Chest and Lower Respiratory Tract Disorders PDF

CHAPTER 23 MANAGEMENT OF PATIENTS WITH CHEST AND LOWER RESPIRATORY TRACT DISORDERS By adult heath nursing team Copyright © 2018 Wolters Kluwer · All Rights Reserved Learning outcome Compare the various pulmonary infections with regard to causes, clinical Compare m...

CHAPTER 23 MANAGEMENT OF PATIENTS WITH CHEST AND LOWER RESPIRATORY TRACT DISORDERS By adult heath nursing team Copyright © 2018 Wolters Kluwer · All Rights Reserved Learning outcome Compare the various pulmonary infections with regard to causes, clinical Compare manifestations, nursing management, complications, and prevention. Use the nursing process as a framework for care of the patient with Use pneumonia. Specify Specify risk factors and measures appropriate for prevention of tuberculosis Identify Identify the role of nurse on diagnoses of tuberculosis Use the nursing process as a framework for care of the patient with Use tuberculosis. Describe Describe nursing measures to prevent aspiration. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Pneumonia Pulmonary Infections Tuberculosis COVID-19 Copyright © 2018 Wolters Kluwer · All Rights Reserved  Pneumonia ❖ Pneumonia is an inflammation of the lung parenchyma associated with alveolar edema and congestion that impair gas exchange. ❖ Pneumonia is caused by a bacterial or viral infection spread by droplets or by contact. ❖ Classification o Community acquired (CAP) o Healthcare associated (HCAP) o Hospital acquired (HAP) o Ventilator associated (VAP) Copyright © 2018 Wolters Kluwer · All Rights Reserved Classification of pneumonia Community-Acquired Pneumonia (CAP): CAP occurs either in the community setting or within the first 48 hours after hospitalization. The causative agents for CAP that needs hospitalization include streptococcus pneumoniae, H. influenza, Legio nella, and Pseudomonas aeruginosa. Only in 50% of the cases does the specific etiologic agent become identified. Copyright © 2018 Wolters Kluwer · All Rights Reserved Healthcare associated (HCAP): Pneumonia occurring in a non-hospitalized patients with extensive healthcare contact Pneumonia in Subcategories into; immunocompromised hosts Aspiration pneumonia. Copyright © 2018 Wolters Kluwer · All Rights Reserved Hospital-Acquired Pneumonia (HAP): HAP is also called nosocomial pneumonia and is defined as the onset of pneumonia symptoms more than 48 hours after admission in patients with no evidence of infection at the time of admission. HAP is the most lethal nosocomial infection and the leading cause of death in patients with such infections. Common microorganisms that are responsible for HAP include Enterobacter species, Escherichia coli, influenza, Klebsiella species, Proteus, Serratia marcescens, S. aureus, and S. pneumonia. The usual presentation of HAP is a new pulmonary infiltrate on chest x-ray combined with evidence of infection. Copyright © 2018 Wolters Kluwer · All Rights Reserved Ventilator associated pneumonia(VAP): Type of HAP that develop ≥48hours after insertion of endotracheal tube Copyright © 2018 Wolters Kluwer · All Rights Reserved Pneumonia Risk Factors ❖ Occurs in patients with certain underlying disorders and diseases. o Heart failure, diabetes, alcoholism, COPD, and AIDS o Influenza ❖ Cystic fibrosis ❖ Refer to Table 23-2 Copyright © 2018 Wolters Kluwer · All Rights Reserved Pathophysiology Pneumonia arises from normal flora present in patients whose resistance has been altered or from aspiration of flora present in the oropharynx. An inflammatory reaction may occur in the alveoli, producing exudates that interfere with the diffusion of oxygen and carbon dioxide. White blood cells also migrate into the alveoli and fill the normally air-filled spaces. Due to secretions and mucosal edema, there are areas of the lung that are not adequately ventilated and cause partial occlusion of the alveoli or bronchi. Hypoventilation may follow, causing ventilation-perfusion mismatch. Venous blood entering the pulmonary circulation passes through the under ventilated areas and travels to the left side of the heart deoxygenated. The mixing of oxygenated and poorly oxygenated blood can result to arterial hypoxemia Copyright © 2018 Wolters Kluwer · All Rights Reserved Clinical Manifestations ❖ Varies depending on type, causal organism, and presence of underlying disease. ❖ Streptococcal: Sudden onset of chills, fever, pleuritic chest pain, tachypnea, and respiratory distress. ❖ Viral, mycoplasma, or Legionella: relative bradycardia ❖ Other: Respiratory tract infection, headache, low-grade fever, pleuritic pain, myalgia, rash, and pharyngitis ❖ Orthopnea, crackles, increased tactile fremitus, cough with purulent sputum. Copyright © 2018 Wolters Kluwer · All Rights Reserved Clinical Manifestations Copyright © 2018 Wolters Kluwer · All Rights Reserved Clinical Manifestations cont… Rapidly rising fever. Since there is inflammation of the lung parenchyma, fever develops as part of the signs of an infection. Pleuritic chest pain. Deep breathing and coughing aggravate the pain in the chest. Rapid and bounding pulse. A rapid heartbeat occurs because the body compensates for the low concentration of oxygen in the body. Tachypnea. There is fast breathing because the body tries to compensate for the low oxygen concentration in the body. Purulent sputum. The sputum becomes purulent because of the infection in the lung parenchyma which produced sputum-filled with pus. Copyright © 2018 Wolters Kluwer · All Rights Reserved Complications Pneumonia has several complications if left untreated or the interventions are inappropriate. Shock and respiratory failure. These complications are encountered chiefly in patients who have received no specific treatment and inadequate or delayed treatment. Pleural effusion. In pleural effusion, the fluid is sent to the laboratory for analysis, and there are three stages: uncomplicated, complicated, and thoracic empyema Copyright © 2018 Wolters Kluwer · All Rights Reserved Assessment and Diagnosis ❖ History: Hx. particularly a recent respiratory tract infection. ❖ Physical exam: Mainly, RR and breath sounds (crackles) ❖ Chest x-ray: Identifies structural distribution (e.g., lobar, bronchial); may also reveal multiple abscesses/infiltrates, empyema ❖ Blood culture: to recover causative organism ❖ Sputum examination ❖ CBC. Leukocytosis usually present, although a low white blood cell (WBC) count may be present in viral infection. Erythrocyte sedimentation rate (ESR) is elevated. ❖ Bronchoscopy:may be used for acute severe infection Copyright © 2018 Wolters Kluwer · All Rights Reserved Medical Management ❖ Administration of the appropriate antibiotic as determined by the results of a culture and sensitivity. ❖ Hydration is an important part of the regimen because fever and tachypnea may result in insensible fluid losses. ❖ Antipyretics are used to treat fever and headache. ❖ Antitussives are used for treatment of the associated cough. ❖ Complete rest is prescribed until signs of infection are diminished. ❖ Oxygen can be given if hypoxemia develops. ❖ Pulse oximetry is used to determine the need for oxygen and to evaluate the effectiveness of the therapy. Copyright © 2018 Wolters Kluwer · All Rights Reserved  The following are the nursing priorities for patients with pneumonia: Improving airway patency Nursing Priorities Improving tolerance to activity Maintaining proper fluid volume Measures to prevent complications Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: Assessment Assess for the Abnormal breath sounds Changes in rate, depth following subjective Vital signs (rhonchi, bronchial lung of respirations and objective data: sounds) Cough, effective or Use of accessory Dyspnea, tachypnea ineffective; with/without Cyanosis muscles sputum production Changes in mental status, fatigue, Decreased breath Purulent sputum; edema, dehydration, sounds over affected Reduced vital capacity amount, odor, color concomitant heart lung areas failure, especially in older adult patients Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: Diagnoses ❖ Based on the nurse’s clinical judgement and understanding of the patient’s unique health condition ❖ Through the data collected during assessment, the following nursing diagnoses are made: ❖ Ineffective airway clearance R/T copious tracheobronchial secretions. ❖ Intolerance of activity R/T impaired respiratory function. ❖ Fluid volume risk for R/T fever and a rapid respiratory rate. ❖ Imbalanced nutrition: less than body requirements ❖ Deficient knowledge about the treatment regimen and preventive measures Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: Planning ❖ Improved airway patency ❖ Increased activity ❖ Maintenance of proper fluid volume ❖ Maintenance of adequate nutrition ❖ Understanding of the treatment protocol and preventive measures ❖ Absence of complications Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: Interventions ❖ To improve airway patency: Removal of secretions. Secretions should be removed because it interfere with gas exchange and may slow recovery. Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions. Humidification may loosen secretions and improve ventilation. Warm, moist inhalations are helpful in relieving bronchial irritation Coughing exercises. An effective, directed cough can also improve airway patency. Chest physiotherapy. Chest physiotherapy is important because it loosens and mobilizes secretions. Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: Interventions cont… To promote rest and conserve energy: Encourage avoidance of overexertion and possible exacerbation of symptoms. Semi-Fowler’s position. The patient should assume a comfortable position to promote rest and breathing and should change positions frequently to enhance secretion clearance and pulmonary ventilation and perfusion. To promote fluid intake: Increase in fluid intake to at least 2-3L per day to replace insensible fluid losses. To maintain nutrition: Fluids with electrolytes. This may help provide fluid, calories, and electrolytes. Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also help restore proper nutrition. To promote patient’s knowledge: Instruct patient and family about the cause of pneumonia, management of symptoms, signs, and symptoms, and the need for follow-up. Instruct patient about the factors that may have contributed to the development of the disease. Copyright © 2018 Wolters Kluwer · All Rights Reserved Expected Outcomes Patient will : ❖ Demonstrate improved ventilation and oxygenation of tissues by ABGs within the patient’s acceptable range and absence of symptoms of respiratory distress. ❖ Maintain optimal gas exchange. ❖ Participate in actions to maximize oxygenation. ❖ Identify/demonstrate behaviors to achieve airway clearance ❖ Display/maintain a patent airway with breath sounds clearing; absence of dyspnea, cyanosis, as evidenced by keeping a patent airway and effectively clearing secretions. ❖ Maintains adequate hydration; adequate dietary intake ❖ Verbalizes increased knowledge about management strategies ❖ Complies with management strategies ❖ Exhibits no complications Copyright © 2018 Wolters Kluwer · All Rights Reserved Documentation Guidelines Documentation of data must be accurate and up-to-date to avoid unnecessary legal situations that might occur. Document breath sounds, presence and character of secretions, use of accessory muscles for breathing. Document character of cough and sputum. Document respiratory rate, pulse oximetry/O2 saturation, and vital signs. Document plan of care and who is involved in planning. Document client’s response to interventions, teaching, and actions performed. Document if there is use of respiratory devices or airway adjuncts. Document response to medications administered. Document modifications to plan of care. Copyright © 2018 Wolters Kluwer · All Rights Reserved Prevention ❖ Pneumococcal vaccine. This vaccine can prevent pneumonia in healthy patients with an efficiency of 65% to 85%. ❖ Staff education. To help prevent HAP, the CDC encouraged staff education and involvement in infection prevention. ❖ Infection and microbiologic surveillance. It is important to carefully observe the infection so that there could be an appropriate application of prevention techniques. ❖ Modifying host risk for infection. The infection should never be allowed to descend on any host, so the risk must be decreased before it can affect one. ❖ Other preventive measures see Table 23-2 Copyright © 2018 Wolters Kluwer · All Rights Reserved Aspiration pneumonia ❖ Inhalation of foreign material into the lungs ❖ Serious complication of pneumonia ❖ Clinical picture: tachycardia, dyspnea, central cyanosis, hypertension, hypotension, and potential death Copyright © 2018 Wolters Kluwer · All Rights Reserved Chart 23-5 RISK FACTORS Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing interventions: Aspiration o Keep HOB elevated >30 degrees o Avoid stimulation of gag reflex with suctioning or other procedures o Check for placement before tube feedings o Thickened fluids for swallowing problems Copyright © 2018 Wolters Kluwer · All Rights Reserved Pulmonary Tuberculosis ❖ Tuberculosis (TB) is an infectious disease that primarily affects the lung parenchyma. ❖ It also may be transmitted to other parts of the body, including the meninges, kidneys, bones, and lymph nodes. ❖ The primary infectious agent, M. tuberculosis, is sensitive to heat and ultraviolet light Copyright © 2018 Wolters Kluwer · All Rights Reserved Transmission of TB ❖ TB spreads from person to person by airborne transmission. ❖ An infected person releases droplet nuclei (usually particles 1 to 5 mcm in diameter) through talking, coughing, sneezing, laughing, or singing. ❖ Small droplets remain suspended in the air and are inhaled by a susceptible person. Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Cascade of tuberculosis transmission. (Source: The Aurum Institute). Copyright © 2018 Wolters Kluwer · All Rights Reserved Pathophysiology of TB Copyright © 2018 Wolters Kluwer · All Rights Reserved Classification of TB Data from the history, physical examination, TB test, chest xray, and microbiologic studies are used to classify TB into one of five classes. Class 0. There is no exposure or no infection. Class 1. There is an exposure but no evidence of infection. Class 2. There is latent infection but no disease. Class 3. There is a disease and is clinically active. Class 4. There is a disease but not clinically active. Class 5. There is a suspected disease, but the diagnosis is pending Copyright © 2018 Wolters Kluwer · All Rights Reserved Risk factors for TB ❖ Close contact with someone who has active TB ❖ Immunocompromised status (e.g., those with HIV infection ❖ Substance abuse (IV/injection drug users and alcoholics). ❖ Any person without adequate health care (homeless) ❖ Preexisting medical conditions or special treatment (e.g., diabetes. Copyright © 2018 Wolters Kluwer · All Rights Reserved Risk factors for TB cont… ❖ Immigration from or travel to countries with a high prevalence of TB (southeastern Asia. ❖ Institutionalization (e.g., long-term care facilities, psychiatric institutions, prisons). ❖ Living in overcrowded, substandard housing. ❖ Being a health care worker performing high-risk activities ❖ Risk factor for TB in Chart 23-7 Copyright © 2018 Wolters Kluwer · All Rights Reserved Prevention and control of TB ❖ Chart 23-8 : CDC Recommendations for Preventing Transmission of Tuberculosis in Health Care Settings , S&S are insidious ❖ To prevent transmission of tuberculosis, the following should be implemented. Identification and treatment. Early identification and treatment of persons with active TB. Prevention. Prevention of spread of infectious droplet nuclei by source control methods and by reduction of microbial contamination of indoor air. Surveillance. Maintain surveillance for TB infection among health care workers by routine, periodic tuberculin skin testing Copyright © 2018 Wolters Kluwer · All Rights Reserved Clinical Manifestations ❖ The signs and symptoms of pulmonary TB are insidious. ❖ Most patients have: o Low-grade fever o Cough (nonproductive, or mucopurulent or hemoptysis) o Night sweats o Fatigue, o Weight loss. Copyright © 2018 Wolters Kluwer · All Rights Reserved Pulmonary TB Assessment/Findings ❖ History and physical ❖ TB skin test; Mantoux method: See Figure 23-3 https://www.youtube.com/watch?v=Qzt-qGgglo0 ❖ Chest x-ray ❖ Sputum testing – for acid fast bacilli ❖ Drug susceptibility testing Copyright © 2018 Wolters Kluwer · All Rights Reserved Medical Management Pulmonary tuberculosis is treated primarily with antituberculosis agents for 6 to 12 months to ensure eradication of the organisms and to prevent relapse. First line treatment. First-line agents for the treatment of tuberculosis are isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide. Active TB. For most adults with active TB, the recommended dosing includes the administration of all four drugs daily for 2 months, followed by 4 months of INH and RIF. Latent TB. Latent TB is usually treated daily for 9 months. Treatment guidelines. Recommended treatment guidelines for newly diagnosed cases of pulmonary TB have two parts: an initial treatment phase and a continuation phase. Initial phase. The initial phase consists of a multiple-medication regimen of INH, rifampin, pyrazinamide, and ethambutol and lasts for 8 weeks. Continuation phase. The continuation phase of treatment include INH and rifampin or INH and rifapentine and lasts for an additional 4 or 7 months. Prophylactic isoniazid. Prophylactic INH treatment involves taking daily doses for 6 to 12 months. DOT. Directly observed therapy may be selected, wherein an assigned caregiver directly observes the administration of the drug Copyright © 2018 Wolters Kluwer · All Rights Reserved Medical Management cont… ❖ Airborne precautions ❖ Contact precautions ❖ TABLE 23-4 First-Line Antituberculosis Medications for Active Disease. Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Management of TB ❖ Nursing Priorities ❖ The following are the nursing priorities for patients with tuberculosis include: 1. Adherence to the treatment medication regimen. 2. Decrease transmission of M. tuberculosis 3. Provide disease information and patient education 4. Provide emotional support and address psychosocial needs 5. Ensure a multidisciplinary approach to care, including coordinating follow-up appointments,and arranging for directly observed therapy if needed Copyright © 2018 Wolters Kluwer · All Rights Reserved  Nursing Assessment Assess for the following subjective and objective data: Persistent cough lasting for several weeks or months Fatigue, weakness, and decreased energy levels Night sweats and unexplained weight loss Loss of appetite and decreased food intake Chest pain or discomfort Shortness of breath or difficulty breathing Crackles, wheezes, or decreased breath sounds Positive tuberculin skin test (Mantoux test) or interferon gamma release assay (IGRA) Presence of infiltrates, nodules, or cavities in the chest X-ray Sputum smear or culture positive for Mycobacterium tuberculosis Elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) Decreased oxygen saturation levels Signs of malnutrition or weight loss Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing diagnosis Risk for infection R/T inadequate primary defenses and lowered resistance. Ineffective airway clearance R/T thick, viscous, or bloody secretions. Risk for impaired gas exchange R/T decrease in effective lung surface. Activity intolerance R/T imbalance between oxygen supply and demand. Imbalanced nutrition: less than body requirements R/T inability to ingest adequate nutrients. Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing intervention Promoting airway clearance. The nurse instructs the patient about correct positioning to facilitate drainage and to increase fluid intake to promote systemic hydration. Adherence to the treatment regimen. The nurse should teach the patient that TB is a communicable disease and taking medications is the most effective means of preventing transmission. Promoting activity and adequate nutrition. The nurse plans a progressive activity schedule that focuses on increasing activity tolerance and muscle strength and a nutritional plan that allows for small, frequent meals. Preventing spreading of tuberculosis infection. The nurse carefully instructs the patient about important hygienic measures including mouth care, covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and handwashing. Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing intervention Acid-fast bacillus isolation. Initiate AFB isolation immediately, including the use of a private room with negative pressure in relation to surrounding areas and a minimum of six air changes per hour. Disposal. Place a covered trash can nearby or tape a lined bag to the side of the bed to dispose of used tissues. Monitor adverse effects. Be alert for adverse effects of medications. Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing intervention cont.. ❖ The nurse educates the patient to take the medication at least 1 hour before meals, because food interferes with medication absorption. ❖ Patients taking INH should avoid foods that contain tyramine and histamine (tuna, aged cheese, soy sauce ❖ The nurse monitors for other side effects of anti-TB medications, including hepatitis, neurologic changes and rash. ❖ The nurse instructs the patient about the risk of drug resistance if the medication regimen is not strictly and continuously followed. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Any questions Copyright © 2018 Wolters Kluwer · All Rights Reserved Exercise ❖ The nurse is caring for a patient diagnosed with pneumonia. Which of the following signs and symptoms would the nurse most likely assess in this patient? (Select all that apply.) 1. Anorexia 2. Cough 3. Ascites 4. Dyspnea 5. Fever Copyright © 2018 Wolters Kluwer · All Rights Reserved ❖ A 50-year-old patient who was admitted with pneumonia reported having dyspnea and difficulty expelling his secretions : RR 32 breaths/minute, chest auscultation reveals bronchial sounds in the left lower lobe. Which of the following treatments does the nurse determine the patient needed first? a. Nutrition intake b. Antibiotics c. Bed rest d. Oxygen Copyright © 2018 Wolters Kluwer · All Rights Reserved