Pneumothorax: Can occur when air collects in the pleura space, causing the lungs to collapse.
**A 56-year-old normally healthy patient at the clinic is diagnosed with community-acquired pneumonia. Before treatment is prescribed, the nurse asks the patient about an allergy to
Azithromycin (THIS: because it's a macrolide!)
**Nursing Process: Pneumonia & ND's
- Respiratory system
- Mental status
- Trends in:CXR, CBCs, ABGs (abrupt change or where they "live".
- Complications: Pleural effusion, progressive dyspnea, "pleurisy" sharp pain with inspiration, decreased chest wall movement on affected, shallow breathing and efflueral friction rub (stethoscope) and atelectasis.s/s that they're responding to therapy: decreased fever, reduced respirations, chest pain, improved reading, WBCs going down to normal level, older: increased activity
- **Nursing Process: Pneumonia (Diagnosis)
- => Ineffective Airway clearance
- => Activity Tolerance
- => Risk for Flluid Volume Deficit: bad with CHF.
- => Risk for imbalanced Nutrition: won't heal well w/o good nutrion, weight.
- => Knowledge deficit regarding POC and complications to report
**Core Measures: Pneumonia
- Average time to first antibiotic dose (initial antibiotic is to be received within 6 hours of hospital arrival).
- Pneumococcal screening and/or vaccination for all patients. (ask them if they've had they're flu vaccines!)
- Smoking cessation counseling for all patients that smoke. (those who smoke or have quit in their last year.)
- Blood culture drawn before initial antibiotic administered for patients diagnosed or suspected of having pneumonia.
- Infection disease Caused by Mycobacterium tuberculosis: SPREAD AIRBORN: NEG PRESSURE ROOMS (SUCK AIR IN)
- -More in the moor, minorities, foreign people, LTC, prisons, hospitals, drug users
- 1/3 of world’s population is infected
- =>Rates in the US have declined since 1992 resurgence peak:
- 2/3 cases occur in foreign-born persons
- Significant cause of death in HIV-infected persons'
=> MDR-TB of concern: once a strain of M. Tuberculosis develops resistance to two of the most potent first-line antituberculous drugs (Isoniazid and rifampin) then defined as multidrug resistant tuberculosis.
- => Risk of transmission increased by close, frequent, prolonged contact and decreased immunity of exposed person; international travels are concern.
- -mostly alcoholics, repeated exposures (cops, Health care peeps),
- -we wear N95 mask. Pts wear simple mask.
- -bacteria ccan be dormant but won't be activated untill stressed.
- -Not contact, just airborne.WE CANT TAKE AIRBORN PTS
-Mycobacterium TB is slow growing.
LTBI: occurs when people carry mycobacterium bacilli dormantly, controlledy by body immune system (no tb symptoms, not infectious, seens as neg on tb test) BUT Tuberculin SKin Test (mantu test)
Mantu-intrademal purified protein derivative (ppd) injected (miexed protein derived from dead tb cultures); immune reaction occurs 48-72 hours with two pt visits and measured the induration (>5mm is positive, bump)
-BCG vaccine. Immunized against TB in other counties but these people can never recieve ppd because no matter what, they will always react to the antigen.
**Pathogenesis of Pulmonary TB
- Gram positive, acid fast bacillus spread via airborne droplets (microbio-acid fast tests
- -test for positivity in hospital patients, need THREE AFB (acid fast bacillus) tests (morning, sputum, one per day. If all negative=No TB infection, don't need negative isolation.
- -airborne prcautions
- => Inhaled tubercle bacilli travel to alveoli and multiply (NOT highly infection, just requires close, frequent or prlonged exposure; can't be spread by kissing, or physical contact)
- -LATENT TB: Tubercles are ingested by alveolar macrophages. The cells form a barrier shell called a granuloma that contain the infection (Latent TB): bacteria encapsulated in lungs-hard to treat because less bloodflow. Doesn't show on CXR but shows on ppds.
- - ACTIVE TB: If immune system cannot contain tubercles, then bacilli can multiply rapidly becoming active (Active TB)
- -start in various places, like spinal, nervous system but usually in lungs.
- -Tubercle bacilli may enter bloodstream and develop extrapulmonary disease (larynx, lymph, kidneys, brain, bone)
- -MILIARY TB: Widely disseminated TB is rare but serious (miliary TB): bacteria spread via bloodstream to distant organs, the infection may be fatal.
**Primary Infection (TB)
when bacteria are inhaled and intiate an inflammatory reaction. The majority of people mount effective immune responses oto encapsulate these organisms for the rest of tehir lives, preventing primary infection from progressing to disease.
**Latent TB Infection (LTBI)
Occurs in a person who not not have active TB disease, they are asymptomatic and cannot transit the TB to others. Treatment of LTBI is still important. If initial immune response is not adequate, the active TB disease results.
-Doesn't feel sick, Normal chest xray and a negative spuum smear, BUT SKIN TEST INDICATES. Still needs treatment for Laten TB infection to prevent active TB disease.
**TB Clinical Manifestations: Subjective vs. Objective
- => Subjective
- History of TB exposure
- => Objective (observed)
- Weight loss --no appetite.
- Low grade fevers (common)
- Night sweats
- Frequent, productive cough
- Dyspnea, hemoptysis w/ advanced cases (late signs including pleural effusion)
- Infiltrates on CXR
**TB Diagnosis: PPD
- => Tuberculin Skin testing (PPD):
- -Induration (not redness) at the injection site means the person has been exposed to TB and has developed antibodies. Interpretation depends on measurement and person’s risk factors (read 48-72 hours later)-Immunosuppressed: (HIV)
- - >5 mm as positive.
- -Normal: >15 for general Immigrant with country where TB is prevalent: <4mm Induration to be positive
- -Drug abuser: >10 mm is specific.
=> Xray: not possible to diagnose soley on xray finding (due to other possible disease)
**Quantiferon-TB (QFT)/ T spot blood serum test:
*GOLD STANDARD to test for TB* Very expensive but diffinitive. Good for people who have had vaccines: do they have active infection or not?
Immune response of patient’s blood exposed to mycobacterial antigens measured
- May be preferred for people who have poor rates of return for TST testing or who have BCG vaccine
- =>Sputum Culture (AFB)
Three consecutive samples from different days
May take up to 8 weeks as tubercle bacillus grows slowly
**Latent vs. Active TB
- =>Latent TB
- Positive skin or blood test BUT Usually normal CXR
- Negative sputum test
- Does not feel sick
- Cannot transmit TB
- Needs treatment to prevent disease
- =>Active TB disease
- Positive skin/blood test
- Abnormal CXR
- Positive sputum culture/smear
- Needs treatment for TB disease
**The nurse interprets an induration of 5 mm resulting from tuberculin skin testing as a positive finding in:
1. patients at low risk for TB.
2. a patient with a 5-year history of human immunodeficiency virus (HIV) infection.
3. immigrants arriving within the past 5 years from high-prevalence countries.
4. individuals with chronic clinical conditions such as diabetes, cancer, or end-stage renal disease.
2. a patient with a 5-year history of human immunodeficiency virus (HIV) infection. (Positive enough for HIV)
**Collaborative Care of TB
-Drug Therapy for active TB without HIV infection
- Notification to the public health department for all TB cases.
- Consider screening for HIV (difficulty to treat due to so many different drug medications, increased ddrug toxiciity due to decreased renal function)
- Most patients treated on an outpatient basis (outpatient should stay home 2-3 weeks, limit contacts, dispose of tissues and good hand hygiene)
- Drug Therapy for active TB without HIV infection
- -Induction Phase (2 months): 4 drugs: INH, RIF, PZA, EMB or SM
- -Continuation Phase (4-7 months): INH, RIFLatent TB treated with INH ONLY(6-9 months)
- Monthly LFTs, monitoring of adherence and response to treatment
- -NEED TWO negative AFB cultures, clinical improvement and chest xray cleared.
**TB: Patient Education- Side Effects (ACTIVE TREAMTMENTS)
- Hepatotoxicity-monthly LFT's-SE: hepatitis: elevation of antnotrasferases (ALT and AST)
- Peripheral neuropathy: deplets B6 vitamin in body-> numbness/tingling in fingers/toes so tell them to take more B6 supplements.
- -ONLY MED USED FOR LATENT)
- =>Rifampin (INH)
- GI upset
- HepatotoxicityFlu-like symptoms
- Body fluids may turn orange-red; contact lenses may be stained perm orange.
- -LATENT: for 9 months.
- monitor for pain in big toe
- =>Ethambutol (Myambutol)
Optic neuritis: monthly eye exams (inflammation of optic nerve)
- Hearing/balance changes and renal toxicity
- -check trough or peak-Dysrrhythmias.
** TB Nursing Considerations
- =>Inpatient management requires isolation with airborne precautions
- Private room w/ negative air pressure
- Use of HEPA masks
- Patient should wear mask when out of room
- Reinforce importance of handwashing
=>DOT for high risk patients (homeless pts- Direct Observation Therapy-Public health nurse go to that persion every single day, and watch them take the pills every single day o:)
=>Vitamin B6 supplementation
- =>Patient teaching
- Side effects of meds
- S/S of TB recurrence/reactivation.
- -avoid alcohol with thiese meds for renal function
**Smoking National problem: & Cessation
- nicotine is a vasoconstrictpr!Single most preventable cause of death in the United States
- Cigarette smoking begins during adolescence
- Addictive behavior
- Smoking prevention: School and community programs
- Smoking cessation: Identify and target current smokers
- => Cessation
- http://www.smoking-cessation.org/index.aspSet a day to quitAvoid situations where people smokeMonitor caffeine intake
- Alcohol consumption may weaken your will power
- Find support in family and friends
- Use approved Nicotine Replacement Systems: Patch, gum, nasal spray, inhaler
- Pharmacology: Wellbutrin (aka Zyban), Chantix (antidepressants but helsp with quitting smoking)
- Hypnosis, Acupuncture/acupressure
Lower Resp Infection/Inflammation of the bronchi; 90% acute bronchial
-Cough lasts up to 3 weeks, clear mucoid sputum usually.
Assess for consolidation: egophony, fremitus, rales-suggestive of pneumonia and not part of bronchitus. (Consolidation: fluid accumulation in lungs, causing lung tissue to become stiff and unable to exchange gases.)
highly contagious infection by gram negative baccillus (Bordetella pertussin); treatment usually macrolides (ertythromycin), don't use cough suppressants b/c ineffective nor are corticosteroids/bronchodilators.
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