Management of Patients With Respiratory Problems PDF

Managment The Patients With The Respiratory Problems Dr. Ganna Pola  Definition The respiratory system is a biological system consisting of specific organs and structures used for gas exchange The respiratory tract is divided into an upper and a lower respi...

Managment The Patients With The Respiratory Problems Dr. Ganna Pola  Definition The respiratory system is a biological system consisting of specific organs and structures used for gas exchange The respiratory tract is divided into an upper and a lower respiratory tract. Part of the Respiratory Tract: The upper tract includes Nose Nasal Cavities Sinuses Pharynx The Part Of the Larynx Above The Vocal Folds The lower tract includes: The Lower Part Of The Larynx The Trachea Bronchi Bronchioles The Alveoli  Ventilatory volumes The lungs expand and contract during the breathing cycle, drawing air in and out of the lungs. The volume of air moved in or out of the lungs under normal resting circumstances (the resting tidal volume of about 500 ml), and volumes moved during maximally forced inhalation and maximally forced exhalation are measured in humans by spirometry. A typical adult human spirogram with the names given to the various excursions in volume the lungs can undergo is illustrated below  Residual Volume Not all the air in the lungs can be expelled during maximally forced exhalation. This is the residual volume of about 1.0-1.5 liters which cannot be measured by spirometry. Volumes that include the residual volume  Respiratory Rate The rates at which air is breathed in or out, either through the mouth or nose, or into or out of the alveoli are tabulated below, together with how they are calculated. The number of breath cycles per minute is known as the respiratory rate.  Pulmonary Alveoli The primary purpose of the respiratory system is the equilibration of the partial pressures of the respiratory gases in the alveolar air with those in the pulmonary capillary blood. This process occurs by simple diffusion, across a very thin membrane (known as the blood–air barrier), which forms the walls of the pulmonary alveoli What is this picture?  At the summit of Mt. Everest (at an altitude of 8,848 m or 29,029 ft) the total atmospheric pressure is 33.7 kPa, of which 7.1 kPa (or 21%) is oxygen.  Respiratory Minute Volume Minute ventilation (or respiratory minute volume or minute volume) is the volume of gas inhaled (inhaled minute volume) or exhaled (exhaled minute volume) from a person's lungs per minute. It is an important parameter in respiratory medicine due to its relationship with blood carbon dioxide levels. It can be measured with devices such as a Wright respirometer or can be calculated from other known respiratory parameters.  Other functions of the lungs Local defenses Irritation of nerve endings within the nasal passages or airways, can induce a cough reflex and sneezing. These responses cause air to be expelled forcefully from the trachea or nose, respectively. In this manner, irritants caught in the mucus which lines the respiratory tract are expelled or moved to the mouth where they can be swallowed. During coughing, contraction of the smooth muscle in the airway walls narrows the trachea by pulling the ends of the cartilage plates together and by pushing soft tissue into the lumen. This increases the expired airflow rate to dislodge and remove any irritant particle or mucus.  Other functions of the lungs Prevention of alveolar collapse The lungs make a surfactant, a surface-active lipoprotein complex (phospholipoprotein) formed by type II alveolar cells. It floats on the surface of the thin watery layer which lines the insides of the alveoli, reducing the water's surface tension. The surface tension of a watery surface (the water-air interface) tends to make that surface shrink Disorders of the respiratory system can be classified into several general groups: Airway obstructive conditions ( emphysema, bronchitis, asthma) Pulmonary restrictive conditions (fibrosis, sarcoidosis, alveolar damage, pleural effusion) Vascular diseases (pulmonary edema, pulmonary embolism, pulmonary hypertension) Infectious, environmental and other "diseases" (pneumonia, tuberculosis, asbestosis, particulate pollutants) Primary cancers ( bronchial carcinoma, mesothelioma) Secondary cancers (cancers that originated elsewhere in the body, but have seeded themselves in the lungs) Insufficient surfactant (respiratory distress syndrome in pre- term babies). Bronchiectasis and Asthma  Bronchiectasis A chronic, irreversible dilation of the bronchi and bronchioles.  Under the new definition of COPD, it is considered a separate disease process from COPD (NIH,2001).  It may be caused by a variety of conditions, including: - Airway obstruction - Diffuse airway injury - Pulmonary infections and obstruction of the bronchus or complications of long-term pulmonary infections - Genetic disorders such as cystic fibrosis - Abnormal host defense (eg, ciliary dyskinesia or humoral immunodeficiency) - Idiopathic causes  Pathophysiology The inflammatory process associated with pulmonary infections damages the bronchial wall, causing a loss of its supporting structure and resulting in thick sputum that ultimately obstructs the bronchi. The walls become permanently distended and distorted, impairing mucociliary clearance. The inflammation and infection extend to the peribronchial tissues;  Bronchiectasis is usually localized, affecting a segment or lobe of a lung, most frequently the lower lobes. The retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis). Inflammatory scarring or fibrosis replaces functioning lung tissue. In time the patient develops respiratory insufficiency with reduced vital capacity, decreased ventilation, and an increased ratio of residual volume to total lung capacity. There is impairment in the matching of ventilation to perfusion (ventilation–perfusion imbalance) and hypoxemia.  Clinical Manifestations Characteristic symptoms of Bronchiectasis include: Chronic cough Production of purulent sputum in copious amounts. Many patients with this disease have hemoptysis. Clubbing of the fingers also is common because of respiratory insufficiency. Repeated episodes of pulmonary infection.  Assessment and Diagnostic Findings Bronchiectasis is not readily diagnosed because the symptoms can be mistaken for those of simple chronic bronchitis. A definite sign is offered by the prolonged history of productive cough, with sputum consistently negative for tubercle bacilli. The diagnosis is established by a computed tomography (CT) scan, which demonstrates either the presence or absence of bronchial dilation.  Medical Management Treatment objectives are to: - Promote bronchial drainage - Clear excessive secretions from the affected portion of the lungs - Prevent or control infection. Postural drainage: draining the Bronchiectasis areas by gravity reduces the amount of secretions and the degree of infection. Sometimes mucopurulent sputum must be removed by bronchoscopy. Chest physiotherapy, including percussion and postural drainage, is important in secretion management.  Smoking cessation: smoking impairs bronchial drainage …by paralyzing ciliary action, increasing bronchial secretions, causing inflammation of the mucous membranes, & hyperplasia of the mucous glands. Infection is controlled: antimicrobial therapy (based on sensitivity studies & sputum culture). A year-round regimen of antibiotic agents (different types of antibiotics) may be prescribed at intervals. It may be prescribed throughout the winter (or when acute upper respiratory tract infections occur). Vaccination against influenza & pneumococcal pneumonia Bronchodilators: assist with secretion management. Surgery: to conserve normal pulmonary tissue & avoid complications  Nursing Management Focuses on alleviating symptoms & to clear pulmonary secretions. Patient teaching: smoking & other factors that increase the production of mucus and hamper its removal Patient and family teaching: to perform postural drainage & to avoid exposure to others with upper respiratory or other infections. Teaching pt: early signs of respiratory infection & progression of disease (so appropriate treatment can be implemented promptly). Assess pt nutritional status, & teach pt strategies to ensure adequate diet and energy conservation  ASTHMA is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: Cough. Chest tightness. Wheezing. Dyspnea. Estimates: nearly 17 million Americans have asthma, & > 5,000 die from this disease annually.  Asthma differs from other obstructive lung diseases in that it is largely reversible, either spontaneously or with treatment. Pts with asthma may experience symptom-free periods alternating with acute exacerbations, which last from minutes to hours or days. Asthma can occur at any age and is the most common chronic disease of childhood. Despite increased knowledge (pathology of asthma), & better medications and management plans, the death rate from asthma continues to increase. It is a disruptive disease, affecting school and work attendance, occupational choices, physical activity, and general quality of life.  Allergy is the strongest predisposing factor for asthma. Chronic exposure to airway irritants or allergens also increases the risk for developing asthma. Common allergens can be seasonal (eg, grass, tree, and weed pollens) or perennial (eg, mold, dust, roaches, or animal dander). Common triggers for asthma symptoms & exacerbations in patients with asthma include airway irritants (eg, air pollutants, cold, heat, weather changes, strong odors or perfumes, smoke), other triggers (exercise, stress or emotional upsets, sinusitis with postnasal drip, medications, viral respiratory tract infections, and gastroesophageal reflux).  A patient’s asthma condition will change depending upon the environment, activities, management practices, and other factors.  Pathophysiology The underlying pathology in asthma is reversible and diffuse airway inflammation. The inflammation leads to obstruction from the following: swelling of the membranes that line the airways (mucosal edema)… ↓ airway diameter; contraction of the bronchial smooth muscle encircles the airways (bronchospasm), ↑narrowing; and increased mucus production, which diminishes airway size and may entirely plug the bronchi. The bronchial muscles and mucus glands enlarge; thick, tenacious sputum is produced; & the alveoli hyperinflate. Airway subbasement membrane fibrosis (called airway “remodeling”) may occur in response to chronic inflammation.  The fibrotic changes in the airway lead to airway narrowing and potentially irreversible airflow limitation Cells that play a key role in the inflammation of asthma are mast cells, neutrophils, eosinophil, and lymphocytes. Mast cells, when activated, release several chemicals mediators (histamine, bradykinin, prostaglandins, and leukotrienes) which perpetuate the inflammatory response, causing increased blood flow, vasoconstriction, fluid leak from the vasculature, attraction of WBC to the area, and bronchoconstriction alpha- and beta2-adrenergic receptors of the sympathetic nervous system are located in the bronchi.  When the alpha-adrenergic receptors are stimulated, bronchoconstriction occurs; when beta2-adrenergic receptors are stimulated, bronchodilation results. The balance between alpha and beta2 receptors is controlled primarily by cyclic adenosine monophosphate (cAMP). Alpha-adrenergic receptor stimulation results in a decrease in cAMP, which leads to an increase of chemical mediators released by the mast cells and bronchoconstriction. Beta2-receptor stimulation results in increased levels of cAMP, which inhibits the release of chemical mediators and causes bronchodilation  Clinical Manifestations The 3 most common symptoms of asthma: cough, dyspnea, and wheezing. Asthma attacks often occur at night or early in the morning, possibly due to circadian variations that influence airway receptor thresholds. Asthma exacerbation may begin abruptly…but most frequently is preceded by increasing symptoms over the previous few days.  cough, with or without mucus production. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and then possibly during inspiration as well. Generalized chest tightness and dyspnea occure In exacerbation (diaphoresis, tachycardia, widened pulse pressure, central cyanosis)  Assessment and Diagnostic Findings A complete Hx: family, environmental, and occupational… are primarily associated with asthma Environmental factors: seasonal changes, high pollen counts, mold, climate changes (cold air), & air pollution,. Occupation-related chemicals and compounds: metal salts, wood & vegetable dust, medications (eg, aspirin, antibiotics, cimetidine), industrial chemicals and plastics, biologic enzymes (eg, laundry detergents), animal & insect dusts, sera, and secretions. Comorbid conditions accompany asthma: gastroesophageal reflux, drug-induced asthma, and allergic bronchopulmonary aspergillosis. Other allergic reactions (eczema, rashes, & temporary edema)  Diagnostic findings Eosinophilia ( increase eosinophil) IgE elevated if allergy is present ABG’s Analysis (hypoxemia, respiratory alkalosis  Prevention Patients with recurrent asthma should undergo tests to identify the substances that precipitate the symptoms. Possible causes are dust, dust mites, roaches, certain types of cloth, pets, horses, detergents, soaps, certain foods, molds, and pollens. If the attacks are seasonal, pollens can be strongly suspected. Teaching pt to avoid the causative agents whenever possible. Knowledge is the key to quality asthma care. National guidelines are available for the care of the asthma pt, yet health care providers may not follow them.  Complications Complications of asthma may include status asthmaticus, respiratory failure, pneumonia, and atelectasis. Airway obstruction, particularly during acute asthmatic episodes, often results in hypoxemia, requiring the administration of oxygen and the monitoring of pulse oximetry and ABG. Fluids are administered because people with asthma are frequently dehydrated from diaphoresis and insensible fluid loss with hyperventilation.  Medical Management Immediate intervention is necessary because the continuing and progressive dyspnea leads to increased anxiety, aggravating the situation.  PHARMACOLOGIC THERAPY Two general classes of asthma medications: - Long-acting medications: to maintain control of persistent asthma - Quick-relief medications for immediate treatment of asthma symptoms and exacerbations Control of persistent asthma: accomplished primarily with regular use of anti inflammatory medications,. These medications have systemic side effects when used long term.  The route of choice for administration of these medications is the Metered Dose Inhalers (MDI) because it allows for topical administration. The success of inhaled therapy is the proper use of the MDI Portable nebulazer Examples of Metered Dose Inhalers, and Spacers A Metered Dose Inhaler and Spacer in Use  Long-Acting Control Medications Corticosteroids: alleviating symptoms, improving airway function, and decreasing peak flow variability. Initially, the inhaled form is used...A spacer should be used with inhaled corticosteroids & the pt should rinse the mouth after administration (to prevent thrush, a common complication of inhaled corticosteroid). Long-acting beta2-adrenergic agonists (used with anti-inflammatory medications): to control asthma symptoms, particularly those occur at night… Also to prevent exercise-induced asthma. Long-acting beta2-adrenergic agonists are not indicated for immediate relief of symptoms.  Quick-Relief Medications Short-acting beta-adrenergic agonists (Ventolin) relieve acute symptoms and prevent exercise-induced asthma. They have a rapid onset of action. Anticholinergics (eg, [Atrovent]) may bring added benefit in severe exacerbations, but they are used more frequently in COPD patients.  Nursing Management The immediate nursing care of the pt with asthma depends on the severity of the symptoms. The pt and family are often frightened and anxious because of the patient’s dyspnea. Thus, an important aspect of care is a calm approach. Assesses pt’s respiratory status: monitor the severity of symptoms, breath sounds, peak flow, pulse oximetry, and vital signs.  Obtains a hx of allergic reactions to medications before administering medications  Identifies pt’s current use of medications.  Administer medications as prescribed and monitor the pt’s responses to it.  Fluids administered if the pt is dehydrated  Antibiotic agents: prescribed if the pt has an underlying respiratory infection.  If the pt requires intubations because of acute respiratory failure: assists with intubations procedure, close monitor of pt, and keep pt & family informed about procedures.  Patient Teaching The nature of asthma as a chronic inflammatory disease Definition of inflammation and bronchoconstriction Purpose & action of medications Identification of triggers and how to avoid them Proper inhalation techniques How to perform peak flow monitoring How to implement an action plan When and how to seek assistance Using a Peak Flow Meter  PEAK FLOW MONITORING: Peak flow meters measure the highest airflow during a forced expiration The pt is instructed in the proper technique, particularly to give maximal effort. The “personal best” is determined after monitoring peak flows for 2 or 3 weeks after receiving optimal asthma therapy. The green (80% to 100% of personal best), yellow (60% to 80%), and red (less than 60%) zones are determined, and specific actions are delineated for each zone. Pulmonary Embolism and COPD  Pulmonary Embolism  Obstruction of pulmonary artery or branch by blood clot (most common & usually arises from peripheral vein), air, fat, amniotic fluid, or septic thrombus  Obstructed area has diminished or absent blood flow ◦ Although area is ventilated, no gas exchange occurs (dead space)  Inflammatory process causes regional blood vessels, bronchioles to constrict, further increasing pulmonary vascular resistance, pulmonary arterial pressure, right ventricular workload  Ventilation-perfusion imbalance, right ventricular failure, shock  Risk Factors:  Venous stasis: Prolonged immobility,  Hypercoagulabilty  Venous endothelial disease: Deep Vein Thrombosis (DVT) & thrombophlebitis  Certain disease states: heart disease (HF), trauma (fracture of hip), postoperative (orthopedic, abdominal) /postpartum, diabetes mellitus (DM), COPD.  Other conditions: Advance age (>50 years), pregnancy, obesity, oral contraceptive use, constrictive clothing, history of PE, DVT, & thrombophlebitis Clinical Manifestation: depend on the size of thrombus and the area occluded Dyspnea most frequent symptoms Tachypnea most frequent sign Chest pain (sudden, substernal, pleuritic in origin) Anxiety, fever, tachycardia, cough, apprehension, hemoptysis, diaphoresis and syncope  Diagnostic Finding  Death occurs within one hour  Cheast X-Ray ( show infiltrate, atelectasis, elevation of diaphragm on the affected side, pleural effusion)  ECG (sinus tachycardia, PR interval depression,  Arterial Blood Gases (ABG’s) ( hypoxemia, hypocapnia from tachypnea)  Ventilation (V) Perfusion (Q) scan: second choice, evaluate different areas in the lungs and compare the V/Q in each area after IV administration of contrast agent and scan.  Diagnostic Finding CT scan for the lung D-diamer assay: blood test for evidence of blood clot. ↑ indicates clotting abnormality such as (hypercoagulability) Pulmonary angiography, (first choice): injection of dye under fluoroscopy through a catheter that goes to vena cava (right side of the heart) to discover the thrombus  Prevention – Exercises to avoid venous stasis – Early ambulation – Anticoagulant therapy (heparin, and low molecular weight heparin: Enoxaparin) – Sequential compression devices (SCDs) as elastic stocking: prevent venous stasis,  Drink water while traveling Stop for a 10 minute break every hour during a road trip Walk around the cabin every hour if you are flying Wear compression stockings Take anticoagulant medication before surgery Elevate your legs after surgery. Exercise at least 25 minutes per day Avoid smoking Maintain a balanced diet Prevention  Medical Management: Purpose to lyse the emboli and prevent new one from forming General measures to improve respiratory and vascular status Anticoagulant therapy: (Heparin and Warfarin) Thrombolytic therapy: ( streptokinase, urokinase) Check partial thromboplastin time (PTT), international normalized ratio (INR), hematocrit (HCT), & platelets count Surgical intervention: (embolectomy) done for Pts who fail to improve with medications or medications were contraindicated  Nursing Management Minimize the risk of PE Preventing thrombus formation: - Early ambulation after surgery, - Leg exercises to avoid venous stasis, avoid dangling of legs, and feet should rest on floor. - Care of IV devices, Assessing potential of PE: risk factors Monitoring thrombolytic therapy Managing O2 therapy Relieving anxiety Providing post op care: vital signs (VS), urinary output (UO), elevation of legs, isometric exercise, elastic stocking, and avoid sitting to prevent hip flexion Monitoring for complications  Chronic Obstructive Pulmonary Disease (COPD) A disease state characterized by airflow limitation that is not full reversible (GOLD: Global initiative for chronic obstructive lung disease). COPD is currently the 4th leading cause of death and the 12th leading cause of disability in US. COPD includes diseases that cause airflow obstruction (emphysema, chronic bronchitis) or a combination of these disorders. Asthma is now considered a separate disorder but can coexist with COPD.  Pathophysiology Airflow limitation is progressive and associated with abnormal inflammatory response of the lungs to noxious agents or gases Inflammatory response occurs throughout the airways, lung parenchyma, and pulmonary vasculature. Scar tissue and narrowing occur in airways. Substances activated by chronic inflammation (proteinase and antiproteinase) damage the parenchyma of lungs. Inflammatory response causes changes in pulmonary vasculature.  Chronic Bronchitis Cough with sputum production on most days for 3 months of a year for 2 consecutive years. Smoke and air pollutants irritation of airways results in inflammation and hypersecretion of mucus. Hallmark goblet cell and mucus glands increase in number & size Ciliary function is reduced (more mucus produced), bronchial walls thicken (due to infiltration of the bronchial wall with inflammatory cell), bronchial airways narrow, and mucus may plug airways Alveoli become damaged and fibrosed, and alveolar macrophage function diminishes. The patient is more susceptible to respiratory infections. Pathophysiology of Chronic Bronchitis  Emphysema Abnormal distention of air spaces beyond the terminal bronchioles with destruction of alveoli walls Decreased alveolar surface area causes an increase in “dead space” & impaired O2 diffusion (hypoxemia). Reduction of the pulmonary capillary bed increases pulmonary vascular resistance and pulmonary artery pressures. Hypoxemia is the result of these pathologic changes. Increased pulmonary artery pressure may cause right- sided heart failure (cor pulmonale). Changes in Alveolar Structure with Emphysema  Risk Factors for COPD Tobacco smoke causes 80-90% of COPD cases! Passive smoking Occupational exposure Ambient air pollution Genetic abnormalities – Alpha1-antitrypsin deficiency: enzyme that protect the lungs’ tissues from destruction  Clinical Manifestation 3 primary symptoms: 1. Chronic cough 2. Sputum production 3. Dyspnea on exertion Wt loss Barrel chest (A-P diameter/ Transverse diameter : 2/1) Retraction in the supraclavicular area on inspiration Shrug shoulder Abdominal muscle contraction on inspiration. Typical Posture of a Person with COPD  Diagnostic finding Health history (exposure to risk factor, past medical history, family Hx) Pulmonary function test Spirometry (FEV1\FVC) = 48hr’s after admission in pt with no evidence of infection at the time of admission - Organism responsible as: Enterobacter species (EC), Klebseilla species, Staphylococcus.aureus, S.pneumoniae. Pneumonia in the immunocompromised host: - Include Pneumocystis Carinii Pneumonia (PCP), fungal pneumonia, mycobacterium tuberculosis. - The organism that causes CPC now known as Pneumocystis jiroveci Pneumonia - Occur with use of corticosteroid, chemotherapy, AIDs, and other factor that cause CAP and HAP Aspiration Pneumonia: - Refer to the pulmonary consequences resulting from entry of endogenous or exogenous substances into the lower airway….(most commonly: bacteria reside normally in URT) - Common pathogens: S. pneumonia, H.influanzae, S.aureus - Other causes aspiration of gastric content, irritating gases.  Pathophysiology Affect both ventilation and perfusion (V/Q) Inflammatory reaction occur in the alveoli produce exudates which interfere with diffusion of O2 and CO2 Area of lungs not adequately ventilated If one or more lobes is involved this called “lobar pneumonia”, the entire lobe of lung consolidated. If one or more localized area within the bronchi and extending to the surrounding parenchyma this called “bronchopneumonia” , patchy area of consolidation occur Bronchopneumonia more common than lobar pneumonia  Risk Factors Cancer, smoking, COPD (produce mucus, or obstruct bronchus Immunocompromised pt Prolonged immobility and shallow breathing Depressed cough reflex, aspiration of foreign material Alcoholism GA, sedative Advance age Respiratory therapy with improperly cleaned equipment Transmission of organisms from staff of health care.  Clinical Manifestation Sudden onset of chills, rapid raising fever (38.5 – 40.5o) Pleuritic chest pain (↑with deep breathing& coughing Orthopnea & Tachypnea ( 25 – 45b\m) Rapid bounding pulse In sever cases: cheeks flushed & the lips with nail beds become cyanosed. Decrease appetite, fatigue Purulent sputum Crackles, PE: increased tactile fremitus, dullness on percussion, bronchial breathing sounds, egophony and whispered pectoriloquy..  Diagnostic Finding Hx (recent respiratory tract infection) Physical examination Chest X-ray Blood culture Sputum culture  Medical Management Supportive treatment includes Fluids, Oxygen for hypoxia, Antipyretics, Antitussives, decongestants, and antihistamines. Antibiotic therapy (determined by Gram stain results) Antibiotics are not indicated for viral infections but are used for secondary bacterial infection  Collaborative Problems Shock Respiratory failure Atelectasis Pleural effusion confusion  Nursing Process: The Care of the Patient with Pneumonia: Assessment Changes in temperature and pulse Secretions (amount, odor, color) Cough (frequency and severity) Tachypnea and shortness of breath Changes in physical assessment, especially inspection and auscultation of the chest Changes in CXR findings Changes in mental status, fatigue, dehydration, and concomitant heart failure, especially in elderly patients  Nursing Process: The Care of the Patient with Pneumonia: Diagnosis Ineffective airway clearance R\T copious tracheobronchial secretions. Activity intolerance R\T impaired respiratory function. Risk for fluid volume deficit R\T fever and rapid respiratory rate Imbalanced nutrition: less than body requirements Deficient knowledge regarding treatment regimen and preventive health measure.  Nursing Process: The Care of the Patient with Pneumonia: Planning Improved airway clearance Maintenance of proper fluid volume Maintenance of adequate nutrition Patient understanding of treatment and prevention Absence of complications (Assessment) Promote rest and conserve energy.  Improving Airway Clearance Encourage hydration: 2-3 L/day, unless contraindicated Humidification may be used to loosen secretions; by face mask or with oxygen Coughing techniques Chest physiotherapy Position changes Oxygen therapy administered to patient needs  Other Interventions Promoting rest – Encourage rest and avoidance of overexertion. – Positioning to promote rest and breathing (semi- Fowler’s) Maintaining nutrition – Provide nutritionally enriched foods and fluids. Patient teaching  Pleural Condition Disorders involve the membranes cover the lung (Visceral ) and the surface of chest wall (parietal) or the space between pleura. Pleurisy Pleural Effusion Empyema  Pleurisy Inflammation of both layers of the pleura Developed due to: pneumonia, TB, trauma to the chest wall, PE, URTI, metastatic cancer. C\M: Pleuritic pain: (local or radiated, usually on one side; ↑with deep breath &cough). Pain ↓when hold breathing, & as pleural fluid develop Dx Finding: Pleural friction rub, CXR, Sputum examination, Thoracentesis, pleural biopsy.  Medical Management: - Discover the underlying condition - Monitor S&S of pleural effusion - Analgesic - NSAID’s Nursing Management: - Place pt on the affected side - Instruct pt to use hands or pillows to splint the rib cage while coughing.  Pleural Effusion A collection of fluid in the pleural space It is occur due to other disease (HF, TB, pneumonia, pulmonary infections (viral), nephrotic syndrome. Normal pleural fluid amount (5-15ml)  Pathophysiology: - Due to accumulation of clear fluid (exudative or transudative) in the pleural space - Transudate: filtrate of plasma moves across intact capillary wall, low in protein (due to Alt. in the formation or reabsorption of pleural fluid) commonly due to heart failure - Exudate: extravasations of fluid into tissue or cavity. Due to inflammation or or tumor in pleural space. - Increase fluid cause compression on lung tissue affect lung expansion.  C\M: Depend on the underlying cause: If due to - Pneumonia (fever, chills, pleuratic chest pain) - Malignant causes (dyspnea, difficulty lying flat, coughing) Severity of symptoms depends on the size of effusion: -Large effusion causes dyspnea, -Moderate effusion causes minimal or no dyspnea. Dx finding: Decrease or absent Breathing sounds SOB Decreased fremitus on palpation Percussion (dullness) In severe effusion: Mediastinum shifts toward (unaffected side). Tracheal deviation away from affected side CXR, chest CT, Thoracentesis (confirm presence of fluid Pleural fluid analysis Pleural biopsy Normal X Ray Decubitus X Ray  Medical Management: - Directed towered the underlying cause - Thoracentesis to remove fluid and obtain specimen - Chest tube connected to water sealed drainage system - Pleurodesis for malignant effusion Nursing Management: - Prepare pt for thoracentesis and specimen - Monitor the chest tube - Place pt on comfortable position - Pain management  Empyema  Accumulation of thick, purulent fluid in the pleural space  Fibrin development and loculated area at the place of infection  Pathophysiology: - Occur as a complication of bacterial pneumonia or lung abscess, penetrating lung trauma. - First pleural fluid is thin and with low leukocyte - Then it become fibropurulent - Finally lung encloses with thick exudative membrane (loculated empyema)  C\M: fever, night sweat, pleural pain, cough, dyspnea, anorexia, Wt loss  Dx finding: decrease breathing sound over the affected area, dullness, decrease fermitus, chest CT  Medical management: Objective: to drain the pleural cavity to achieve lung expansion - AB for 4-6weeks - Thoracentesis (needle aspiration) [small volume, not too purulant fluid] - Tube thoracostomy (chest drainage) with fibrinolytic agent - Open chest drainage with rib resection: to remove thickened pleura & debris the diseased pulmonary tissue  Nursing management: - Help pt cope with condition - Instruct pt in lung expansion exercise - Care to the method of drainage to remove pleural fluid  Pulmonary Edema  Abnormal accumulation of fluid in the lung tissue, the alveolar space, or both  Pathophysiology: - Increase microvascular pressure in pulmonary vasculature ( inadequate left ventricular function - Rapid shift of fluid from the plasma to pulmonary interstitial tissue and alveoli - Causes impaired gas exchange  C\M: Respiratory distress : dyspnea, air hunger, central cyanosis. Anxiety, agitation, foam, frothy blood tinged sputum, confusion.  Dx finding: - Crackles in the base of the lung (posterior base) - Tachycardia - Decrease O2 saturation - ABG’s: hypoxemia  Medical Management: - Vasodilators, & medication enhance contractility of the heart - If fluid overload is the cause diuretic is administered with fluid restriction - O2 for hypoxemia - Morphine to decrease pain and control anxiety. - Mechanical ventilator  Nursing Management: - Administer O2, medication and monitor pt responses