Medsurg Nursing: Upper Respiratory & Lung Disorders PDF

​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Chapter 18 ​ ​ ​ ​ ​ ​ Management of Patients with Upper Respiratory Tract Disorders ​ ​ ​ ​ ​ ​ Learning Outcomes ​ ​...

​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Chapter 18 ​ ​ ​ ​ ​ ​ Management of Patients with Upper Respiratory Tract Disorders ​ ​ ​ ​ ​ ​ Learning Outcomes ​ ​ ​ ​ ​ ​ 1.Describe nursing management of pt.'s with upper airway disorders & of pt.'s with epistaxis. ​ ​ ​ ​ ​ ​ 2.Compare & contrast the upper respiratory tract infections according to cause, incidence, clinical manifestations, management, & the significance of preventive health care. ​ ​ ​ ​ ​ ​ 3.Use the nursing process as a framework for care of the pt. with upper airway infection. ​ ​ ​ ​ ​ ​ Upper Airway Infections (URIs) ​ ​ ​ ​ ​ ​ Most common cause for illness, reason for seeking health care & absences from school & work ​ ​ ​ ​ ​ ​  May be minor, acute, chronic, severe, or life threatening​ Treated in community settings: doctor offices, urgent care clinics, long- ​ ​ ​ ​ ​ ​ term care facilities, or self-care at home​ Early detection of signs & symptoms & appropriate interventions can ​ ​ ​ ​ ​ ​ avoid unnecessary complications​ pt. teaching focus on prevention & health promotion Special considerations for older adults: Refer to Chart 18-1 ​ ​ ​ ​ ​ ​ URIs ​ ​ ​ ​ ​ ​ Rhinitis & rhinosinusitis: acute, chronic, bacterial, viral (Charts 18-2 & 18-3) ​ ​ ​ ​ ​ ​ Pharyngitis: acute, chronic Tonsillitis​ Laryngitis ​ ​ ​ ​ ​ ​ Viral Rhinitis​ aka Common Cold ​ ​ ​ ​ ​ ​ Symptoms 2-3 days after infection ​ ​ ​ ​ ​ ​ Runny nose, watery eyes, nasal congestion, sneezing, coughing, sore throat, fever, HA, fatigue ​ ​ ​ ​ ​ ​ Lasts 7-10 days​ Management: Symptom relief NOT antibiotics ​ ​ ​ ​ ​ ​ –Rest, fluids, antipyretics, analgesics ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 3 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 4 ​ ​ ​ ​ ​ ​ 5 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 2/19/25 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Copyright 2015 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 1 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 6 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Management: Symptom relief NOT antibiotics –Rest, fluids, antipyretics, analgesics​ –Warm salt gargles ​ ​ ​ ​ ​ ​ ​ –8 oz. warm water, 1 tsp. salt, 1 tsp baking soda –Saline nasal spray- don’t share​ –Lozenges, ice chips​ –OTC Antihistamines, decongestants –Echinacea- care with flower allergies, vit. C, Zinc ​ ​ ​ ​ ​ ​ ​ Education​ –S&S of worsening, avoid crowds/sick people, good hand hygiene –Chronic disease- sputum changes, SOB, chest tightness ​ ​ ​ ​ ​ ​ ​ Influenza aka Flu ​ ​ ​ ​ ​ ​ ​ Highly Contagious = ↑morbidity & mortality​ Classified by: A, B, C, D​  A = most common​ Droplet transmission, aerosolized particles, contaminated surfaces Peak season: December to February ​ ​ ​ ​ ​ ​ ​ –Abrupt onset: 7 days chills, fever, myalgia, HA, cough sore throat, fatigue ​ ​ ​ ​ ​ ​ ​ –Culture- swab​ –Prevention (flu vaccine starting in September)​ –Symptom relief- rest, hydration, analgesics, antipyretics, Tamiflu. ​ ​ ​ ​ ​ ​ ​ Pharyngitis​ Nursing Interventions for the Patient with URI ​ ​ ​ ​ ​ ​ ​ Elevatehead​ Ice collar to reduce inflammation & bleeding​ Hot packs to reduce congestion​ Analgesics for pain​ Topical anesthetics​ Monitor for severe complications​ Gargles for sore throat​ Use alternative communication​ Encourage liquids & use of room vaporizers or steam inhalation to ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 789 ​ ​ ​ ​ ​ ​ ​ 10​ 1 ​ ​ ​ ​ ​ ​ ​ 2 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 11 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 11 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Use alternative communication​ Encourage liquids & use of room vaporizers or steam inhalation to ​ ​ ​ ​ ​ ​ keep secretions loose & moist for easier expectoration Rest ​ ​ ​ ​ ​ ​ Epistaxis aka Nosebleed ​ ​ ​ ​ ​ ​ First aid:​ –Sitting position, lean forward, w/ head tilted forward; direct pressure ​ ​ ​ ​ ​ ​ lower part nose for 5 to 15 minutes Medical management ​ ​ ​ ​ ​ ​ –Packing, balloon, vasoconstrictor, chemical/thermal cauterization, embolization ​ ​ ​ ​ ​ ​ –Monitor respiratory status, LOC, VS, pulse ox, dyspnea, & dysphagia –Administer analgesia & antibiotics​ –Premedicate before removal of packing ​ ​ ​ ​ ​ ​ Patient education:​ –Humidifier or nasal spray​ –Sneeze w/ mouth open​ –Avoid aspirin & NSAIDs​ –Avoid vigorous nose blowing, strenuous activity, lifting or straining for ​ ​ ​ ​ ​ ​ 4 to 6 weeks, nose picking​ –If bleeding does not stop in 15 mins. seek medical attention ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Chapter 12​ Management of Patients with Oncologic Disorders ​ ​ ​ ​ ​ ​ 2 Chapter Objectives​ ́Discuss the role of the nurse in the prevention & management of ​ ​ ​ ​ ​ ​ cancer.​ ́Compare & contrast the goals of cancer care in prevention, ​ ​ ​ ​ ​ ​ diagnosis, cure, control, & palliation.​ ́Describe the role of surgery, radiation therapy, chemotherapy, ​ ​ ​ ​ ​ ​ hematopoietic stem cell transplantation, immunotherapy, & targeted therapy in the treatment of cancer. ​ ​ ​ ​ ​ ​ ́Use the nursing process as a framework for the care of the pt. with cancer throughout the disease trajectory, from the time of diagnosis, to survivorship, & at the end of life. ​ ​ ​ ​ ​ ​ 3 Development of Cancer​ ́Carcinogenic agents: chemical, radiation, viral, etc. ​ ​ ​ ​ ​ ​ ́Viruses, sunlight, radiation, asbestos ́Lifestyle factors: smoking, alcohol, diet, obesity ́Genetic, familial factors (chart 12-1) ​ ​ ​ ​ ​ ​ ́Latent period​ ́clinically evident, tumor must reach a critical mass for detection ​ ​ ​ ​ ​ ​ ́Progression ́Characterized by ​ ​ ​ ​ ​ ​ ́↑ growth rate of tumor ́↑ invasiveness ́Metastasis ​ ​ ​ ​ ​ ​ ́́ ​ ​ ​ ​ ​ ​ 4 Main Sites of Metastasis 5 Prevention is Key ​ ​ ​ ​ ​ ​ Public education​ ́Primary, secondary, tertiary prevention​ ́Encourage awareness & participation in health-promoting behaviors ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 67 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 1 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ́Recommended cancer screenings ́Self-examination​ ́Know warning signs of cancer​ ́Seek medical care if cancer is suspected ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 2/19/25 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ́Seek medical care if cancer is suspected ́ ​ ​ ​ ​ ​ ​ 6 ​ ​ ​ ​ ​ ​ 7 Prevention & Detection of Cancer Lifestyle habits to reduce risks ​ ​ ​ ​ ​ ​ §Avoid/reduce exposure to known or suspected carcinogens §Cigarette smoke, excessive sun exposure ​ ​ ​ ​ ​ ​ §Balanced diet​ §Limit alcohol intake​ §Exercise regularly & maintain healthy weight §Get adequate rest​ §Eliminate, reduce, or cope w/stress​ §Have a regular health examination ​ ​ ​ ​ ​ ​ §Be familiar with your family history ​ ​ ​ ​ ​ ​ §Know your risk factors ́ ​ ​ ​ ​ ​ ​ 8 Diagnoses of Cancer​ ́Pt. may experience fear & anxiety ​ ​ ​ ​ ​ ​ ́Actively listen to pt.’s concerns ́Manage your own discomfort ​ ​ ​ ​ ​ ​ ́Avoid false reassurance, redirecting discussion, & using technical language ​ ​ ​ ​ ​ ​ ́Give clear explanations; repeat if necessary ́Give written information for reinforcement ́Refer to oncology team when possible ​ ​ ​ ​ ​ ​ ́ ​ ​ ​ ​ ​ ​ 9 Classification of Cancer 1 Whyweclassify? ​ ​ ​ ​ ​ ​ ́Benign vs. malignant Benign- not cancerous Malignant- cancerous ​ ​ ​ ​ ​ ​ ́Anatomic site- Tissue origin ​ ​ ​ ​ ​ ​ ́Histology​ Grading severity ​ ​ ​ ​ ​ ​ Grade I ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 2 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Grading severity Grade I Grade II Grade III Grade IV ​ ​ ​ ​ ​ ​ 2 ́Extent of disease Staging ​ ​ ​ ​ ​ ​ 0: Cancer in situ​ I: Tumor limited to tissue of origin; localized tumor growth II: Limited local spread​ III: Extensive local & regional spread​ IV: Metastasis ​ ​ ​ ​ ​ ​ §TNM chart 12-3​ Tumor size & invasiveness (T) Spread to lymph nodes (N) Metastasis (M) ​ ​ ​ ​ ​ ​ § ​ ​ ​ ​ ​ ​ 10 Diagnoses of Cancer​ Tumor markers- protein detected in blood ​ ​ ​ ​ ​ ​ ́CEA carcinoembryonic antigen ​ ​ ​ ​ ​ ​ ́PSA prostate specific antigen​ CT, MRI, Ultrasound, radioisotope scan, x-ray, PET scan Direct visualization ​ ​ ​ ​ ​ ​ ́endoscopy ​ ​ ​ ​ ​ ​ ́laparoscopy​ Blood tests (CBC, chemistry profile) ​ ​ ​ ​ ​ ​ ́Begin to memorize normal levels Biopsy ​ ​ ​ ​ ​ ​ ́ ​ ​ ​ ​ ​ ​ 11 Cancer Management Goals ​ ​ ​ ​ ​ ​ ́Cure- eradication​ ́Control-​ ́Palliation- relief or control of symptoms ​ ​ ​ ​ ​ ​ 12 Surgery 13 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 12 Surgery​ 13 Radiation Therapy ​ ​ ​ ​ ​ ​ Targets rapidly multiplying cells...but kills other cells within its path ​ ​ ​ ​ ​ ​ ́Cure, control (combined w/surgery & chemotherapy; or to shrink tumor), palliative ​ ​ ​ ​ ​ ​ Low-energy beams Expend energy quickly Penetrate a short distance Useful for skin lesions ​ ​ ​ ​ ​ ​ High-energy beams​ Greater depth of penetration​ Optimal dosing of internal targets while sparing skin ​ ​ ​ ​ ​ ​ Doses divided, typically 1/day for 5 days a week for 2- 8 weeks ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 14 Treatment Simulation ​ ​ ​ ​ ​ ​ Planning for treatment Treatment ​ ​ ​ ​ ​ ​ External ​ ​ ​ ​ ​ ​  Internal- brachytherapy​ ALARA (as low as reasonable achievable) Time, distance, & shielding ​ ​ ​ ​ ​ ​ 15 Chemotherapy​ Antineoplastic therapy- chemicals as a systemic therapy. ​ ​ ​ ​ ​ ​ Can offer cure, control, or palliative care ́Effect on cells ​ ​ ​ ​ ​ ​ Effective against dividing cells, so cancer cells escape death by staying in G0 phase (resting phase)​ ØClassified by ​ ​ ​ ​ ​ ​ Molecular structure ​ ​ ​ ​ ​ ​ Mechanism of action ØTwo major categories ​ ​ ​ ​ ​ ​ Cell cycle phase nonspecific & specific ØTypically given in combination ​ ​ ​ ​ ​ ​ ́ ​ ​ ​ ​ ​ ​ 16 Chemotherapy Effects on Normal Tissue Cannot distinguish between normal &cancer cells ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 17 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 16 Chemotherapy Effects on Normal Tissue Cannot distinguish between normal &cancer cells ​ ​ ​ ​ ​ ​ Acute Delayed Chronic ​ ​ ​ ​ ​ ​ 17 Nursing Issues with Chemotherapy​ Requires specific training, only properly trained staff should handle ​ ​ ​ ​ ​ ​ cancer drugs​ Pt teaching about side effects, how long they will last ́Routes ​ ​ ​ ​ ​ ​ Oral​ IM​ IV most common ​ ​ ​ ​ ​ ​ ØCentral venous access device (CVAD) Regional- directly into tumor ​ ​ ​ ​ ​ ​ 18 Preparation & Handling of Chemotherapy Agents ́May pose an occupational hazard​ ́Drugs may be absorbed through ​ ​ ​ ​ ​ ​ Skin ​ ​ ​ ​ ​ ​ Inhalation during preparation, transportation, & admin ́Only properly trained personnel should handle cancer drugs ​ ​ ​ ​ ​ ​ 19 Nursing Management Common side effects ​ ​ ​ ​ ​ ​ Bone marrow suppression: infection Fatigue​ GI disturbances: N&V Integumentary & mucosal reactions Pulmonary effects ​ ​ ​ ​ ​ ​ Reproductive effects Review pages 325-327 ​ ​ ​ ​ ​ ​ 20 Hematopoietic Stem Cell Transplantation (HSCT)​ Bone Marrow Transplant (BMT)​ Allows high doses for treatment​ ́Failing to respond to standard doses of chemotherapy or radiation ́Develop resistance (refractory) ​ ​ ​ ​ ​ ​ ́Many risks & possible death (Graft-VS- Host Disease) 21 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 20 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ́Develop resistance (refractory)​ ́Many risks & possible death (Graft-VS- Host Disease)​ ́Tumor cells eliminated & bone marrow is rescued by infusing healthy ​ ​ ​ ​ ​ ​ ​ cells ​ ​ ​ ​ ​ ​ ​ 21 Immunotherapy & Targeted Therapy​ Immunotherapy uses the immune system to fight cancer ​ ​ ​ ​ ​ ​ ​ ́Boost or manipulate the immune system & create an environment not conducive for cancer cells to grow ​ ​ ​ ​ ​ ​ ​ ́Attack cancer cells directly​ Targeted therapy interferes by targeting cell receptors pathways ​ ​ ​ ​ ​ ​ ​ involved in tumor growth ​ ​ ​ ​ ​ ​ ​ Side effects: anorexia/weight loss, fatigue, malaise, weakness, n & v, photosensitivity, tachycardia, orthostatic hypo, CNS, hepatotoxicity, renal system​ Table 12-8 ​ ​ ​ ​ ​ ​ ​ 22 Hormone Therapy Sex hormones ​ ​ ​ ​ ​ ​ ​ ́Hormone therapy blocks the effects of the hormone & stops growth of cancer cells ​ ​ ​ ​ ​ ​ ​ ́Surgical interventions (oophorectomy, castration) remove effects of hormones ​ ​ ​ ​ ​ ​ ​ Corticosteroids​ ́Used in combination w/drug regimens to help curb side effects ́Reduces swelling & inflammation ​ ​ ​ ​ ​ ​ ​ 23 Nursing Care of Patients with Cancer ́Tissue integrity- stomatitis, alopecia ​ ​ ​ ​ ​ ​ ​ ́Nutrition- sore mouth, taste, anorexia, malabsorption, cachexia syndrome ​ ​ ​ ​ ​ ​ ​ ́Infection​ ́Oncologic emergencies: table 12-13 ́Pain- table 12-9​ ́Coping with cancer & treatment ́Cancer survivorship ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ hapter 33​ Assessment and Management of Patients with Allergic Disorders ​ ​ ​ ​ ​ ​ 2 Allergic Rhinitis Classified: ​ ​ ​ ​ ​ ​ ØSeasonal or perennial ØEpisodic, intermittent, persistent ​ ​ ​ ​ ​ ​ Ex: seasonal- spring & fall, pollens from trees, flowers, etc. pollen counts are high symptoms develop 4- 8 hrs. after exposure ​ ​ ​ ​ ​ ​ Sneezing, watery, itchy eyes & nose, altered smell, thin watery nasal discharge, postnasal drip, cough, chronic exposure = HA, sinus pressure, nasal congestion, hoarseness​ Management ​ ​ ​ ​ ​ ​ ØIdentify & avoid triggers​ Ø↓ inflammation & symptoms ​ ​ ​ ​ ​ ​ nasal corticosteroid sprays, antihistamines, decongestants, immunotherapy ​ ​ ​ ​ ​ ​ § ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Chapter 19​ Management of Patients with Chest & Lower Respiratory Problems ​ ​ ​ ​ ​ ​ 2 Learning Outcomes ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Identify patients at risk for atelectasis and the nursing interventions​ ​ ​ ​ ​ ​ ​ ​ ​ ​ related to its prevention and management.​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Compare the various pulmonary infections with regard to causes, clinical manifestations, nursing management, complications, and prevention.​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Describe preventive measures appropriate for controlling and eliminating occupational lung disease.​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Discuss the modes of therapy and related nursing management of patients with lung cancer.​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 3 Atelectasis​ Closure or collapse of alveoli​ Acute or chronic​ Most common is acute atelectasis, which occurs in the postoperative ​ ​ ​ ​ ​ ​ setting​ Symptoms: insidious, ↑ dyspnea, cough, crackles, ↓ breath sounds, ​ ​ ​ ​ ​ ​ and sputum production ​ ​ ​ ​ ​ ​ Acute: tachycardia, tachypnea, pleural pain, and central cyanosis if large areas of the lung are affected ​ ​ ​ ​ ​ ​ Chronic: similar to acute, pulmonary infection may be present ​ ​ ​ ​ ​ ​ 4 Nursing Interventions for Atelectasis Prevention ​ ​ ​ ​ ​ ​ Frequent turning​ Early mobilization​ Strategies to expand lungs and manage secretions Incentive spirometer​ Voluntary deep breathing​ Secretion management​ Pressurized metered-dose inhaler ​ ​ ​ ​ ​ ​ 5 Acute Tracheobronchitis ​ ​ ​ ​ ​ ​ Inflammation of lower respiratory tract, w/possible infection​ Cough is most common symptom can last as long as 3 wks.- clear to ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 2/19/25 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 1 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 5​ Inflammation of lower respiratory tract, w/possible infection​ Cough is most common symptom can last as long as 3 wks.- clear to ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 6 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ thick green​ HA, fever, malaise, dyspnea, chest pain, crackles or wheezes ​ ​ ​ ​ ​ ​  Diagnosed from symptoms, consolidation on x-ray Goal is to prevent pneumonia & treat symptoms ​ ​ ​ ​ ​ ​ Cough suppressants, oral fluid intake, humidifier Beta2 agonists- bronchodilators- inhalers (if wheezing) Antibiotics ONLY if evidence of infection​ No smoking, wash hands frequently, avoid irritants Antivirals if due to influenza ​ ​ ​ ​ ​ ​ Pneumonia ​ ​ ​ ​ ​ ​ Acute infection of lung tissue (parenchyma) Failure of defense mechanisms ​ ​ ​ ​ ​ ​ Mucous, cilia, cough reflex, epiglottis closure, reflex bronchoconstriction ​ ​ ​ ​ ​ ​ Risk factors Table 30.1 Entry to lungs ​ ​ ​ ​ ​ ​ Aspiration​ Inhalation of microbes​ Spread through blood from other body infection ​ ​ ​ ​ ​ ​ Bacteria, virus, fungus, parasite, chemicals & aspirated food ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 7​ 1 ​ ​ ​ ​ ​ ​ 2 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Classification & Types of Pneumonia ​ ​ ​ ​ ​ ​ Community acquired (CAP)​ Not hospitalized or in long-term care within 14 days of onset Health care associated (HCAP)/Hospital acquired (HAP)​ 48 hrs. after hospitalization & not present on admission Ventilator-associated (VAP)​ Multidrug-resistant organisms​ 48 hrs. after mechanical ventilation ​ ​ ​ ​ ​ ​ Viral​ Bacterial​ Mycoplasma- age 40 ↓​ Aspiration- ↓LOC, ↓ cough or gag reflex, swallowing issues, NG tube ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 8 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Mycoplasma- age 40 ↓ ​ ​ ​ ​ ​ ​ Aspiration- ↓LOC, ↓ cough or gag reflex, swallowing issues, NG tube w/or w/o tube feedings ​ ​ ​ ​ ​ ​ Necrotizing- rare​ Opportunistic (altered immune system) ​ ​ ​ ​ ​ ​ Pneumocystis jiroveci (carinii)- rare in healthy, fungal ​ ​ ​ ​ ​ ​ Cytomegalovirus (CMV)– after stem cell transplants ​ ​ ​ ​ ​ ​ Pneumonia Clinical Manifestations ​ ​ ​ ​ ​ ​ Cough (productive or nonproductive) (green, yellow, or rust-colored sputum), fever, chills, dyspnea, tachypnea, pleuritic chest pain, orthopnea ​ ​ ​ ​ ​ ​ Fine or coarse crackles​ With consolidation- egophony, ↑ fremitus With pleural effusion- dull percussion Older or debilitated pts. ​ ​ ​ ​ ​ ​ Confusion may be the only finding Hypothermia rather than fever Diaphoresis, H/A, anorexia, fatigue ​ ​ ​ ​ ​ ​ Diagnostic Tests ​ ​ ​ ​ ​ ​ History​ Physical exam​ Chest x-ray​ Sputum gram stain, culture & sensitivity ​ ​ ​ ​ ​ ​ Ideally before antibiotics are started CBS w/ Diff, ABGs​ Pulse Ox​ Blood cultures ​ ​ ​ ​ ​ ​ Possibly- blood cultures, thoracentesis, bronchoscopy ​ ​ ​ ​ ​ ​ Pneumonia Management ​ ​ ​ ​ ​ ​ Prevention: vaccines​ Prevnar- children over 5, adults 65+​ Pneumovax -adults 65+​ Anyone with long-term health illness, or weak immune system ​ ​ ​ ​ ​ ​ Increase fluid- at least 3L/day, thin & loosen secretions Small, frequent, high calorie, nutritious meals ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 9 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 10 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 2 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Increase fluid- at least 3L/day, thin & loosen secretions Small, frequent, high calorie, nutritious meals Analgesic, antipyretics​ Balance activity & rest ​ ​ ​ ​ ​ ​ O2 if pulse ox below 90% Antibiotics- improvement in 3-5 days ​ ​ ​ ​ ​ ​ IV then switch to oral when stable Antivirals for influenza pneumonia ​ ​ ​ ​ ​ ​ 11 Nursing Management​ Monitor lung sounds, SOB, activity tolerance​ Encourage fluids = thin & loosen secretions​ Encourage small nutritious meals: high calorie​ Prevent spread- use tissues or elbow to cough or sneeze, ​ ​ ​ ​ ​ ​ handwashing​ Vaccinate close family members C&DB with I.S. every hour ​ ​ ​ ​ ​ ​ Pain management to encourage​ Ambulation & therapeutic positioning​ Avoid cigarette smoke​ Prevent aspiration pneumonia​ Teaching- take full course of antibiotics, handwashing, vaccines ​ ​ ​ ​ ​ ​ 12 Implementation: Ambulatory Care​ Patient teaching for home care​ Emphasize need to take full course of antibiotics Drug-drug & drug-food interactions​ Adequate rest​ Adequate hydration​ Avoid alcohol & smoking​ Cool mist humidifier or warm bath​ Chest x-ray, vaccinations​ Takes several weeks (or more) to recover Future influenza & pneumococcal vaccines ​ ​ ​ ​ ​ ​ 13 Complications ​ ​ ​ ​ ​ ​ Multidrug-resistant (MDR) pathogens—major problem in TX Risk factors: ​ ​ ​ ​ ​ ​ Advanced age, immunosuppression, history of antibiotic use, ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 13 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Risk factors:​ Advanced age, immunosuppression, history of antibiotic use, ​ ​ ​ ​ ​ ​ prolonged mechanical ventilation ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Atelectasis, pleurisy, pleural effusion, bacteremia, pneumothorax​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Acute respiratory failure​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Sepsis/septic shock​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Lung abscess​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​  Empyema ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 14 Pulmonary Tuberculosis​ Infectious disease caused by Mycobacterium tuberculosis Usually involved lungs, but any organ can be infected​ Poor, underserved, & minorities ​ ​ ​ ​ ​ ​ Homeless, inner city, prisons, shelters, IV drug users, poverty, immunosuppression ​ ​ ​ ​ ​ ​ Airborne droplets- can be suspended in air for mins. to hrs. ​ ​ ​ ​ ​ ​ Transmission requires close, frequent, or prolonged exposure Low incidence until 1980’s ​ ​ ​ ​ ​ ​ High rates of HIV ​ ​ ​ ​ ​ ​ Multi-drug resistant strains​ Primary, latent TB infection, active TB disease ​ ​ ​ ​ ​ ​ 15 TB- Clinical Manifestations ​ ​ ​ ​ ​ ​ Cough (2-3 weeks to develop symptoms) Dry cough that becomes productive longer that 3 weeks​ Crackles &/or adventitious breath sounds ​ ​ ​ ​ ​ ​  Pain in chest ​ ​ ​ ​ ​ ​ Weakness or fatigue, malaise, anorexia, weight loss, low grade fever, night sweats ​ ​ ​ ​ ​ ​ Hemoptysis & dyspnea– late symptom, indicated considerable lung damage ​ ​ ​ ​ ​ ​ 16 TB- Diagnosis​ PPD- Mantoux for screening- 0.1 ml intradermally ​ ​ ​ ​ ​ ​ Read in 48-72 hrs by inspection & palpation- induration indicates a (+) response- measured in millimeters ​ ​ ​ ​ ​ ​ Interferon gamma- QuantiFERON ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 16 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ (+) response- measured in millimeters Interferon gamma- QuantiFERON ​ ​ ​ ​ ​ ​ Blood test- more expensive, measures interferon gamma released from T-lymphocytes in response to mycobacterium antigens ​ ​ ​ ​ ​ ​ No 2nd visit needed, no reader subjectivity, not affected by other vaccinations ​ ​ ​ ​ ​ ​ Chest X-Ray​ Identifies active disease, but not used alone to diagnose TB ​ ​ ​ ​ ​ ​ Microscopic sputum analysis (TB sputum culture is gold standard) Can also collect samples from other suspected TB sites​ For sputum, 3 specimen on 3 different days are analyzed ​ ​ ​ ​ ​ ​ 8-24 hr intervals, at least 1 in the am ​ ​ ​ ​ ​ ​ 17 TB- Treatment​ Drug treatment is aggressive due to multi-drug resistance. Generally, ​ ​ ​ ​ ​ ​ 4 drugs for 2 months​ See table 19-4​ Combinations of these drugs are available to ↑ adherence ​ ​ ​ ​ ​ ​ Infectious for first 2 weeks after starting treatment Restrict visitors & limit public exposure​ Hand hygiene & oral hygiene ​ ​ ​ ​ ​ ​ Latent TB is treated with 1 drug for 3-9 months Notify public health department ​ ​ ​ ​ ​ ​ 18 Nursing Issues with TB Screening of high-risk people ​ ​ ​ ​ ​ ​ ER admits w/ respiratory symptoms are screened​ Airborne isolation, negative pressure room, door always closed HEPA masks worn by staff when entering isolation room- needs fit ​ ​ ​ ​ ​ ​ testing​ Teach pt. to cover mouth w/ tissue when coughing, flush or in paper ​ ​ ​ ​ ​ ​ bag in trash, handwashing after handling sputum-soiled tissues Pt. to wear standard isolation mask when out of the room Identify & screen close family contacts​ If home, sleep alone in well ventilated room, avoid public ​ ​ ​ ​ ​ ​ transportation, monthly sputum cultures (2 consec. neg. = noninfectious) ​ ​ ​ ​ ​ ​ Educate: adherence to drug regimen, symptoms of recurrence, ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 19 ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ noninfectious) ​ ​ ​ ​ ​ ​ Educate: adherence to drug regimen, symptoms of recurrence, smoking cessation ​ ​ ​ ​ ​ ​ Health department is notified of all active TB cases ​ ​ ​ ​ ​ ​ 19 Lung Cancer ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Leading cause of cancer death in U.S.​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Smoking causes 85% of lung cancers​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ High levels of pollution, radiation, radon, asbestos, coal dust,​ ​ ​ ​ ​ ​ ​ ​ ​ ​ formaldehyde, beryllium, smoking (smoked & secondhand), silica​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Most in segmented bronchi or beyond in upper lobes ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ 20 Clinical Manifestations​ Non-specific & only late in the disease- depends on type, location, & ​ ​ ​ ​ ​ ​ metastatic spread ​ ​ ​ ​ ​ ​ Anorexia, chronic cough (smoker), bloody sputum, chest pain, wt. loss, hoarseness if laryngeal nerve is involved, wheezing, chest pain, dysphagia ​ ​ ​ ​ ​ ​ Thoracentesis may reveal malignant cells Small cell & Large cell are rapidly growing ​ ​ ​ ​ ​ ​ Lung biopsy for definitive diagnosis ​ ​ ​ ​ ​ ​ 21 Screening & Treatment​ Annually in adults ages 50 to 80 with a history of smoking ​ ​ ​ ​ ​ ​ 20 pack-year history Current smoker​ Quit less than15 years ago ​ ​ ​ ​ ​ ​ Completed with low dose CT​ Treatment​ Depends on the type of cancer​ Health promotion, pt. & family support, symptom management ​ ​ ​ ​ ​ ​ 22 Pertussis Pg. 2175 ​ ​ ​ ​ ​ ​  Highly contagious infection- Bordetella pertussis​ Bacteria attach to cilia, release toxins, causing inflammation & ​ ​ ​ ​ ​ ​ swelling ​ ​ ​ ​ ​ ​ One-time Tdap recommended for all adults (tetanus, diphtheria, pertussis) ​ ​ ​ ​ ​ ​ Symptoms occur in stages ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ pertussis)​ Symptoms occur in stages ​ ​ ​ ​ ​ ​ Stage 1- low-grade fever, mild cough, runny nose, watery eyes (1-2 wks.) ​ ​ ​ ​ ​ ​ Stage 2- cough progresses- worse at night, short rapid coughs followed by high-pitched whoop sound when breathing in (2-10 wks.) ​ ​ ​ ​ ​ ​ Coughing forceful that causes vomiting, breaking ribs, exhaustion ​ ​ ​ ​ ​ ​ 6 to 10 weeks​ Stage 3- less severe cough, weak (2-3 wks.) ​ ​ ​ ​ ​ ​ Treatment​ Antibiotics (erythromycin) Encourage fluids, humidification Monitor for respiratory distress ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​