MS1-LEC-STUDENTS-COPY-PRELIM-UPDATED (1) PDF - Nursing Study Notes

EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Course Code...

EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Course Code: NCM1331L Course Title: CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID & ELECTROLYTES, INFECTIOUS, INFLAMMATORY AND IMMUNOLOGIC RESPONSE, CELLULAR ABBERATIONS {ACUTE & CHRONIC} Prepared By: Mary Grace Sescon-Penticostes, RN CLASS RULES: ✽WEAR COMPLETE UNIFORM ✽Observe proper grooming: No rings, earing etc ✽Observe Punctuality ✽NO Cheating ✽Mobile Phones: Strictly NOT allowed during classes ✽Listen and participate ✽Attendance: Secure Medical Certificate for absence/s GRADING SYSTEM: ✽MAJOR EXAM 60% Prelim, Midterm, Finals ✽CLASS STANDING 40% Attendance & Attitude 20% Quizzes & Oral Exams 50% Activities & Assignments 30% ✽CONTENTS: ANATOMY & PHYSIOLOGY OF THE RESPIRATORY SYSTEM ✓ is composed of the upper and lower respiratory tracts-responsible for ventilation (movement of air in and out of the airways). ✓ Upper tract, known as the upper airway- warms and filters inspired air so that the lower respiratory tract (the lungs) can accomplish gas exchange. Gas exchange involves delivering oxygen to the tissues through the bloodstream and expelling waste gases, such as carbon dioxide, during expiration. UPPER RESPIRATORY TRACT nose, sinuses and nasal passages, pharynx, tonsils and adenoids, larynx, and trachea. Nose >composed of an external and an internal portion. >external portion protrudes from the face and is supported by the nasal bones and cartilage >anterior nares (nostrils) are the external openings of the nasal cavities >internal portion of the nose is a hollow cavity separated into the right and left nasal cavities by a narrow vertical divider, the septum >each nasal cavity is divided into three passageways by the projection of the turbinates (also called conchae) from the lateral walls >nasal cavities are lined with highly vascular ciliated mucous membranes called the nasal mucosa. Mucus, secreted continuously by goblet cells, covers the surface of the nasal mucosa and is moved back to the nasopharynx by the action of the cilia (fine hairs). >nose serves as a passageway for air to pass to and from the lungs, filters impurities and humidifies and warms the air as it is inhaled >responsible for olfaction (smell) because the olfactory receptors are located in the nasal mucosa >function diminishes with age. Paranasal Sinuses >four pairs of bony cavities that are lined with nasal mucosa and ciliated pseudostratified columnar Epithelium >these air spaces are connected by a series of ducts that drain into the nasal cavity. The sinuses are named by their location: frontal, ethmoidal, sphenoidal, and maxillary (Fig. 21-1) QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING >prominent function of the sinuses is to serve as a resonating chamber in speech >sinuses are a common site of infection. Turbinate Bones (Conchae) >also called conchae (the name suggested by their shell-like appearance) >because of their curves, these bones increase the mucous membrane surface of the nasal passages and slightly obstruct the air flowing through them (Fig. 21-2). Air entering the nostrils is deflected upward to the roof of the nose, and it follows a circuitous route before it reaches the nasopharynx, comes into contact with a large surface of moist, warm mucous membrane that catches practically all the dust and organisms in the inhaled air, and air is moistened, warmed to body temperature, and brought into contact with sensitive nerves. Some of these nerves detect odors; others provoke sneezing to expel irritating dust. Pharynx, Tonsils, and Adenoids >pharynx, or throat, is a tubelike structure that connects the nasal and oral cavities to the larynx. It is divided into three regions: nasal, oral, and laryngeal >nasopharynx is located posterior to the nose and above the soft palate >oropharynx houses the faucial, or palatine, tonsils. The laryngopharynx extends from the hyoid bone to the cricoid cartilage >epiglottis forms the entrance of the larynx. >adenoids, or pharyngeal tonsils, are located in the roof of the nasopharynx >tonsils, the adenoids, and other lymphoid tissue encircle the throat >these structures are important links in the chain of lymph nodes guarding the body from invasion by organisms entering the nose and the throat >pharynx functions as a passageway for the respiratory and digestive tracts. Larynx >larynx, or voice organ, is a cartilaginous epithelium-lined structure that connects the pharynx and the trachea >major function of the larynx is vocalization >also protects the lower airway from foreign substances and facilitates coughing >is frequently referred to as the voice box and consists of the following: Epiglottis—a valve flap of cartilage that covers the opening to the larynx during swallowing Glottis—the opening between the vocal cords in the larynx Thyroid cartilage—the largest of the cartilage structures; part of it forms the Adam’s apple Cricoid cartilage—the only complete cartilaginous ring in the larynx (located below the thyroid cartilage) Arytenoid cartilages—used in vocal cord movement with the thyroid cartilage Vocal cords—ligaments controlled by muscular movements that produce sounds; located in the lumen of the larynx Trachea >trachea, or windpipe, is composed of smooth muscle with C-shaped rings of cartilage at regular intervals >cartilaginous rings are incomplete on the posterior surface and give firmness to the wall of the trachea, preventing it from collapsing >trachea serves as the passage between the larynx and the bronchi. ANATOMY OF THE LOWER RESPIRATORY TRACT: LUNGS >lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. Lungs >are paired elastic structures enclosed in the thoracic cage, which is an airtight chamber with distensible walls (Fig. 21-3). Ventilation requires movement of the walls of the thoracic cage and of its floor, the diaphragm. The effect of these movements is alternately to increase and decrease the capacity of the chest. When the capacity of the chest is increased, air enters through the trachea (inspiration) because of the lowered pressure within and inflates the lungs When the chest wall and diaphragm return to their previous positions (expiration), the lungs recoil and force the air out through the bronchi and trachea. The inspiratory phase of respiration normally requires energy; the expiratory phase is normally passive. Inspiration occurs during the first third of the respiratory cycle, expiration during the latter two thirds. PLEURA >lungs and wall of the thorax are lined with a serous membrane called the pleura >visceral pleura covers the lungs >parietal pleura lines the thorax QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. MEDIASTINUM >is in the middle of the thorax, between the pleural sacs that contain the two lungs >extends from the sternum to the vertebral column and contains all the thoracic tissue outside the lungs. LOBES >each lung is divided into lobes left lung consists of an upper and lower lobe, whereas the right lung has an upper, middle, and lower lobe (Fig. 21-4) >each lobe is further subdivided into two to five segments separated by fissures, which are extensions of the pleura. BRONCHI AND BRONCHIOLES >there are several divisions of the bronchi within each lobe of the lung >First are the lobar bronchi (three in the right lung and two in the left lung) >Lobar bronchi divide into segmental bronchi (10 on the right and 8 on the left), which are the structures identified when choosing the most effective postural drainage position for a given patient >Segmental bronchi then divide into subsegmental bronchi These bronchi are surrounded by connective tissue that contains arteries, lymphatics, and nerves. >subsegmental bronchi then branch into bronchioles, which have no cartilage in their walls Their patency depends entirely on the elastic recoil of the surrounding smooth muscle and on the alveolar pressure. The bronchioles contain submucosal glands, which produce mucus that covers the inside lining of the airways. The bronchi and bronchioles are lined also with cells that have surfaces covered with cilia. These cilia create a constant whipping motion that propels mucus and foreign substances away from the lung toward the larynx. The bronchioles then branch into terminal bronchioles, which do not have mucous glands or cilia. Terminal bronchioles then become respiratory bronchioles, which are considered to be the transitional passageways between the conducting airways and the gas exchange airways. Up to this point, the conducting airways contain about 150 mL of air in the tracheobronchial tree that does not participate in gas exchange. This is known as physiologic dead space. The respiratory bronchioles then lead into alveolar ducts and alveolar sacs and then alveoli. Oxygen and carbon dioxide exchange takes place in the alveoli. ALVEOLI >lung is made up of about 300 million alveoli, which are arranged in clusters of 15 to 20 These alveoli are so numerous that if their surfaces were united to form one sheet, it would cover 70 square meters—the size of a tennis court. >There are three types of alveolar cells ✓ Type I alveolar cells are epithelial cells that form the alveolar walls ✓ Type II alveolar cells are metabolically active---secrete surfactant, a phospholipid that lines the inner surface and prevents alveolar collapse ✓ Type III alveolar cell macrophages are large phagocytic cells that ingest foreign matter (eg, mucus, bacteria) and act as an important defense mechanism. FUNCTION OF THE RESPIRATORY SYSTEM >facilitating life-sustaining processes such as oxygen transport, respiration and ventilation, and gas exchange. 1. Oxygen Transport Oxygen is supplied to, and carbon dioxide is removed from, cells by way of the circulating blood. Cells are in close contact with capillaries, whose thin walls permit easy passage or exchange of oxygen and carbon dioxide. Oxygen diffuses from the capillary through the capillary wall to the interstitial fluid. At this point, it diffuses through the membrane of tissue cells, where it is used by mitochondria for cellular respiration. The movement of carbon dioxide occurs by diffusion in the opposite direction—from cell to blood. 2. Respiration After these tissue capillary exchanges, blood enters the systemic veins (where it is called venous blood) and travels to the pulmonary circulation. The oxygen concentration in blood within the capillaries of the lungs is lower than in the lungs’ air sacs (alveoli). Because of this concentration gradient, oxygen diffuses from the alveoli to the blood. Carbon dioxide, which has a higher concentration in the blood than in the alveoli, diffuses from the blood into the alveoli. Movement of air in and out of the airways (ventilation) continually replenishes the oxygen and removes the QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING carbon dioxide from the airways in the lung. This whole process of gas exchange between the atmospheric air and the blood and between the blood and cells of the body is called respiration. 3. Ventilation During inspiration, air flows from the environment into the trachea, bronchi, bronchioles, and alveoli. During expiration, alveolar gas travels the same route in reverse. Physical factors that govern air flow in and out of the lungs are collectively referred to as the mechanics of ventilation and include air pressure variances, resistance to air flow, and lung compliance UPPER RESPIRATORY SYSTEM DISORDERS Upper Airway Infections >are common conditions that affect most people on occasion >some infections are acute, with symptoms that last several days; others are chronic, with symptoms that last a long time or recur >seldom require hospitalization 1. RHINITIS >a group of disorders characterized by inflammation and irritation of the mucous membranes of the nose >may be classified as nonallergic or allergic >may be an acute or chronic condition. Pathophysiology ✓ Nonallergic rhinitis may be caused by a variety of factors, including environmental factors such as changes in temperature or humidity, odors, or foods; infection; age; systemic disease; drugs (cocaine) or prescribed medications; or the presence of a foreign body ✓ Drug-induced rhinitis is associated with use of antihypertensive agents and oral contraceptives and chronic use of nasal decongestants ✓ may be a manifestation of an allergy referred to as allergic rhinitis Clinical Manifestations >signs and symptoms of rhinitis include: ✓ rhinorrhea (excessive nasal drainage, runny nose), nasal congestion, nasal discharge (purulent with bacterial rhinitis), nasal itchiness, and sneezing. ✓ Headache may occur, particularly if sinusitis is also present. Medical Management >depends on the cause--identified in the history and physical examination >examiner asks the patient about recent symptoms as well as possible exposure to allergens in the home, environment, or workplace >if viral rhinitis is the cause, medications are given to relieve the symptoms >allergic rhinitis, tests may be performed to identify possible allergens >Depending on the severity of the allergy, desensitizing immunizations and corticosteroids may be required >If symptoms suggest a bacterial infection, an antimicrobial agent will be used PHARMACOLOGIC THERAPY >focuses on symptom relief >antihistamines are administered for sneezing, itching, and rhinorrhea >oral decongestant agents are used for nasal obstruction >intranasal corticosteroids may be used for severe congestion >ophthalmic agents are used to relieve irritation, itching, and redness of the eyes Nursing Management TEACHING PATIENTS SELF-CARE ✓ nurse instructs the patient to avoid or reduce exposure to allergens and irritants, such as dusts, molds, animals, fumes, odors, powders, sprays, and tobacco smoke ✓ patient is instructed about the importance of controlling the environment at home and work. ✓ Saline nasal or aerosol sprays may be helpful in soothing mucous membranes, softening crusted secretions, and removing irritants ✓ nurse instructs the patient in the proper use of and technique for administrating nasal medications ✓ to achieve maximal relief--the patient is instructed to blow the nose before applying any medication into the nasal cavity ✓ in the case of infectious rhinitis--nurse reviews with the patient hand hygiene technique as a measure to prevent transmission of organisms ✓ nurse teaches methods to treat symptoms of the viral rhinitis QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING ✓ for elderly and other high-risk populations--nurse reviews the value of receiving a vaccination in the fall in order to achieve immunity prior to the beginning of the “flu season.” 2. VIRAL RHINITIS (COMMON COLD) The term “common cold” often is used when referring to an upper respiratory tract infection that is self-limited and caused by a virus (viral rhinitis). Nasal congestion, rhinorrhea, sneezing, sore throat, and general malaise characterize it. Specifically, the term “cold” refers to an afebrile, infectious, acute inflammation of the mucous membranes of the nasal cavity. More broadly, the term refers to an acute upper respiratory tract infection, whereas terms such as “rhinitis,” “pharyngitis,” and “laryngitis” distinguish the sites of the symptoms. It can also be used when the causative virus is influenza (“the flu”). Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. It is estimated that adults in the United States average two to four colds each year. The common cold is the most common cause of absenteeism from work and school (Mandell, Bennett, & Dolin, 2000). The six viruses known to produce the signs and symptoms of the viral rhinitis are rhinovirus, parainfluenza virus, coronavirus, respiratory syncytial virus (RSV), influenza virus, and adenovirus. Each virus may have multiple strains. For example, there are over 100 strains of rhinovirus, which accounts for 50% of all colds. Immunity after recovery is variable and depends on many factors, including a person’s natural host resistance and the specific virus that caused the cold. Clinical Manifestations >Signs and symptoms: ✓ nasal congestion, runny nose, sneezing, nasal discharge, nasal itchiness, tearing watery eyes, “scratchy” or sore throat, general malaise, low-grade fever, chills, and often headache and muscle aches ✓ as the illness progresses, cough usually appears ✓ in some people--viral rhinitis exacerbates the herpes simplex, commonly called a cold sore ✓ symptoms last from 1 to 2 weeks If there is significant fever or more severe systemic respiratory symptoms, it is no longer viral rhinitis but one of the other acute upper respiratory tract infections. Allergic conditions can also affect the nose, mimicking the symptoms of a cold. Medical Management ✓ no specific treatment--management consists of symptomatic therapy ✓ providing adequate fluid intake ✓ encouraging rest QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING ✓ preventing chilling ✓ increasing intake of vitamin C ✓ using expectorants as needed ✓ warm salt-water gargles soothe the sore throat ✓ nonsteroidal anti-inflammatory agents (NSAIDs) such as aspirin or ibuprofen relieve the aches, pains, and fever in adults ✓ antihistamines are used to relieve sneezing, rhinorrhea, and nasal congestion ✓ Topical (nasal) decongestant agents may relieve nasal congestion; however, if they are overused they may create a rebound congestion that may be worse than the original symptoms ✓ zinc lozenges may reduce the duration of cold symptoms if taken within the first 24 hours of onset (Prasad, Fitzgerald, & Bao, 2000) ✓ Amantadine (Symmetrel) or rimantadine (Flumadine) may be prescribed prophylactically to decrease the signs and symptoms as well ✓ Antimicrobial agents (antibiotics) should not be used because they do not affect the virus or reduce the incidence of bacterial complications. Nursing Management TEACHING PATIENTS SELF-CARE Most viruses can be transmitted in several ways: direct contact with infected secretions; inhalation of large particles that land on a mucosal surface from coughing or sneezing; or inhalation of small particles (aerosol) that may be suspended in the air for up to an hour. It is important to teach the patient how to break the chain of infection. Hand washing remains the most effective measure to prevent transmission of organisms. The nurse teaches methods to treat symptoms of the common cold and preventive measures (Chart 22-2) 3. ACUTE SINUSITIS The sinuses, mucus-lined cavities filled with air that drain normally into the nose, are involved in a high proportion of upper respiratory tract infections. If their openings into the nasal passages are clear, the infections resolve promptly. However, if their drainage is obstructed by a deviated septum or by hypertrophied turbinates, spurs, or nasal polyps or tumors, sinus infection may persist as a smoldering secondary infection or progress to an acute suppurative process (causing purulent discharge). Sinusitis affects over 14% of the population and accounts for billions of dollars in direct health care costs (Tierney, McPhee, & Papadakis, 2001). Some individuals are more prone to sinusitis because of their occupations. For example, continuous exposure to environmental hazards such as paint, sawdust, and chemicals may result in chronic inflammation of the nasal passages. Pathophysiology QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Acute sinusitis is an infection of the paranasal sinuses. It frequently develops as a result of an upper respiratory infection, such as an unresolved viral or bacterial infection, or an exacerbation of allergic rhinitis. Nasal congestion, caused by inflammation, edema, and transudation of fluid, leads to obstruction of the sinus cavities (Fig. 22-1). This provides an excellent medium for bacterial growth. Bacterial organisms account for more than 60% of the cases of acute sinusitis, namely Streptococcus pneumoniae, Haemophilus inflfluenzae, and Moraxella catarrhalis (Murray & Nadel, 2001). Dental infections also have been associated with acute sinusitis. Clinical Manifestations ✓ facial pain or pressure over the affected sinus area ✓ nasal obstruction ✓ fatigue ✓ purulent nasal discharge ✓ fever ✓ headache ✓ ear pain and fullness ✓ dental pain ✓ cough ✓ decreased sense of smell ✓ sore throat ✓ eyelid edema, or facial congestion or fullness Assessment and Diagnostic Findings ✓ careful history and physical examination are performed---head and neck, particularly the nose, ears, teeth, sinuses, pharynx, and chest, are examined ✓ There may be tenderness to palpation over the infected sinus area ✓ sinuses are percussed using the index finger---tapping lightly to determine if the patient experiences pain ✓ affected area is also transilluminated; with sinusitis, there is a decrease in the transmission of light ✓ Sinus x-rays may be performed to detect sinus opacity, mucosal thickening, bone destruction, and air–fluid levels. ✓ Computed tomography scanning of the sinuses is the most effective diagnostic tool---also used to rule out other local or systemic disorders, such as tumor, fistula, and allergy. Complications ▪ Acute sinusitis, if left untreated, may lead to severe and occasionally life-threatening complications such as meningitis, brain abscess, ischemic infarction, and osteomyelitis. ▪ Other complications of sinusitis, although uncommon, include severe orbital cellulitis, subperiosteal abscess, and cavernous sinus thrombosis. Medical Management ▪ The goals of treatment of acute sinusitis are to treat the infection, shrink the nasal mucosa, and relieve pain. There is a growing concern over the inappropriate use of antibiotics for viral upper respiratory infections; such overuse has resulted in antibiotics being less effective (more resistant) in treating bacterial infections such as sinusitis. As a result, careful consideration is given to the potential pathogen before antimicrobial agents are prescribed. The antimicrobial agents of choice for a bacterial infection vary in clinical practice. ▪ First-line antibiotics include amoxicillin (Amoxil), trimethoprim/sulfamethoxazole (Bactrim, Septra), and erythromycin. ▪ Second-line antibiotics include cephalosporins such as cefuroxime axetil (Ceftin), cefpodoxime (Vantin), and cefprozil (Cefzil) and amoxicillin clavulanate (Augmentin). ▪ Newer and more expensive antibiotics with a broader spectrum include macrolides, azithromycin (Zithromax), and clarithromycin (Biaxin). ▪ Quinolones such as ciprofloxacin (Cipro), levofloxacin (Levaquin) (used with severe penicillin allergy), and sparfloxacin (Zagam) have also been used. ▪ The course of treatment is usually 10 to 14 days. ▪ A recent report found little difference in clinical outcomes between first-line and second-line antibiotics; however, costs were greater when newer second-line antibiotics were used (Piccirillo, Mager, Frisse et al., 2001). ▪ Use of oral and topical decongestant agents may decrease mucosal swelling of nasal polyps, thereby improving drainage of the sinuses. ▪ Heated mist and saline irrigation also may be effective for opening blocked passages. ▪ Decongestant agents such as pseudoephedrine (Sudafed, Dimetapp) have proven effective because of their vasoconstrictive properties. QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING ▪ Topical decongestant agents such as oxymetazoline (Afrin) may be used for up to 72 hours. It is important to administer them with the patient’s head tilted back to promote maximal dispersion of the medication. ▪ Guaifenesin (Robitussin, Anti-Tuss), a mucolytic agent, may also be effective in reducing nasal congestion. In 2000, the U.S. Food and Drug Administration issued a public health advisory concerning phenylpropanolamine, which previously had been commonly used in oral decongestants and diet pills. The voluntary recall of products containing this ingredient was based on a study linking its use with hemorrhagic stroke in women. Men may also be at risk (Kernan et al., 2000). ▪ Antihistamines such as diphenhydramine (Benadryl), cetirizine (Zyrtec), and fexofenadine (Allegra) may be used if an allergic component is suspected. If the patient continues to have symptoms after 7 to 10 days, the sinuses may need to be irrigated and hospitalization may be required. Nursing Management TEACHING PATIENTS SELF-CARE ✓ nurse instructs the patient about methods to promote drainage such as inhaling steam (steam bath, hot shower, and facial sauna) ✓ increasing fluid intake, and applying local heat (hot wet packs) ✓ nurse also informs the patient about the side effects of nasal sprays and about rebound congestion. ▪ In the case of rebound congestion, the body’s receptors, which have become dependent on the decongestant sprays to keep the nasal passages open, close and congestion results after the spray is discontinued. ✓ nurse stresses the importance of following the recommended antibiotic regimen, because a consistent blood level of the medication is critical to treat the infection ✓ nurse teaches the patient the early signs of a sinus infection and recommends preventive measures such as following healthy practices and avoiding contact with people who have upper respiratory infections (Chart 22-2) ✓ nurse should explain to the patient that fever, severe headache, and nuchal rigidity are signs of potential complications---if fever persists despite antibiotic therapy, the patient should seek additional care. 4. CHRONIC SINUSITIS is an inflammation of the sinuses that persists for more than 3 weeks in an adult and 2 weeks in a child. It is estimated that 32 million people a year develop chronic sinusitis. Pathophysiology A narrowing or obstruction in the ostia of the frontal, maxillary, and anterior ethmoid sinuses usually causes chronic sinusitis, preventing adequate drainage to the nasal passages. This combined area is known as the osteomeatal complex. Blockage that persists or greater than 3 weeks in an adult may occur because of infection, allergy, or structural abnormalities. This results in stagnant secretions, an ideal medium for infection. The organisms that cause chronic sinusitis are the same as those implicated in acute sinusitis. Immunocompromised patients, however, are at increased risk for developing fungal sinusitis. Aspergillus fumigatus is the most common organism associated with fungal sinusitis. Clinical Manifestations ✓ impaired mucociliary clearance and ventilation ✓ cough (because the thick discharge constantly drips backward into the nasopharynx) ✓ chronic hoarseness ✓ chronic headaches in the periorbital area, and facial pain ✓ symptoms are generally most pronounced on awakening in the morning ✓ Fatigue and nasal stuffiness are also common ✓ some patients experience a decrease in smell and taste and a fullness in the ears. Assessment and Diagnostic Findings >computed tomography scan of the sinuses or magnetic resonance imaging (if fungal sinusitis is suspected), are performed to rule out other local or systemic disorders, such as tumor, fistula, and allergy >Nasal endoscopy may be indicated to rule out underlying diseases such as tumors and sinus mycetomas (fungus balls) --is usually a brown or greenish-black material with the consistency of peanut butter or cottage cheese. Complications >uncommon---include severe orbital cellulitis, subperiosteal abscess, cavernous sinus thrombosis, meningitis, encephalitis, and ischemic infarction. QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Medical Management ▪ antimicrobial agents of choice include amoxicillin clavulanate (Augmentin) or ampicillin (Ampicin) ▪ Clarithromycin (Biaxin) and third-generation cephalosporins such as cefuroxime axetil (Ceftin), cefpodoxime (Vantin), and cefprozil (Cefzil) have also been effective ▪ Levofloxacin (Levaquin), a quinolone, may also be used ▪ course of treatment may be 3 to 4 weeks ▪ Decongestant agents, antihistamines, saline sprays, and heated mist may also provide some symptom relief SURGICAL MANAGEMENT When standard medical therapy fails, surgery, usually endoscopic, may be indicated to correct structural deformities that obstruct the ostia (openings) of the sinus. Excising and cauterizing nasal polyps, correcting a deviated septum, incising and draining the sinuses, aerating the sinuses, and removing tumors are some of the specific procedures performed. When sinusitis is caused by a fungal infection, surgery is required to excise the fungus ball and necrotic tissue and drain the sinuses. Oral and topical corticosteroids are usually prescribed. Antimicrobial agents are administered before and after surgery. Some patients with severe chronic sinusitis obtain relief only by moving to a dry climate. Nursing Management TEACHING PATIENTS SELF-CARE ✓ nurse teaches the patient how to promote sinus drainage by increasing the environmental humidity (steam bath, hot shower, and facial sauna) ✓ increasing fluid intake ✓ applying local heat (hot wet packs) ✓ nurse also instructs the patient about the importance of following the medication regimen ✓ Instructions on the early signs of a sinus infection are provided and preventive measures are reviewed. 5. ACUTE PHARYNGITIS is an inflammation or infection in the throat, usually causing symptoms of a sore throat. Pathophysiology Most cases of acute pharyngitis are caused by viral infection. When group A beta-hemolytic streptococcus, the most common bacterial organism, causes acute pharyngitis, the condition is known as strep throat (Bisno, 2001). The body responds by triggering an inflammatory response in the pharynx. This results in pain, fever, vasodilation, edema, and tissue damage, manifested by redness and swelling in the tonsillar pillars, uvula, and soft palate. A creamy exudate may be present in the tonsillar pillars (Fig. 22-3) Uncomplicated viral infections usually subside promptly, within 3 to 10 days after the onset. However, pharyngitis caused by more virulent bacteria such as group A beta-hemolytic streptococci is a more severe illness. If left untreated, the complications can be severe and life- threatening. Complications include sinusitis, otitis media, peritonsillar abscess, mastoiditis, and cervical adenitis. In rare cases the infection may lead to bacteremia, pneumonia, meningitis, rheumatic fever, or nephritis. Clinical Manifestations ✓ fiery-red pharyngeal membrane and tonsils ✓ lymphoid follicles that are swollen and flecked with white-purple exudate ✓ enlarged and tender cervical lymph nodes and no cough ✓ Fever, malaise, and sore throat also may be present Assessment and Diagnostic Findings >Rapid screening tests for streptococcal antigens such as the latex agglutination (LA) antigen test and solid-phase enzyme immunoassays (ELISA) >optical immunoassay (OIA) >streptolysin titers >throat cultures are used to determine the causative organism--after which appropriate therapy is prescribed >Nasal swabs and blood cultures may also be necessary to identify the organism (Corneli, 2001). Medical Management >Viral pharyngitis is treated with supportive measures since antibiotics will have no effect on the organism >Bacterial pharyngitis is treated with a variety of antimicrobial agents QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING PHARMACOLOGIC THERAPY ✓ bacterial cause--penicillin is usually the treatment of choice ✓ patients who are allergic to penicillin or have organisms that are resistant to erythromycin (one fifth of group A beta-hemolytic streptococci and most S. aureus organisms are resistant to penicillin and erythromycin), cephalosporins and macrolides (clarithromycin and azithromycin) may be used ✓ Antibiotics are administered for at least 10 days to eradicate the infection from the oropharynx. ✓ Severe sore throats can also be relieved by analgesic medications, as prescribed--example, aspirin or acetaminophen (Tylenol) can be taken at 3- to 6-hour intervals; if required, acetaminophen with codeine can be taken three or four times daily ✓ Antitussive medication, in the form of codeine, dextromethorphan (Robitussin DM), or hydrocodone bitartrate (Hycodan), may be required to control the persistent and painful cough that often accompanies acute pharyngitis NUTRITIONAL THERAPY A liquid or soft diet is provided during the acute stage of the disease, depending on the patient’s appetite and the degree of discomfort that occurs with swallowing. Occasionally, the throat is so sore that liquids cannot be taken in adequate amounts by mouth. In severe situations, fluids are administered intravenously. Otherwise, the patient is encouraged to drink as much fluid as possible (at least 2 to 3 L per day). Nursing Management ✓ nurse instructs the patient to stay in bed during the febrile stage of illness and to rest frequently once up and about ✓ Used tissues should be disposed of properly to prevent the spread of infection ✓ It is important to examine the skin once or twice daily for possible rash, because acute pharyngitis may precede some other communicable diseases (ie, rubella). ✓ Warm saline gargles or irrigations are used depending on the severity of the lesion and the degree of pain--benefits of this treatment depend on the degree of heat that is applied ✓ nurse teaches the patient about the recommended temperature of the solution: high enough to be effective and as warm as the patient can tolerate, usually 105°F to 110°F (40.6°C to 43.3°C) ✓ Irrigating the throat properly is an effective means of reducing spasm in the pharyngeal muscles and relieving soreness of the throat ▪ Unless the purpose of the procedure and its technique are understood clearly by the patient and family, the results may be less than satisfactory. ▪ An ice collar also can relieve severe sore throats. Mouth care may add greatly to the patient’s comfort and prevent the development of fissures (cracking) of the lips and oral inflammation when bacterial infection is present ✓ nurse instructs the patient to resume activity gradually ▪ A full course of antibiotic therapy is indicated in patients with group A beta-hemolytic streptococcal infection in view of the possible development of complications such as nephritis and rheumatic fever, which may have their onset 2 or 3 weeks after the pharyngitis has subsided ✓ nurse instructs the patient and family about the importance of taking the full course of therapy and informs them about the symptoms to watch for that may indicate complications. 6. CHRONIC PHARYNGITIS is a persistent inflammation of the pharynx--common in adults who work or live in dusty surroundings, use their voice to excess, suffer from chronic cough, and habitually use alcohol and tobacco. Three types of chronic pharyngitis are recognized: Hypertrophic: characterized by general thickening and congestion of the pharyngeal mucous membrane Atrophic: probably a late stage of the first type (the membrane is thin, whitish, glistening, and at times wrinkled) Chronic granular (“clergyman’s sore throat”): characterized by numerous swollen lymph follicles on the pharyngeal wall Clinical Manifestations ✓ constant sense of irritation or fullness in the throat, mucus that collects in the throat and can be expelled by coughing, and difficulty swallowing. Medical Management relieving symptoms avoiding exposure to irritants correcting any upper respiratory, pulmonary, or cardiac condition that might be responsible for a chronic cough QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Nasal congestion may be relieved by short-term use of nasal sprays or medications containing ephedrine sulfate (Kondon’s Nasal) or phenylephrine hydrochloride (Neo-Synephrine) If there is a history of allergy, one of the antihistamine decongestant medications, such as Drixoral or Dimetapp, is taken orally every 4 to 6 hours Aspirin or acetaminophen is recommended for its anti-inflammatory and analgesic properties. Nursing Management TEACHING PATIENTS SELF-CARE ✓ nurse instructs the patient to avoid contact with others until the fever subsides ✓ Alcohol, tobacco, second-hand smoke, and exposure to cold are avoided, as are environmental or occupational pollutants if possible ✓ patient may minimize exposure to pollutants by wearing a disposable facemask ✓ nurse encourages the patient to drink plenty of fluids ✓ Gargling with warm saline solutions may relieve throat discomfort ✓ Lozenges will keep the throat moistened. 7. TONSILLITIS AND ADENOIDITIS The tonsils are composed of lymphatic tissue and are situated on each side of the oropharynx. The faucial or palatine tonsils and lingual tonsils are located behind the pillars of fauces and tongue, respectively. They frequently serve as the site of acute infection (tonsillitis). Chronic tonsillitis is less common and may be mistaken for other disorders such as allergy, asthma, and sinusitis. The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infection of the adenoids frequently accompanies acute tonsillitis. Group A beta-streptococcus is the most common organism associated with tonsillitis and adenoiditis. Clinical Manifestations ✓ symptoms of tonsillitis include sore throat, fever, snoring, and difficulty swallowing ✓ Enlarged adenoids may cause mouth breathing, earache, draining ears, frequent head colds, bronchitis, foul-smelling breath, voice impairment, and noisy respiration. ▪ Unusually enlarged adenoids fill the space behind the posterior nares, making it difficult for the air to travel from the nose to the throat and resulting in a nasal obstruction. Infection can extend to the middle ears by way of the auditory (eustachian) tubes and may result in acute otitis media, which can lead to spontaneous rupture of the eardrums and further extension of the infection into the mastoid cells, causing acute mastoiditis. The infection also may reside in the middle ear as a chronic, low-grade, smoldering process that eventually may cause permanent deafness. Assessment and Diagnostic Findings thorough physical examination is performed and a careful history is obtained to rule out related or systemic conditions tonsillar site is cultured to determine the presence of bacterial infection In adenoiditis, if recurrent episodes of suppurative otitis media result in hearing loss, the patient should be given a comprehensive audiometric examination Medical Management Tonsillectomy is usually performed for recurrent tonsillitis when medical treatment is unsuccessful and there is severe hypertrophy, asymmetry, or peritonsillar abscess that occludes the pharynx, making swallowing difficult and endangering the airway (particularly during sleep Tonsillectomy or adenoidectomy is indicated only if the patient has had any of the following problems: repeated bouts of tonsillitis; hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive sleep apnea; repeated attacks of purulent otitis media; suspected hearing loss due to serous otitis media that has occurred in association with enlarged tonsils and adenoids; and some other conditions, such as an exacerbation of asthma or rheumatic fever. Appropriate antibiotic therapy is initiated for patients undergoing tonsillectomy or adenoidectomy. The most common antimicrobial agent is oral penicillin, which is taken for 7 days. Amoxicillin and erythromycin are alternatives. Nursing Management PROVIDING POSTOPERATIVE CARE ✓ most comfortable position is prone with the head turned to the side to allow drainage from the mouth and pharynx ✓ nurse must not remove the oral airway until the patient’s gag and swallowing re- flexes have returned ✓ nurse applies an ice collar to the neck, and a basin and tissues are provided for the expectoration of blood and mucus. QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING ▪ Hemorrhage is a potential complication after a tonsillectomy and adenoidectomy. If the patient vomits large amounts of dark blood or bright-red blood at frequent intervals, or if the pulse rate and temperature rise and the patient is restless, the nurse notifies the surgeon immediately ✓ nurse should have the following items ready for examination of the surgical site for bleeding: a light, a mirror, gauze, curved hemostats, and a waste basin. ▪ Occasionally, suture or ligation of the bleeding vessel is required. In such cases, the patient is taken to the operating room and given general anesthesia. After ligation, continuous nursing observation and postoperative care are required, as in the initial postoperative period. ▪ If there is no bleeding, water and ice chips may be given to the patient as soon as desired ✓ patient is instructed to refrain from too much talking and coughing because these activities can produce throat pain. TEACHING PATIENTS SELF-CARE Tonsillectomy and adenoidectomy usually do not require hospitalization and are performed as outpatient surgery with a short length of stay. Because the patient will be sent home soon after surgery, the patient and family must understand the signs and symptoms of hemorrhage. Hemorrhage usually occurs in the first 12 to 24 hours. The patient is instructed to report frank red bleeding to the physician. ✓ Alkaline mouthwashes and warm saline solutions are useful in coping with the thick mucus and halitosis that may be present after surgery ✓ explain to the patient that a sore throat, stiff neck, and vomiting may occur in the first 24 hours ✓ liquid or semiliquid diet is given for several days--Sherbet and gelatin are acceptable foods ✓ patient should avoid spicy, hot, acidic, or rough foods ✓ Milk and milk products (ice cream and yogurt) may be restricted because they may make removal of mucus more difficult ✓ nurse explains to the patient that halitosis and some minor ear pain may occur for the first few days ✓ nurse instructs the patient to avoid vigorous tooth brushing or gargling, since these actions could cause bleeding 8. PERITONSILLAR ABSCESS A peritonsillar abscess is a collection of purulent exudate between the tonsillar capsule and the surrounding tissues, including the soft palate. It is believed to develop after an acute tonsillar infection, which progresses to a local cellulitis and abscess. Clinical Manifestations ✓ raspy voice, odynophagia (a severe sensation of burning, squeezing pain while swallowing) ✓ dysphagia (difficulty swallowing) ✓ otalgia (pain in the ear) ✓ drooling ✓ swelling of the soft palate, often occluding almost half of the opening from the mouth into the pharynx ✓ unilateral tonsillar hypertrophy ✓ dehydration Assessment and Diagnostic Findings Aspiration of purulent material (pus) by needle aspiration is required to make the appropriate diagnosis--aspirated material is sent for culture and Gram’s stain CT scan is performed when it is not possible to aspirate the abscess. Medical Management Antibiotics (usually penicillin) are extremely effective in controlling the infection in peritonsillar abscess--If antibiotics are prescribed early in the course of the disease, the abscess may resolve without needing to be incised. SURGICAL MANAGEMENT If treatment is delayed, the abscess is evacuated as soon as possible. The mucous membrane over the swelling is first sprayed with a topical anesthetic and then injected with a local anesthetic. Single or repeated needle aspirations are performed to decompress the abscess {abscess may also be incised and drained} These procedures are performed best with the patient in the sitting position to make it easier to expectorate the pus and blood that accumulate in the pharynx. Almost immediate relief is experienced. Approximately 30% of patients with peritonsillar abscess have indications for tonsillectomy (Tierney et al., 2001). Nursing Management topical anesthetic agents and throat irrigations or the frequent use of mouthwashes or gargles, using saline or alkaline solutions at a temperature of 105°F to 110°F (40.6°C to 43.3°C). The nurse QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING instructs the patient to gargle at intervals of 1 or 2 hours for 24 to 36 hours. Liquids that are cool or at room temperature are usually well tolerated. 9. LARYNGITIS Laryngitis, an inflammation of the larynx, often occurs as a result of voice abuse or exposure to dust, chemicals, smoke, and other pollutants, or as part of an upper respiratory tract infection. It also may be caused by isolated infection involving only the vocal cords. The cause of infection is almost always a virus. Bacterial invasion may be secondary. Laryngitis is usually associated with allergic rhinitis or pharyngitis. The onset of infection may be associated with exposure to sudden temperature changes, dietary deficiencies, malnutrition, and an immunosuppressed state. Laryngitis is common in the winter and is easily transmitted. Clinical Manifestations ✓ hoarseness or aphonia (complete loss of voice) ✓ severe cough ✓ Chronic laryngitis is marked by persistent hoarseness ✓ Laryngitis may be a complication of upper respiratory infections. Medical Management resting the voice avoiding smoking resting, and inhaling cool steam or an aerosol ▪ If the laryngitis is part of a more extensive respiratory infection due to a bacterial organism or if it is severe, appropriate antibacterial therapy is instituted. The majority of patients recover with conservative treatment; however, laryngitis tends to be more severe in elderly patients and may be complicated by pneumonia. >For chronic laryngitis, the treatment includes: ✓ resting the voice, eliminating any primary respiratory tract infection, eliminating smoking, and avoiding second-hand smoke Topical corticosteroids, such as beclomethasone dipropionate (Vanceril) inhalation, may also be used. These preparations have no systemic or long-lasting effects and may reduce local inflammatory reactions. Nursing Management ✓ nurse instructs the patient to rest the voice and to maintain a well-humidified environment ▪ If laryngeal secretions are present during acute episodes, expectorant agents are suggested, along with a daily fluid intake of 3 L to thin secretions. NURSING PROCESS: THE PATIENT WITH UPPER AIRWAY INFECTION Assessment health history may reveal signs and symptoms of headache, sore throat, pain around the eyes and on either side of the nose, difficulty in swallowing, cough, hoarseness, fever, stuffiness, and generalized discomfort and fatigue determining when the symptoms began, what precipitated them, what if anything relieves them, and what aggravates them is part of the assessment determine any history of allergy or the existence of a concomitant illness Inspect for swelling, lesions, or asymmetry of the nose as well as bleeding or discharge nurse inspects the nasal mucosa for abnormal findings such as increased redness, swelling, or exudate, and nasal polyps, which may develop in chronic rhinitis nurse palpates the frontal and maxillary sinuses for tenderness, which suggests inflmmation, and then inspects the throat by having the patient open the mouth wide and take a deep breath tonsils and pharynx are inspected for abnormal findings such as redness, asymmetry, or evidence of drainage, ulceration, or enlargement nurse palpates the trachea to determine the midline position in the neck and to detect any masses or deformities neck lymph nodes also are palpated for associated enlargement and tenderness Diagnosis NURSING DIAGNOSES ▪ Based on the assessment data, the patient’s major nursing diagnoses may include the following: Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation Acute pain related to upper airway irritation secondary to an infection Impaired verbal communication related to physiologic changes and upper airway irritation secondary to infection or swelling QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Deficient fluid volume related to increased fluid loss secondary to diaphoresis associated with a fever Deficient knowledge regarding prevention of upper respiratory infections, treatment regimen, surgical procedure, or postoperative care COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS ▪ Based on assessment data, potential complications may include: ✓ Sepsis ✓ Meningitis ✓ Peritonsillar abscess ✓ Otitis media ✓ Sinusitis Planning and Goals ✓ maintenance of a patent airway ✓ relief of pain ✓ maintenance of effective means of communication ✓ normal hydration ✓ knowledge of how to prevent upper airway infections and absence of complications Nursing Interventions MAINTAINING A PATENT AIRWAY The nurse can implement several measures to loosen thick secretions or to keep the secretions moist so that they can be easily expectorated. Increasing fluid intake helps thin the mucus. Use of room vaporizers or steam inhalation also loosens secretions and reduces inflammation of the mucous membranes. To enhance drainage from the sinuses, the nurse instructs the patient about the best position to assume; this depends on the location of the infection or inflammation. For example, drainage for sinusitis or rhinitis is achieved in the upright position. In some conditions, topical or systemic medications, when prescribed, help to relieve nasal or throat congestion. PROMOTING COMFORT The nurse encourages the patient to take analgesics, such as acetaminophen with codeine, as prescribed, which will help relieve this discomfort. Other helpful measures include topical anesthetic agents for symptomatic relief of herpes simplex blisters (Chart 22-1) and sore throats, hot packs to relieve the congestion of sinusitis and promote drainage, and warm water gargles or irrigations to relieve the pain of a sore throat. The nurse encourages rest to relieve the generalized discomfort and fever that accompany many upper airway conditions (especially rhinitis, pharyngitis, and laryngitis). The nurse instructs the patient in general hygiene techniques to prevent the spread of infection. For postoperative care following tonsillectomy and adenoidectomy, an ice collar may reduce swelling and decrease bleeding. PROMOTING COMMUNICATION The nurse instructs the patient to refrain from speaking as much as possible and to communicate in writing instead, if possible. ▪ Additional strain on the vocal cords may delay full return of the voice. ENCOURAGING FLUID INTAKE The nurse encourages the patient to drink 2 to 3 L of fluid per day during the acute stage of airway infection, unless contraindicated, to thin secretions and promote drainage. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care The nurse advises the patient to avoid exposure to others at risk for serious illness if respiratory infection is transmitted. Those at risk include elderly adults, immunosuppressed people, and those with chronic health problems. The nurse teaches patients and their families, strategies to relieve symptoms of upper respiratory infections. ▪ These include increasing the humidity level, encouraging adequate fluid intake, getting adequate rest, using warm water gargles or irrigations and topical anesthetic agents to relieve sore throat, and applying hot packs to relieve congestion. The nurse reinforces the need to complete the treatment regimen, particularly when antibiotics are prescribed. Continuing Care The nurse may advise elderly patients and those who would be at increased risk from a respiratory infection to consider an annual influenza vaccine. QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING A follow-up appointment with the primary care provider may be indicated for patients with compromised health status to ensure that the respiratory infection has resolved. MONITORING AND MANAGING POTENTIAL COMPLICATIONS ▪ Sepsis and meningitis may occur in patients with compromised immune status or in those with an overwhelming bacterial infection. The patient with an upper respiratory infection and family members are instructed to seek medical care if the patient’s condition fails to improve within several days of the onset of symptoms, if unusual symptoms develop, or if the patient’s condition deteriorates. They are instructed about signs and symptoms that require further attention: persistent or high fever, increasing shortness of breath, confusion, and increasing weakness and malaise. The patient and family are instructed about the signs and symptoms of otitis media and sinusitis and about the importance of follow-up with the primary health care practitioner to ensure adequate evaluation and treatment of these conditions. Evaluation EXPECTED PATIENT OUTCOMES ▪ Expected patient outcomes may include: 1. Maintains a patent airway by managing secretions a. Reports decreased congestion b. Assumes best position to facilitate drainage of secretions 2. Reports feeling more comfortable a. Uses comfort measures: analgesics, hot packs, gargles, rest b. Demonstrates adequate oral hygiene 3. Demonstrates ability to communicate needs, wants, level of comfort 4. Maintains adequate fluid intake 5. Identifies strategies to prevent upper airway infections and allergic reactions a. Demonstrates hand hygiene technique b. Identifies the value of the influenza vaccine 6. Demonstrates an adequate level of knowledge and performs self-care adequately 7. Becomes free of signs and symptoms of infection a. Exhibits normal vital signs (temperature, pulse, respiratory rate) b. Absence of purulent drainage c. Free of pain in ears, sinuses, and throat QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING LOWER RESPIRATORY SYSTEM DISORDERS 1. ATELECTASIS Atelectasis refers to closure or collapse of alveoli and often is described in relation to x-ray findings and clinical signs and symptoms. Atelectasis may be acute or chronic and may cover a broad range of pathophysiologic changes, from micro-atelectasis (which is not detectable on chest x-ray) to macro-atelectasis with loss of segmental, lobar, or overall lung volume. The most commonly described atelectasis is acute atelectasis, which occurs frequently in the postoperative setting or in people who are immobilized and have a shallow, monotonous breathing pattern. Excess secretions or mucus plugs may also cause obstruction of airflow and result in atelectasis in an area of the lung. Atelectasis also is observed in patients with a chronic airway obstruction that impedes or blocks air flow to an area of the lung (eg obstructive atelectasis in the patient with lung cancer that is invading or compressing the airways). -This type of atelectasis is more insidious and slower in onset. Pathophysiology Atelectasis may occur in the adult as a result of reduced alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli that normally receive air through the bronchi and network of airways. The trapped alveolar air becomes absorbed into the bloodstream, but outside air cannot replace the absorbed air because of the blockage. As a result, the isolated portion of the lung becomes airless and the alveoli collapse. This may occur with altered breathing patterns, retained secretions, pain, alterations in small airway function, prolonged supine positioning, increased abdominal pressure, reduced lung volumes due to musculoskeletal or neurologic disorders, restrictive defects, and specific surgical procedures (eg, upper abdominal, thoracic, or open heart surgery).Persistent low lung volumes, secretions or a mass obstructing or impeding airflow, and compression of lung tissue may all cause collapse or obstruction of the airways, which leads to atelectasis. The postoperative patient is at high risk for atelectasis because of the numerous respiratory changes that may occur. A monotonous low tidal breathing pattern may cause airway closure and alveolar collapse. This results from the effects of anesthesia or analgesic agents, supine positioning, splinting of the chest wall because of pain, and abdominal distention. The postoperative patient may also have secretion retention, airway obstruction, and an impaired cough reflex or may be reluctant to cough because of pain. Atelectasis resulting from bronchial obstruction by secretions may occur in patients with impaired cough mechanisms (eg, postoperative, musculoskeletal or neurologic disorders) or in debilitated, bedridden patients. Atelectasis may also result from excessive pressure on the lung QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING tissue, which restricts normal lung expansion on inspiration. Such pressure may be produced by fluid accumulating within the pleural space (pleural effusion), air in the pleural space (pneumothorax), or blood in the pleural space (hemothorax). The pleural space is the area between the parietal and the visceral pleurae. Pressure may also be produced by a pericardium distended with fluid (pericardial effusion), tumor growth within the thorax, or an elevated diaphragm. Clinical Manifestations ✓ Cough ✓ sputum production ✓ low-grade fever ▪ Fever is universally cited as a clinical sign of atelectasis, but there are few data to support this. Most likely the fever that accompanies atelectasis is due to infection or inflammation distal to the obstructed airway. ▪ In acute atelectasis involving a large amount of lung tissue (lobar atelectasis), marked respiratory distress may be observed. ✓ Dyspnea ✓ Tachycardia ✓ Tachypnea ✓ pleural pain ✓ central cyanosis (a bluish skin hue that is a late sign of hypoxemia) may be anticipated ✓ difficulty breathing in the supine position and is anxious ▪ Signs and symptoms of chronic atelectasis are similar to those of acute atelectasis. Because the alveolar collapse is chronic, infection may occur distal to the obstruction. Thus, the signs and symptoms of a pulmonary infection also may be present. Assessment and Diagnostic Findings Decreased breath sounds and crackles are heard over the affected area chest x-ray findings may reveal patchy infiltrates or consolidated areas ▪ In the patient who is confined to bed, atelectasis is usually diagnosed by chest x-ray or identified by physical assessment in the dependent, posterior, basilar areas of the lungs. Depending on the degree of hypoxemia, pulse oximetry (SpO2) may demonstrate a low saturation of hemoglobin with oxygen (less than 90%) or a lower-than-normal partial pressure of arterial oxygen (PaO2). Prevention and Management Respiratory Infections 2. ACUTE TRACHEOBRONCHITIS Acute tracheobronchitis, an acute inflammation of the mucous membranes of the trachea and the bronchial tree, often follows infection of the upper respiratory tract. A patient with a viral infection has decreased resistance and can readily develop a secondary bacterial infection. Thus, adequate treatment of upper respiratory tract infection is one of the major factors in the prevention of acute bronchitis. Aside from infection, inhalation of physical and chemical irritants, gases, and other air contaminants can also cause acute bronchial irritation. Pathophysiology QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING In acute tracheobronchitis, the inflamed mucosa of the bronchi produces mucopurulent sputum, often in response to Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae. In addition, a fungal infection (eg, Aspergillus tracheobronchitis) may also cause tracheobronchitis. A sputum culture is essential to identify the specific causative organism. Clinical Manifestations ✓ Initially--dry, irritating cough and expectorates a scanty amount of mucoid sputum, sternal soreness from coughing, fever or chills and night sweats, headache, general malaise ✓ As infection progresses--short of breath, have noisy inspiration and expiration (inspiratory stridor and expiratory wheeze), and produce purulent (pus-filled) sputum ✓ With severe tracheobronchitis--blood-streaked secretions may be expectorated as a result of the irritation of the mucosa of the airways Medical Management Antibiotic treatment may be indicated depending on the symptoms, sputum purulence, and results of the sputum culture Antihistamines are usually not prescribed because they may cause excessive drying and make secretions more difficult to expectorate. Expectorants may be prescribed, although their efficacy is questionable Fluid intake is increased to thin the viscous and tenacious secretions. ▪ Copious, purulent secretions that cannot be cleared by coughing place the patient at risk for increasing airway obstruction and the development of a more severe lower respiratory tract infection, such as pneumonia. Suctioning and bronchoscopy may be needed to remove secretions. The patient is advised to rest. Mild analgesics or antipyretics may be indicated. Nursing Management ✓ primary nursing function is to encourage bronchial hygiene, such as increasing fluid intake and directed coughing to remove secretions ✓ nurse should encourage and assist the patient to sit up frequently to cough effectively and to prevent retention of mucopurulent sputum ✓ emphasize the need to complete the full course of antibiotics prescribed ✓ nurse must caution the patient against overexertion, which can induce a relapse or exacerbation of the infection 3. PNEUMONIA Pneumonia is an inflammation of the lung parenchyma that is caused by a microbial agent. “Pneumonitis” is a more general term that describes an inflammatory process in the lung tissue that may predispose a patient to or place a patient at risk for microbial invasion. Pneumonia is the most common cause of death from infectious diseases in the United States. It is the seventh leading cause of death in the United States for all ages and both genders, resulting in almost 70,000 deaths per year. In persons 65 years of age and older, it is the fifth leading cause of death (National Center for Health Statistics, 2000; Minino & Smith, 2001). It is treated extensively on both an inpatient and outpatient basis. QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Pathophysiology Pneumonia arises from normally present flora in a patient whose resistance has been altered, or it results from aspiration of flora present in the oropharynx. It may also result from bloodborne organisms that enter the pulmonary circulation and are trapped in the pulmonary capillary bed, becoming a potential source of pneumonia. Pneumonia often affects both ventilation and diffusion. An inflammatory reaction can occur in the alveoli, producing an exudate that interferes with the diffusion of oxygen and carbon dioxide. White blood cells, mostly neutrophils, also migrate into the alveoli and fill the normally air-containing spaces. Areas of the lung are not adequately ventilated because of secretions and mucosal edema that cause partial occlusion of the bronchi or alveoli, with a resultant decrease in alveolar oxygen tension. Bronchospasm may also occur in patients with reactive airway disease. Because of hypoventilation, a ventilation–perfusion mismatch occurs in the affected area of the lung. Venous blood entering the pulmonary circulation passes through the under ventilated area and exits to the left side of the heart poorly oxygenated. The mixing of oxygenated and unoxygenated or poorly oxygenated blood eventually results in arterial hypoxemia. If a substantial portion of one or more lobes is involved, the disease is referred to as “lobar pneumonia.” The term “bronchopneumonia” is used to describe pneumonia that is distributed in a patchy fashion, having originated in one or more localized areas within the bronchi and extending to the adjacent surrounding lung parenchyma. Bronchopneumonia is more common than lobar pneumonia. QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Risk Factors QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING Pneumonia is common with certain underlying disorders such as heart failure, diabetes, alcoholism, COPD, and AIDS. The CDC has identified three specific strategies for preventing HAP: (1) staff education and infection surveillance, (2) interruption of transmission of microorganisms through person-to- person transmission and equipment transmission, and (3) modification of host risk of infection (CDC, 1997). To reduce or prevent serious complications of CAP in high risk groups, vaccination against pneumococcal infection is advised for the following: ✓ People 65 years of age or older ✓ Immunocompetent people who are at increased risk for ill ✓ ness and death associated with pneumococcal disease be ✓ cause of chronic illness (eg, cardiovascular, pulmonary, ✓ diabetes mellitus, chronic liver disease) ✓ People with functional or anatomic asplenia ✓ People living in environments or social settings in which the ✓ risk of disease is high ✓ Immunocompromised people at high risk for infection (CDC, 1998) The vaccine provides specific prevention against pneumococcal pneumonia and other infections caused by this organism (otitis media, other upper respiratory tract infections). Vaccines should be avoided in the first trimester of pregnancy. Clinical Manifestations Pneumonia varies in its signs and symptoms depending on the organism and the patient’s underlying disease. However, regardless of the type of pneumonia (CAP, HAP, immunocompromised host, aspiration), a specific type of pneumonia cannot be diagnosed by clinical manifestations alone. For example, the patient with streptococcal (pneumococcal) pneumonia usually has a sudden onset of shaking chills, rapidly rising fever (38.5° to 40.5°C [101° to 105°F]), and pleuritic chest pain that is aggravated by deep breathing and coughing. The patient is severely ill, with marked tachypnea (25 to 45 breaths/min), accompanied by other signs of respiratory distress (eg, shortness of breath, use of accessory muscles in respiration). The pulse is rapid and bounding, and it usually increases about 10 beats/min for every degree. Assessment and Diagnostic Findings Taking history (particularly of a recent respiratory tract infection) physical examination chest x-ray studies blood culture sputum examination---obtained by having the patient: (1) rinse the mouth with water to minimize contamination by normal oral flflora, (2) breathe deeply several times, (3) cough deeply, and (4) expectorate the raised sputum into a sterile container. Medical Management ✓ administration of the appropriate antibiotic as determined by the results of the Gram stain Recommendations for treatment of outpatients with CAP who have no cardiopulmonary disease or other modifying factors include: ✓ macrolide (erythromycin, azithromycin [Zithromax], or clarithromycin [Biaxin]), doxycycline (Vibramycin), or a fluoroquinolone (eg, gatifloxacin [Tequin], levofloxacin [Levaquin]) For those outpatients who have cardiopulmonary disease or other modifying factors, treatment should include: ✓ beta-lactam (oral cefpodoxime [Vantin], cefuroxime [Zinacef, Ceftin], high-dose amoxicillin or amoxicillin/clavulanate [Augmentin, Clavulin]) plus a macrolide or doxycycline ✓ beta-lactam plus an anti-pneumococcal fluoroquinolone For patients with CAP who are hospitalized and do not have cardiopulmonary disease or modifying factors, management consists of: ✓ intravenous azithromycin (Zithromax) or monotherapy with an anti-pneumococcal fluoroquinolone For inpatients with cardiopulmonary disease or modifying factors, the treatment involves: ✓ intravenous beta-lactam plus an intravenous or oral macrolide or doxycycline ✓ intravenous anti-pneumococcal fluoroquinolone For acutely ill patients admitted to the intensive care unit, management includes: ✓ intravenous beta-lactam plus either an intravenous macrolide or fluoroquinolone QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING NURSING PROCESS: THE PATIENT WITH PNEUMONIA Assessment Nursing assessment is critical in detecting pneumonia. A fever, chills, or night sweats in a patient who also has respiratory symptoms should alert the nurse to the possibility of bacterial pneumonia. A respiratory assessment will further identify the clinical manifestations of pneumonia: pleuritic- type pain, fatigue, tachypnea, use of accessory muscles for breathing, bradycardia or relative bradycardia, coughing, and purulent sputum. It is important to identify the severity, location, and cause of the chest pain, along with any medications or procedures that provide relief. The nurse should monitor the following: ✓ Changes in temperature and pulse ✓ Amount, odor, and color of secretions ✓ Frequency and severity of cough ✓ Degree of tachypnea or shortness of breath ✓ Changes in physical assessment findings (primarily assessed by inspecting and auscultating the chest) ✓ Changes in the chest x-ray findings In addition, it is important to assess the elderly patient for unusual behavior, altered mental status, dehydration, excessive fatigue, and concomitant heart failure. Diagnosis NURSING DIAGNOSES Based on the assessment data, the patient’s major nursing diagnoses may include: Ineffective airway clearance related to copious tracheobronchial secretions Activity intolerance related to impaired respiratory function Risk for deficient fluid volume related to fever and dyspnea Imbalanced nutrition: less than body requirements Deficient knowledge about the treatment regimen and preventive health measures COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on the assessment data, collaborative problems or potential complications that may occur include: ✓ Continuing symptoms after initiation of therapy ✓ Shock ✓ Respiratory failure ✓ Atelectasis ✓ Pleural effusion ✓ Confusion ✓ Superinfection Planning and Goals patient may have: improved airway patency rest to conserve energy maintenance of proper fluid volume maintenance of adequate nutrition an understanding of the treatment protocol and preventive measures absence of complications Nursing Interventions IMPROVING AIRWAY PATENCY ✓ Removing secretion {because retained secretions interfere with gas exchange and may slow recovery} ✓ nurse encourages hydration (2 to 3 L/day) because adequate hydration thins and loosens pulmonary secretions ✓ Humidification may be used to loosen secretions and improve ventilation. ▪ A high humidity facemask (using either compressed air or oxygen) delivers warm, humidified air to the tracheobronchial tree, helps to liquefy secretions, and relieves tracheobronchial irritation. ✓ Coughing can be initiated either voluntarily or by reflex ✓ Lung expansion maneuvers, such as deep breathing with an incentive spirometer, may induce a cough ✓ A directed cough may be necessary to improve airway patency. The nurse encourages the patient to perform an effective, directed cough, which includes correct positioning, a deep inspiratory maneuver, glottic closure, contraction of the expiratory muscles against the closed glottis, sudden glottic opening, and an explosive expiration. In some cases, the nurse may assist the patient by placing both hands on the patient’s lower rib cage (anteriorly or posteriorly) to QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING focus the patient on a slow deep breath, and then manually assisting the patient by applying external pressure during the expiratory phase. ✓ Chest physiotherapy (percussion and postural drainage) is important in loosening and mobilizing secretions ▪ Indications for chest physiotherapy include sputum retention not responsive to spontaneous or directed cough, a history of pulmonary problems previously treated with chest physiotherapy, continued evidence of retained secretions (decreased or abnormal breath sounds, change in vital signs), abnormal chest x-ray findings consistent with atelectasis or infiltrates, or deterioration in oxygenation. The patient is placed in the proper position to drain the involved lung segments, and then the chest is percussed and vibrated either manually or with a mechanical percussor. After each position change, the nurse encourages the patient to breathe deeply and cough. If the patient is too weak to cough effectively, the nurse may need to remove the mucus by nasotracheal suctioning. ▪ It may take time for secretions to mobilize and move into the central airways for expectoration. Thus, it is important for the nurse to monitor the patient for cough and sputum production after the completion of chest physiotherapy. ✓ The nurse administers and titrates oxygen therapy as prescribed. The effectiveness of oxygen therapy is monitored by improvement in clinical signs and symptoms, and adequate oxygenation values measured by pulse oximetry or arterial blood gas analysis. PROMOTING REST AND CONSERVING ENERGY nurse encourages the debilitated patient to rest and avoid overexertion and possible exacerbation of symptoms. The patient should assume a comfortable position to promote rest and breathing (eg, semi-Fowler’s) and should change positions frequently to enhance secretion clearance and ventilation/perfusion in the lungs. It is important to instruct outpatients not to overexert themselves and to engage in only moderate activity during the initial phases of treatment. PROMOTING FLUID INTAKE The respiratory rate of a patient with pneumonia increases because of the increased workload imposed by labored breathing and fever. An increased respiratory rate leads to an increase in insensible fluid loss during exhalation and can lead to dehydration. Therefore, it is important to encourage increased fluid intake (at least 2 L/day), unless contraindicated. MAINTAINING NUTRITION Patients with shortness of breath and fatigue often have a decreased appetite and will take only fluids. Fluids with electrolytes (commercially available drinks, such as Gatorade) may help provide fluid, calories, and electrolytes. Other nutritionally enriched drinks or shakes may be helpful. In addition, fluids and nutrients may be administered intravenously if necessary. PROMOTING THE PATIENT’S KNOWLEDGE The patient and family are instructed about the cause of pneumonia, management of symptoms of pneumonia, and the need for follow-up (discussed later). The patient also needs information about factors (both patient risk factors and external factors) that may have contributed to developing pneumonia and strategies to promote recovery and to prevent recurrence. If hospitalized for treatment, the patient is instructed about the purpose and importance of management strategies that have been implemented and about the importance of adhering to them during and after the hospital stay. Explanations need to be given simply and in language that the patient can understand. If possible, written instructions and information should be provided. Because of the severity of symptoms, the patient may require that instructions and explanations be repeated several times. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care If oral antibiotics are prescribed, it is important to teach the patient about their proper administration and potential side effects. The nurse encourages breathing exercises to promote secretion clearance and volume expansion. It is important to instruct the patient to return to the clinic or caregiver’s office for a follow-up chest x-ray and physical examination. {Often improvement in chest x-ray findings lags behind improvement in clinical signs and symptoms.} The nurse encourages the patient to stop smoking. ▪ Smoking inhibits tracheobronchial ciliary action, which is the first line of defense of the lower respiratory tract. Smoking also irritates the mucous cells of the bronchi and inhibits the function of alveolar macrophage (scavenger) cells. QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING The patient is instructed to avoid stress, fatigue, sudden changes in temperature, and excessive alcohol intake, all of which lower resistance to pneumonia. The nurse reviews with the patient the principles of adequate nutrition and rest, because one episode of pneumonia may make the patient susceptible to recurring respiratory tract infections. Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Demonstrates improved airway patency, as evidenced by adequate oxygenation by pulse oximetry or arterial blood gas analysis, normal temperature, normal breath sounds, and effective coughing 2. Rests and conserves energy by limiting activities and remaining in bed while symptomatic and slowly increasing activities 3. Maintains adequate hydration, as evidenced by an adequate fluid intake and urine output and normal skin turgor 4. Consumes adequate dietary intake, as evidenced by maintenance or increase in body weight without excess fluid gain 5. States explanation for management strategies 6. Complies with management strategies 7. Exhibits no complications a. Has normal vital signs, pulse oximetry, and arterial blood gas measurements b. Reports productive cough that diminishes over time c. Has absence of signs or symptoms of shock, respiratory failure, or pleural effusion d. Remains oriented and aware of surroundings e. Maintains or increases weight 8. Complies with treatment protocol and prevention strategies Pleural Conditions Pleural conditions are disorders that involve the membranes covering the lungs (visceral pleura) and the surface of the chest wall (parietal pleura) or disorders affecting the pleural space. PLEURISY Pathophysiology Pleurisy (pleuritis) refers to inflammation of both layers of the pleurae (parietal and visceral). Pleurisy may develop in conjunction with pneumonia or an upper respiratory tract infection, TB, or collagen disease; after trauma to the chest, pulmonary infarction, or pulmonary embolism; in patients with primary and metastatic cancer; and after thoracotomy. The parietal pleura has nerve endings; the visceral pleura does not. When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain. Clinical Manifestations ✓ key characteristic of pleuritic pain is its relationship to respiratory movement--Taking a deep breath, coughing, or sneezing worsens the pain. ▪ Pleuritic pain is restricted in distribution, usually occurs only on one side. ▪ The pain may become minimal or absent when the breath is held, or it may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases. Assessment and Diagnostic Findings QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING pleural friction rub can be heard chest x-rays sputum examinations thoracentesis to obtain a specimen of pleural fluid for examination pleural biopsy Medical Management discover the underlying condition causing the pleurisy and to relieve the pain monitor for signs and symptoms of pleural effusion, such as shortness of breath, pain, assumption of a position that decreases pain, and decreased chest wall excursion Prescribed analgesics and topical applications of heat or cold steroidal anti-inflammatory drug (NSAID), may provide pain relief while allowing the patient to take deep breaths and cough more effectively Nursing Management ✓ nurse can offer suggestions to enhance comfort, such as turning frequently onto the affected side to splint the chest wall and reduce the stretching of the pleurae ✓ nurse also can teach the patient to use the hands or a pillow to splint the rib cage while coughing. PLEURAL EFFUSION Pleural effusion, a collection of fluid in the pleural space, is rarely a primary disease process but is usually secondary to other diseases. Normally, the pleural space contains a small amount of fluid (5 to 15 mL), which acts as a lubricant that allows the pleural surfaces to move without friction (Fig. 23-5) Pleural effusion may be a complication of heart failure, TB, pneumonia, pulmonary infections (particularly viral infections), nephrotic syndrome, connective tissue disease, pulmonary embolism, and neoplastic tumors. Bronchogenic carcinoma is the most common malignancy associated with a pleural effusion. Pathophysiology The effusion can be composed of a relatively clear fluid, or it can be bloody or purulent. An effusion of clear fluid may be a transudate or an exudate. A transudate (filtrates of plasma that move across intact capillary walls) occurs when factors influencing the formation and reabsorption of pleural fluid are altered, usually by imbalances in hydrostatic or oncotic pressures. The finding of a transudative effusion generally implies that the pleural membranes are not diseased. The most common cause of a transudative effusion is heart failure. An exudate (extravasation of fluid into tissues or a cavity) usually results from inflammation by bacterial products or tumors involving the pleural surfaces. Clinical Manifestations QF-PQM-035 (05.03.2023) Rev.06 VIRTUE EXCELLENCE SERVICE  EMILIO AGUINALDO COLLEGE Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines Tel. Nos. (046) 416-4339/41 www.eac.edu.ph SCHOOL OF NURSING