Respiratory Disorders: Epistaxis

Respiratory Disorders

Epistaxis (nosebleed)

• Risk factors for epistaxis include trauma (surgery), low humidity, infection, allergies, overuse of decongestant sprays, tumors, and medications that affect bleeding, such as aspirin, NSAIDs, and warfarin.
• Anterior nosebleeds are most common, easy to visualize, and usually stop with self-treatment, this is not as concerning as posterior.
• Posterior nosebleeds are closer to the throat and harder to assess for the amount of blood loss, may need medical intervention and can cause concern for aspiration of blood into the lungs.
• Initial treatment for epistaxis involves applying pressure while tilting the head forward.
• Secondary treatment options include cauterizing the capillaries, applying internal pressure, or using gauze/balloons.
• Focus assessment includes respiratory status (RR, O2 saturation, any dyspnea), neuro status (LOC, decreased oxygenation), VS (BP), and swallowing (any dysphagia, aspiration drooling).
• Expected outcomes include controlled bleeding.
• Patient education focuses on the cause (humidification, stopping nasal sprays, treating infection) and avoiding NSAIDs, aspirin, and vigorous nose-blowing.

Tuberculosis

• Social determinants of health that may lead to tuberculosis include homelessness, poor neighborhoods, close proximity living (long-term care, prisons, shelters, hospitals), IV drug users, and poor access to care.
• Mycobacterium tuberculosis most frequently causes a pulmonary problem, but can also affect the kidneys, bones, meninges, and other tissues.
• Passive tuberculosis spreads easier.
• Latent tuberculosis resides in the lungs and remains dormant until it arises during immunocompromised states.
• Nursing assessment findings include slow onset of symptoms 2-3 weeks after exposure, a dry cough that becomes productive, night sweats, fever, weight loss, fatigue, malaise, pleuritic chest pain, crackles, dyspnea, and hemoptysis.
• Nursing interventions: airborne isolation (single room, negative pressure, N-95 masks/HEPA), appropriate drug therapy (4-drug combo therapy for at least 2 months), teaching to prevent spread (cover cough/sneeze, wash hands, patient wears mask outside of neg pressure room, is infectious for 2 weeks after starting treatment), identifying and screening close contacts.
• To discontinue airborne isolation there must be 3 negative sputum tests on 3 different days.
• A fluorochrome or acid-fast bacilli sputum test is negative under normal circumstances.
• If positive, three samples obtained on three different days indicated mycobacterium tuberculosis.
• A tuberculin skin test (Mantoux) is read 48-72 hours post initial testing, less than 15mm iduration is normal.
• A positive result with high risk individuals is greater than 10mm.
• A positive result with immunocompromised patients is greater than 5mm, you are considered positive.
• An interferon-Y release assay (blood test)(IGRA) comes back negative under normal conditions.
• A positive test indicates the presence of INF-Gamma release from T cells.
• A chest x-ray shows normal lung structures.
• A positive result may indicate active tuberculosis or old lesions.

Pneumonia

• Community acquired pneumonia is diagnosed < 48 hrs of being hospitalized.
• Hospital acquired pneumonia is diagnosed > 48 hours of being hospitalized. Including Ventilator Associated Pneumonia (VAP/VAE) which is diagnosed when on vent for > 48hrs. Routine oral care significantly decreases risk of HAP/VAP
• Aspiration pneumonia can occur with CAP or HAP when oral/gastric contents enter lower airway.
• Risk factors for aspiration pneumonia: impaired gag reflex, swallowing problems, intubation.
• Clinical presentations of pneumonia may be cough, fever, chills, tachycardia, pleuritic chest pain, green/yellow sputum, change in LOC, diaphoresis, headache, myalgias, fatigue, and dyspnea.
• On respiratory assessment there may be Rhonchi or crackles, bronchial breath sounds, increased fremitus, egophony, dyspnea, change in O2 saturation, and decreased O2 saturation with activity.
• Treatment interventions: antibiotics, antivirals, oxygen, antipyretics, analgesics, hydration, and activity with frequent rests.
• Preventative measures: Keep HOB @ least 30, assist with eating, assess gag reflex, monitor gastric residuals if NG present, mobilize, cough, deep breathe, IS, and oral hygiene.
• Diagnostic tests: CXR, CBC with differential, Bronchoscopy/bronchoalveolar lavage.

Bronchoscopy

• A bronchoscopy provides direct visualization of the bronchi.
• Indications include diagnostic procedures, obtaining a biopsy or specimens, and treatment for foreign body removal
• Nursing interventions: place the patient in fowlers or semi-fowlers position, remain NPO until gag reflex returns and monitor VS during conscious sedation.
• Expected outcomes include blood-tinged mucus and that adequate VS is maintained. An unexpected outcome is a new or worsened dyspnea, SOB, tachycardia, decreased sat.

Pleural Effusion

• Pleural effusion is an abnormal amount of fluid in the pleural space.
• Transudative pleural effusion (watery fluid) can be caused by heart failure, pulmonary embolism, cirrhosis, and surgery.
• Exudative pleural effusion (protein-rich fluid) can be caused by pneumonia, cancer, pulmonary embolism, kidney disease, and inflammatory diseases. Diuretics are administered if due to heart failure.
• Other treatment methods: Chemotherapy, radiation, or medications are necessary for malignancies.
• A thoracentesis must be done to drain fluid.
• At most 1-1.2 L should be removed at one time due to the risk of (hypotension, hypoxemia).
• Assessment findings include dyspnea, cough, non-radiating chest pain that worsens on inhalation, decreased movement of the chest, dullness to percussion, and diminished breath sounds over the affected area.
• Tests that can be used to diagnose Pleural Effusion: Chest X-Ray, CT Scan, Ultrasound and Thoracentesis w/ fluid anylisis

Thoracentesis

• A percutaneous insertion of a large bore needle through the chest wall into the pleural space.
• Indications include obtaining a specimen and a procedure to remove of fluid.
• Nursing Interventions: position the pt sitting up, leaning over table.
• Prepare local anesthetic.
• Prepare for Chest Tube insertion.
• Expected outcomes include maintaining VS, and Oxygenation and to improve the condition.
• Unexpected outcomes include decreased O2 saturation, bleeding, decreased BP and increased HR.

Pulmonary Embolism

• Clots lodge in the pulmonary circulation
• Causes an imability for the lungs to oxygenate and ventilate.
• Risk Factors include immobility, recent surgery or history of DVT.
• Can also be caused by cancer (possible change in blood clottting), Obesity, or the use of Oral Contraceptives (hormones).
• In addition Smoking, Prolonged air travel, or pregnancy put pt's at risk or clotting disorders

Diagnostic Tests

• An ABG that displays a PaO2 <80 PaCo2 <35 and a SaO2 <95% may indicate a PE. This also indicated poor gas exchange and/or shunting leads to hypoxemia and hypercapnia due to an increased RR.
• A High-Resolution, multi detector, Computed tomographic angiography (CT-angio, sprial CT) can obstruct blood flow and can detect clots. It is a gold standard of diagnostics for this disease but uses contract dye which can be harmful to the kidneys.

Interventions / Teaching

• Nursing inverventions include evaluating possible Chest Pain and focused assessment to rule out any signs of illness. It may include Respiratory Rate, O2 Sauration, and ABG's
• Anticoagulation Medication like IV Heprin or Warfrin (short term) are beneficial to stop clotting or bleeding.
• Education includes a decrease of risk factors and avoiding smoking with other birth control alternatives. Pts should always follow up with healthcare providers and watch symptoms.

Asthma

• Key feature of asthma is inflammation of the airways.
• Asthma is defined as a recurrent wheezing.
• Most commonly triggered by allergen (dust mites, cockroaches & cats).
• This greatly increases Risk for Respiratory Failure.
• Asthma, attacks are very unpredictable and variable. The is also a risk of Risk for complete obstruction and rispiratory arrist.
• Asthma is fully reversible by giving treatments to treat the inflammation
• Normal is expected normal airflow in between exacerbations
• There are too many classifications- which are fairly inconsistent (mild, moderate, severe... intermittent, persistent]

COPD

• Fourth leading cause of death
• Result of chronic inflammation from noxious stimulus (smoking, pollutants, particles, gases)
• Social determinants of health: higher rates poorer housing, lower socio-economic status have higher rates
• Risk factors include living in highly polluted areas, family history of disease, alcoholism
• COPD is often co-existed with heart disease
• There are too many classifications- which are fairly inconsistent (mild, moderate, severe... intermittent, persistent]
• This disease can lead to (barreled chest, destruction of alveolar spaces
• Not fully reversible.
• Key Assessmetn: Dypsnea exerction or in rest
• Assess with Fatigue that interferes with ADL's
• Barrel chest and see how their accsesory muscles can produce symptoms of Chronic Hypocia.
• Diagnostic gold standart: Spirometry Baseline, reduced FEV1/FVC ratio less air.

Asthma and COPD IDD:

In both cases you want to to prevent the smoking and screen to minimize secondary smoke. Both cases must be adapted appropriately and tailored to all patients.

Overview of epistaxis (nosebleed) including risk factors, anterior and posterior types, and treatments. Initial treatment involves applying pressure while tilting the head forward. Secondary treatment options include cauterizing the capillaries, applying internal pressure, or using gauze/balloons.