M2S1 Respiratory (1).pptx

Module Two Session One ATI MS Chapter 21 Acute Respiratory Disorders Chapter 22 Asthma Chapter 23 COPD Chapter 24 Tuberculosis Chapter 18 Respiratory Diagnostic and Therapeutic Procedures  Struc...

Module Two Session One ATI MS Chapter 21 Acute Respiratory Disorders Chapter 22 Asthma Chapter 23 COPD Chapter 24 Tuberculosis Chapter 18 Respiratory Diagnostic and Therapeutic Procedures  Structures of the Lower Respiratory Tract Trachea: Air transport to lungs. Ringed. Bronchi: Transport and Moisturize air Bronchioles: Alveoli huggers, Air distributors Alveoli: Gas exchange https://www.verywellmind.com/what-are-alveoli-in-the-lungs-  Anatomy and physiology Airways Upper airway Nose, The priority concept: sinuses, Gas Exchange pharynx, larynx Lower airway Trachea, two Interrelated concepts: main stem Perfusion bronchi, lobar, Inflammation segmental, and sub- Cellular regulation segmental bronchi; bronchioles; alveolar ducts; alveoli Gas exchange is oxygen transports to cells and carbon dioxide transports away from cell through ventilation and diffusion Perfusion is arterial blood flow through tissues and blood pumped by the heart. Physical Assessment Endotracheal Tracheal Intubation Intubation  Normal Resp rate 12-20 Auscultating Lung Soundsbreaths/min What? Wheeze: high-pitched whistling Crackles (rales): bubbling, popping, clicking noises Rhonchi: low-pitched rattling sounds, snoring Stridor: high-pitched variable sound Pleural friction rub: creaking, Where? grating, rubbing Wheeze: most lung spaces Crackles (rales): lung bases Rhonchi: over larger airways Stridor: trachea and upper airways, more commonly during inspiration Pleural friction rub: most lung spaces Lung sounds Rales. This is a fine, high-pitched crackling or rattling sound that can occur when you inhale. (Rale and Wheezing. This is a high-pitched crackles are the same thing and Rhonchi. This is a low-pitched sound, almost like a long squeak, occur in the tiny air sacs called sound that resembles snoring. that can occur as you inhale or alveoli) Rhonchi in the bronchi which is the exhale. In asthma, bronchitis, and Types of rales include: larger airways of the lungs Fine like is asthma, pulmonary edema chronic emphysema Coarse like in PNA, pulmonary edema dry moist Stridor indicates a narrowed or obstructed upper airway, which can Pleural friction rub: audible raspy significantly impede airflow. In Three lobes on the right and two on breathing sound, grating, loss of croup, epiglottitis and airway the Left lobe lubrication due to inflammation obstruction Requires Medical attention! Indicators of Respiratory Adequacy Skin and ABG’s mucous pH 7.35-7.45 membra PaCO2 35-45 mmHg ne PaO2 80-100 mmHg changes HCO3 22-26 mEq/L General Enduranc appearan e ce  Caution Signs and symptoms indicating Respiratory problems shortness of breath coughing weakness or fatigue pain with breathing difficulty breathing Respiratory system FIO2 fraction of inspired oxygen, the room air is 21% SpO2 is arterial oxygen saturation measure with pulse ox PaO2 partial pressure of O2 measured from an ABG 80-100 A bluish color to the skin or mucous membrane is usually due to a lack of oxygen in the blood. The medical term is cyanosis. Typically, when spO2 level is 50 distress, thus, to With Respiratory affect the pt and then patient tight and acidosis monitor cause shallow may need restricts Potassium level breathing, endotracheal movement. range is 3.5-5 because it affect tube. Resulting in our muscles restricted air “Alkalosis” movement “acidosis”  The effects of aging on the respiratory system are similar to those that occur in other organs: maximum function gradually declines. Age- related changes in the lungs include Associated with Aging Decreases in peak airflow (how quickly someone can exhale) and exchange of carbon Respiratory Changes dioxide and oxygen, influenced by the alveoli Decreases in measures of lung function such as vital capacity (the maximum amount of air that can be breathed out following a maximum inhalation) Weakening of the respiratory muscles, and diaphragm Decline in the effectiveness of lung defense mechanisms, prone to infection- flu, PNA, colds, COVID-19  Smoking and Vaping E-cigarettes’ biggest threat to public health may be this: The increasing popularity of vaping may “re-normalize” smoking, which has declined for years. Smoking is still the leading preventable cause of death, modifiable behavior  Promoting Smoking Cessation Fast, simple, and easy to do. Patient readiness is key. Important to have the patient think about quitting Smoking Cessation Options Smoking cessation is The likelihood of a Medications, including associated with clear successful quit attempt is nicotine replacement, health benefits. Cigarette increased if counseling is varenicline, and bupropion smoking is the leading provided along with the have demonstrated preventable cause of Have gum, transdermal medications. An overview efficacy as smoking death in the United States patches. Hospital stay pt of smoking cessation cessation aids. These and and worldwide. Tobacco should receive a patch. management and the other pharmacologic use increases the risk of benefit of adjuvant options to help patients many acute and chronic behavioral therapies for stop smoking are diseases, including smoking cessation are discussed here. cancers at many sites. discussed separately.  Calculating Pack history Pack history Example 1 pack per day for 30 year =30 pack year history If I smoked 2 packs per day for 15 years=30 year history A patient with a 20 pack year history or longer will show early- stage COPD with PFT changes. 2 packs per day for 10 years=20 pack year history then 1 pack for 20 years=20 pack year so 20+20=40 pack year history total. Question Which patient social behavior can be modified to help avoid chronic respiratory problems and physical limitations? A. Walking 1 mile daily B. Getting their influenza shot annually C. Eating healthy diet and staying hydrated D. Stop smoking Question Which patient social behavior can be modified to help avoid chronic respiratory problems and physical limitations? A. Walking 1 mile daily B. Getting their influenza shot annually C. Eating healthy diet and staying hydrated D. Stop smoking Answer is D. stop smoking. Smoking cessation should be addressed at every appt. Smoking is notable for being bad for your health and contributes to increased respiratory problems and increased mortality. Lung Cancer Lung Cancer: Repeated exposure to inhaled substances that cause Incidence and chronic irritation or inflammation Cigarette smoking is major risk factor Prevalence Nonsmokers exposed to secondhand and thirdhand smoke Lung have risk Cancer: Etiology Chronic exposure to chemicals and inhalants Sometimes occurs in adults who never smoked, especially and Genetic Risk in women Lung Cancer: Reduce tobacco smoking Health Promotion Screening as secondary prevention and Maintenance Lung Cancer: Risk Factors SOB hemopty sputum sis cough Hoarsen enduranc ess e changes chest pain Lung Cancer Lung Cancer is Lung Blood tests the leading Cancer is to check Low-dose Bronchosc cause of diagnosis Tumor Chest x- PET scan CT scan opy& death for with markers ray or MRIs screening Biopsy both men multiple CEA and and tests: CA125 women  Lung Cancer Treatment Nonsurgical Surgical management Chemotherapy management Removal of lobe or entire Targeted therapy lung Immunotherapy Chest tube Radiation therapy Lobectomy Photodynamic therapy Wedge resection Question A 60-year-old woman with COPD who smoked cigarettes for 40 years is admitted to the hospital. The ED nurse reports the following to the medical-surgical nurse: Has a saline lock in the R forearm and is on oxygen at 2 L per nasal cannula Had a bronchodilator respiratory treatment in the ED. Has bilateral expiratory wheezes and crackles, anteriorly and posteriorly. Which assessment finding does the nurse expect to see when the client arrives? (Select all that apply.) A.Bradycardia B.Shortness of breath C.Use of accessory muscles D.Sitting in a forward posture E.Barrel chest appearance Question A 60-year-old woman with COPD who smoked cigarettes for 40 years is admitted to the hospital. The ED nurse reports the following to the medical- surgical nurse: Has a saline lock in the R forearm and is on oxygen at 2 L per nasal cannula Had a bronchodilator respiratory treatment in the ED. Has bilateral expiratory wheezes and crackles, anteriorly and posteriorly. Which assessment finding does the nurse expect to see when the client arrives? (Select all that apply.) A.Bradycardia B.Shortness of breath C.Use of accessory muscles D.Sitting in a forward posture E.Barrel chest appearance The client with COPD often has a barrel chest appearance, is short of breath, and may use accessory muscles when breathing. These clients tend to move slowly and are slightly stooped. Usually they sit with a forward-bending posture. With severe dyspnea, they exhibit activity intolerance and activities such as bathing and grooming are avoided. Bradycardia is not anticipated. Normal to tachycardia is expected.  Chronic, Intermittent, Reversible Bronchoconstricti on Inflammation & hyperresponsive https://www.wealthmeta.com/blog/rural-vs-urban-living-budgets-and-net-worth ness ASTHMA OVERVIEW Rural v. Urban Asthma Asthma is airway inflammation, followed by bronchospasm. Evidence for the diagnosis of asthma should be confirmed before starting controller treatment, if possible, to avoid inappropriate treatment or missing other important diagnoses and because diagnosis is often more difficult later. Results from clinical examination, including chest auscultation, may be completely normal. First, a clinical diagnosis starts with a history of respiratory symptoms (such as cough, wheeze, difficulty breathing and/or shortness of breath) that typically vary over time and intensity. Symptoms of asthma are often worse at night and in the early morning and may be triggered by factors such as viral infections, allergen exposure, exercise, strong smells, cigarette smoke, exhaust fumes and laughter. Asthma Pathophysiology Review Chronic disease that occurs intermittently Inflammation and airway tissue sensitivity Asthma Asthma is a chronic intermittent disease in which acute airway obstruction is reversible but has the potential to cause severe lower airway obstruction and death. Obstruction occurs by both inflammation and airway tissue sensitivity (Hyperresponsiveness) with bronchoconstriction. Well controlled asthma is fully reversible. Poorly controlled asthma (chronic inflammation) leads to airway damage and altered cellular regulation. Bronchospasm is the narrowing of the bronchial tubes by constriction of the smooth muscle. Small amounts of pollutants/viruses stimulate nerve fibers. This can profoundly limit airflow. Asthma Questions The following questions can be used to elicit features suggestive of asthma in young children and features that help support the diagnosis: Does your child have wheezing? Wheezing is a high-pitched noise that comes from the chest and not the throat. Use of a video questionnaire or asking a parent to record an episode on a smartphone if available can help to confirm the presence of wheeze and differentiate from upper airway abnormalities. Does your child wake up at night because of coughing, wheezing, or difficult breathing, heavy breathing, or breathlessness? Does your child have to stop running, or play less hard, because of coughing, wheezing or difficult breathing, heavy breathing, or shortness of breath? Does your child cough, wheeze or get difficult breathing, heavy breathing, or shortness of breath when laughing, crying, playing with animals, or when exposed to strong smells or smoke? Has your child ever had eczema, or been diagnosed with allergy to foods? Has anyone in your close family had asthma, hay fever, food allergy, eczema, or any other disease with breathing problems?  Seasonal Irritants Illness Exercise ASA/NSAIDS https://www.verywellhealth.com/severe-asthma-attack-5206130 GERD ASTHMA TRIGGERS Asthma The symptoms of severe asthma can vary from person to person, but the following signs could indicate a severe asthma attack: Coughing, Nocturia coughing, coughing in the middle of the night Tightness in the chest Shortness of breath Wheezing Difficulty talking Blue lips or fingernails Feeling confused or agitated Symptoms that do not improve with medication  ASTHMA Physical Assessment Audible wheeze Tachypnea, Accessory Muscle Use Non-productive cough Hypoxia Altered LOC, Tachycardia Tight chest SOB Chronic Asthma can have barrel chest Concept Application Which assessment findings does A. Audible wheezing the nurse expect to see in a B. Breathlessness while client having an acute asthma speaking. attack? Select all that apply. C. Clubbing of the fingers. D. Cyanosis of the nail beds. E. Use of pursed-lip respirations. F. Sternal retractions. Answer Rationale A. Audible wheezing B. Breathlessness while Common symptoms during an asthma speaking. attack are wheezing, increased RR, and breathlessness. If hypoxemia is present, C. Clubbing of the fingers. cyanosis of the nail beds and oral mucosa may be present. Accessory D. Cyanosis of the nail beds. muscles may be used, which is seen as muscle retraction at the sternum. E. Use of pursed-lip Clubbing of the fingers occurs only with respirations. chronic hypoxic disorders, not intermittent. Pursed lip breathing is F. Sternal retractions. associated with COPD.  Measure’s forced expiratory volume at 1 second/forced vital capacity (FVC) ratio Asthma is Diagnosed by Post SABA FEV1 > 12% and > 200ml from baseline Noninvasive What 3 things impact the peak flow reading? https://allergymontana.com/pulmonary-function-testing/ Height Age Gender Asthma: Pulmonary Function Tests Asthma Classification of Asthma >80% Asthm Intermittent a Mild Persistent Asthm 80-60% a Moderate Asthm /= 60 mEq/L Diagnostic < 30 mEq/L Unlikely https://www.cff.org/intro-cf/sweat-test CF Universal Screening of Newborns  CF Consequence s GI: Malnourished, Steatorrhea Bone: Osteoporosis/Osteopenia Sexuality: Male sterility Pancreatic: Insufficiency, Diabetes Respiratory: Infection, scarring, cough, dyspnea, abscess  CF Interventions No Cure Life-long, progressive, irreversible Daily therapy Pancreatic enzymes Nutrition: Supplementation Chest physiotherapy HANDWASHING Concept Application Which laboratory test will the A. Sweat chloride level nurse expect to be ordered as B. Alpha1-Antitrypsin (AAT) most appropriate for an adult level. client who has persistent pulmonary symptoms to C. ABG analyses determine whether CF is the D. Genetic analysis of the CFTR cause? gene. Answer Rationale A. Sweat chloride level B. Alpha1-Antitrypsin (AAT) The defect in the CFTR gene that level. causes FR results in a high concentration of chloride ions in the C. ABG analyses client’s sweat. It is quick, D. Genetic analysis of the CFTR noninvasive, and inexpensive. AAT gene. r/t COPD. ABG nonspecific. Genetic analysis of the CFTR gene is performed after diagnosis to help determine the most beneficial therapy.  Infectious Lower Respiratory Conditions Flu, Covid 19, Pneumonia, TB, Rhinosinusitis, Peritonsillar Abscess Which one?  Seasonal Influenza Transmission? Droplet Precautions, private room 7 days in Contagious period? Adults contagious 24 hours before symptoms begin and up to 5 days after. At what age should influenza vaccine admin begin? 6 months #1 preventative measure? Handwashing Stay home if sick https://www.vitalityurgentcare.com/is-it-already-the-influenza-flu-season/ Flu Highly contagious acute viral respiratory infection. HEALTH PROMOTION Epidemics are common AND MAINTANENCE and lead to complications of PNA or death especially Severity reduced with annual in older adults, those with vaccination. Vaccine changed HF, lung disorders, and annually based on which stains are most likely to cause illness. immunocompromised “Senior flu shot” is available for patients. Rapid onset severe headache, muscle those > 65 years (higher dose). aches, fever, chills, fatigue, weakness. Promote hand hygiene to reduce Adults contagious 24 hours before risk of spreading influenza. symptoms begin and up to 5 days after. Other precautions: Stay home Influenza strain B can lead to N/V, and when sick, cover mouth and nose diarrhea. when sneezing or coughing. Most people feel fatigue for up to 2 Flu: Health Promotion Severity reduced with annual vaccination. Recommended for all including children, pregnancy, older adults High-dose flu vaccines for higher risk populations like seniors >65 yo, Quadrivalent Promote hand hygiene to reduce risk of spreading influenza. Other Precautions: Cover mouth and nose when sneezing or coughing. Flu Treatment Antibiotics are NOT effective to treat viral illnesses. Antivirals such as Oseltamivir (Tamiflu) have been effective in prevention and treatment. They can be given to high-risk adults to prevent infection before they are able to receive the vaccine. These drugs also limit infection duration and prevent viral spread. TO be most effective for treatment, they must be taken within 24-48 hrs. after symptoms begin. Rest and increase fluid intake. Most cases in immunocompetent adults are self- limiting. Concept Application Which action by the assisted A. Prepare to administer living facility nurse is most antibiotics. appropriate to prevent influenza B. Have the resident eat meals spread when a resident client in their room. tests positive for influenza A? C. Provide Oseltamivir to the staff. D. Arrange follow-up CXR in 2 weeks. Answer Rationale A. Prepare to administer antibiotics. Unless the client develops B. Have the resident eat meals complications, they are most in their room. likely going to be managed at C. Provide Oseltamivir to the the facility. Influenza is highly staff. contagious. Keeping the client D. Arrange follow-up CXR in 2 in their room will help prevent weeks. spread of infection. Concept Application For which client does the nurse A. 19-year-old living in a college recommend the influenza dormitory. “quadrivalent” vaccine? B. 36-year-old who has T1DM? C. 50-year-old who just underwent aortic valve replacement. D. 75-year-old community- dwelling client after hip replacement surgery. Answer Rationale A. 19-year-old living in a college dormitory. For adults aged over 65 years, B. 36-year-old who has T1DM? a new formulation is available. C. 50-year-old who just AKA “High-dose flu vaccine”, underwent aortic valve which was designed for more replacement. effective protection r/t reduced D. 75-year-old community- immunity in this vulnerable dwelling client after hip population. replacement surgery.  COVID-19 The CDC recommends several steps to identify and care for persons with suspected or confirmed COVID-19. Have masks available for patients to don before entering the health care facility Once identified, place a patient in a private room with the door closed for assessment. Limit the number of staff entering the room. All staff entering the room must don a N95 respirator, gown, gloves, face shield or goggles for eye protection Health care personnel entering the room should use standard precautions, contact precautions, droplet precautions, airborne precautions, and eye protection (goggles or a face shield) Have guidelines for the proper use of PPE displayed throughout the health care facility, dependent on area you work https://www.theguardian.com/world/2020/apr/28/face-masks-coveted-commodity-coronavirus- pandemic PNA Pneumonia Vaccination can help prevent PNA. Two vaccines currently exist for prevention of PNA (PPSV23 & PCV13). The CDC recommends adults > 65 years be vaccinated with both. First PCV13, followed by PPSV23 12 months later. These recommendations HEALTH also apply to adults between 19-64 years old at high risk. PROMOTION AND MAINTANENC E https://www.news-medical.net/health/What-is-Viral-Pneumonia.aspx Pneumonia Who is at risk for However, the Diagnostic pneumonia? following groups Tests are at the Anyone can get highest Adults ages risk: 65 and Chest X-ray, pneumonia. older consolidation Children younger (solidification, than age 2 years old density) of affected lung tissue, lower People with certain lobes predominately medical conditions Pulse oximetry, level People that smoke will drop below normal 95-100% Who needs the Hospital? Types of Pneumonia Pneumonia from respiratory infection is associated with formation of thick exudate containing proteins and other particles that reduce gas exchange. If organisms move into the bloodstream, septicemia and sepsis result. Bacterial: Viral: Fungal More common in More common in (mycoplasma): adults. pediatrics, caused Atypical “walking 60-80% of cases by influenza or RSV pneumonia” Nasty cough, very Dry hacking Milder symptoms tired, fever, chills coughing  Antibiotics: one or two depending on existing co-morbidities Treatment for Movement Hydration Pneumonia Bronchodilators Cough medication (night) Tools to help our respiratory patients Concept Application Which specific signs and A. Confusion symptoms does the nurse expect B. Decreased oxygen saturation to see in an 80-year-old client admitted with bacterial C. Productive cough pneumonia? Select all that apply. D. Weakness and fatigue E. Elevated WBCs F. Fever Answer Rationale A. Confusion B. Decreased oxygen The older adult with pneumonia saturation has weakness, fatigue, lethargy, C. Productive cough confusion, and poor appetite. Fever and elevated WBC are D. Weakness and fatigue often absent initially because of E. Elevated WBCs reduce immune and inflammatory responses. F. Fever Hypoxemia is often present, but cough is not in older adults. Concept Application Which CXR finding will the nurse A. Patchy areas of increased expect to see for a client density. suspected to have pneumonia? B. “Ground-glass” appearance of the lung C. Mediastinal widening D. Large hyperinflated airways Answer Rationale A. Patchy areas of increased density. The classic CXR findings for a B. “Ground-glass” appearance PNA is are patchy areas of of the lung increased density in the C. Mediastinal widening involved lung areas. “ground- D. Large hyperinflated airways glass” is r/t acute respiratory distress. Mediastinal widening is r/t inhalation anthrax. Large, hyperinflated lungs is r/t COPD.  Tuberculosis TB is a highly communicable bacterial infection that infects the lungs. One of the most common bacterial infections worldwide and one of the top 10 causes of Transmission: death. Airborne, from the infected person’s laughing, coughing, singing, or sneezing https://www.statcarewalkin.com/DocTalksBlog/why-should-i-get-a-2-step-ppd-test/ Tuberculosis: Physical Assessment Progressive fatigue, lethargy, nausea, anorexia, weight loss, irregular menses, low grade fever. Cough with thick, Symptoms may be mucopurulent sputum, present for weeks or often streaked with blood. months. Dull, aching chest pain with cough, night sweats.  Tuberculosis test results >5mm (+) positive HIV Immunocompromised Next step after Recent contact with exposure to active TB a positive Tuberculin Skin >10mm (+) positive Immigrant Testing with IV drug user High risk population: LTC facility the purified protein derivative >15mm (+) positive General public with no risk factors (PPD) is Chest X-ray Two step process: get initial shot, then it needs to be read within 48-72 hours Confirming TB Sputum is the most sensitive and specific test for finding out if a patient is positive After treatment sputum cultures are used. Monthly testing is conducted until the patient has 2 consecutive negative tests Problem with sputum cultures is the turn around time to have results Latent TB If a patient has Positive TB skin test and NO symptoms, they are in latent phase. Not contagious Do need treatment to help prevent it from becoming active TB TB Treatment Educate the Typical Drug patient not to regimens last 4, drink alcohol RIPE: Rifampin, 6, to 9 months. while taking Treatment Isoniazid, This depending these medication adherence is vital Pyrazinamide, on severity and because of to combating TB. Ethambutol response to increased risk of treatment, this liver damage, could be longer especially with Rifampin  Rhinosinusitis Symptoms: Sinus pressure/headache Purulent nasal drainage >10-days symptoms Bacterial