Respiratory Disorders PPT AH2 PDF

Respiratory Diseases By; Dr. Hernandez, PhD, MSN-Ed, RN  Sub-concepts with Exemplars Ch. 20: COPD Ch. 19: Tuberculosis Ch. 19: Lung Cancer Ch. 19: Pneumonia Nursing Skill & Procedure: Chapter 19: Tracheostomy Ch. 20: COPD 14 million cases 3rd cause of death...

Respiratory Diseases By; Dr. Hernandez, PhD, MSN-Ed, RN  Sub-concepts with Exemplars Ch. 20: COPD Ch. 19: Tuberculosis Ch. 19: Lung Cancer Ch. 19: Pneumonia Nursing Skill & Procedure: Chapter 19: Tracheostomy Ch. 20: COPD 14 million cases 3rd cause of death 133,000 deaths/yr. U.S  Chronic bronchitis Emphysema COPD (bronchi) (alveoli) Destruction of alveoli group of diseases Presence of cough & without fibrosis, that cause airflow sputum production describes one of blockage and for at least 3 months several structural breathing-related in each of 2 abnormalities in problems consecutive years COPD clients  NGN Type of question: Highlighting Select to highlight which (1)client has a history of 40 pack-years smoking cigarettes. findings the nurses will (2)client states he would like to recognize as factors quit smoking. that increase the (3)client was exposed to secondhand client's risk for smoke during his childhood and development of lung and teen years. breathing problems. (4)client started smoking at age 13. (5)client tried e-cigarettes, which were not successful. (6)Most members of the client's family are smokers. (7)client's daughter does not want to be around smokers while she is pregnant. Etiology & Pathophysiolo gy Smoking Air pollution Genetics Infection Risk Persistent airflow limitation that has chronic inflammation of bronchioles and alveoli Wheezing sound Oxygenation -lung function -cardiac function (RSHF)  Treatment: Symptom management, bronchodilator s, fluids, antibiotics as needed. Complications: respiratory insufficiency/failure, pneumonia, pneumothorax, pulmonary arterial hypertension p. 638 Diagnostic Studies (COPD) History and Physical Serum CBC, BMP/CMP, Mg & P Serum alpha 1-antitrypsin ABGs Diagnostic Studies (COPD continued…) Sputum studies (culture & Chest X-Ray sensitivity)  Diagnostic Studies (COPD continued…) 6-minute walk test COPD Assessment Test or Clinical COPD Questionnaire Spirometry Spirometry  COPD Collaborative Care: Pharmacotherapy Bronchodilators Bronchodilators 1. β2-Adrenergic agonists Relax smooth muscle albuterol (SHORT- in the airway Improve ventilation of acting) the lungs salmeterol (LONG- Inhaled route is acting) preferred (MDI, What should you give first, nebulization therapy, bronchodilator or corticosteroid? dry powder inhaler) Bronchodilators (continued) 2. Anticholinergics (Ipratropium/ Atrovent) Tiotropium (Spiriva)-LA  Bronchodilators (continued) 3. Methylxanthines (theophylline) “narrow margin of safety” Monitor the theophylline level (Adult= 5 to 15 mcg/ml; Children and neonate= 5 to 10 mcg/ml) Theophylline toxicity: n/v, confusion, tremors Bronchodilators delivered via MDI or DPI Metered-dose Inhaler Dry-powder inhaler (DPI) (MDI) Where do you keep DPI? What is the purpose of the spacer?  COPD Collaborative Care (continued) Corticosteroids Antibiotics Azithromycin Inhaled corticosteroid (Zithromax) therapy Used for moderate to severe cases Phosphodiesterase Intravenous inhibitors- for Methylprednisolo smooth muscle ne relaxation (roflumilast)  COPD Collaborative Care Oxygen Therapy (continued) Improve oxygenation Keep O2 saturation > 90% during rest, sleep, and exertion, or PaO2 greater than 60 mm Hg (via ABG) Long-term O2 therapy (Home) Survival Exercise capacity Cognitive performance Sleep in hypoxemic clients Oxygen Complications (p. 512) NOTE: While delivering oxygen: Assess for confusion, restlessness, pallor tachycardia, tachypnea, HTN 1. Combustion (can cause FIRE; Put O2 in use) 2. CO2 narcosis 3. O2 toxicity (> 50% Fio2 for over 24 hours s/s substernal discomfort, paresthesia, refractory hypoxemia, alveolar infiltrates, atelectasis) 4. Absorption atelectasis 5. Infection COPD Collaborative Care: Environment Reduce environmental exposure Smoking cessation  COPD Collaborative Care (continued..) Nutritional therapy Weight loss and malnutrition are common. High calorie, High protein Avoid foods that require heavy chewing, gas producing foods Pressure on diaphragm from a full stomach causes dyspnea. Difficulty breathing while eating leads to inadequate consumption To decrease dyspnea and conserve energy Rest at least 30 minutes before eating.  COPD Collaborative Care Surgical therapy Bullectomy Used for emphysema Large bullae are resected to improve lung function specifically recoil Palliative surgery in most cases Lung transplantation  Nursing Considerations Sleep Psychosocial considerations Adequate sleep is Healthy coping is difficult. extremely important. May feel guilt, depression, Can be difficult anxiety, social isolation, because of denial, and dependence medications, postnasal drip, or Sexual activity coughing Plan when breathing is best. Nasal saline sprays, Use slow, pursed lip breathing. decongestants, or Refrain after strenuous nasal steroid activity. inhalers can help. Do not assume dominant position or prolong foreplay.  NCLEX-RN: SATA The nurse is caring for a 55-year- old female client with chronic obstructive pulmonary disease (COPD) and hypertension. She has no known allergies. Albuterol and Symbicort inhalers are prescribed for COPD. Hydrochlorothiazide (HCTZ) and lisinopril are prescribed for hypertension. Vital Signs: Pulse 68 beats/min Respiration 32 breaths/min Blood Pressure 164/90 mmHg Oxygen Saturation 90% Which of the following statements made by the client are important with her COPD? Select all that apply. A I get short of breath when I walk more than 2 blocks. B My father died a year ago and I still grieve for having lost him. C I’m afraid that I’ll need home oxygen soon and I still smoke 5 to 6 cigarettes a day. D I’ve had a cough for about 4 weeks now. E I use my inhalers just twice a day. F I rest better at night when I sleep in my recliner chair. G I often have to get up to urinate during the day and night. Ch. 19: Pulmonary Tuberculosis Tuberculosis (TB) Infectious disease caused by Mycobacterium tuberculosis Lungs most commonly infected Can be transmitted to other parts of the body: meninges, kidneys, bones and lymph nodes Primary cause of death worldwide Leading cause of death in clients with HIV/AIDs Greater than 2 billion people infected worldwide Risk Factors** Homeless Residents of inner-city neighborhoods Foreign-born persons Living or working in institutions (includes health care workers) IV injecting drug users Poverty, poor access to health care Immunosuppression Asian descent  NCLEX-RN:SATA The client is a 45-year-old man who immigrated from Central America a year ago. He reports fatigue, cough, nausea, and weight loss. His vital signs reveal a low-grade temperature of 99.4°F (37.4°C); blood pressure: 128/82; heart rate 88 beats/minute, and respiratory rate: 18 breaths/minute. The nurse suspects tuberculosis (TB). What additional information would the nurse collect? (Select all that apply.) A. Country of origin B. Previous test results for TB C. Respiratory infections over the past year D. Chest radiograph results E. History of bacillus Calmette–Guérin (BCG) vaccine F. Illness resulting in decreased immune function  Clinical Manifestations Spread via airborne Pulmonary TB: 2-3 weeks droplets after infection/reactivation Can be suspended in air Initial: dry cough for minutes to hours Transmission requires Active TB: fatigue, close, frequent, or malaise, anorexia, prolonged exposure. (Chart unexplained weight loss, 23-8 p. 601 Prevention of fever, night sweats** transmission) Acute onset: high fever, NOT spread by touching, chills flu like symptoms, sharing food utensils, kissing, pleuritic pain, productive or other physical contact cough.  Diagnostic Studies* Tuberculin skin test (TST) AKA: Mantoux test protein derivative (PPD) injected intradermally Assess for induration in 48 – 72 hours Presence of induration (not redness) at injection site indicates development of antibodies secondary to exposure to TB. Positive if ≥15 mm induration in low-risk individuals** Response ↓ in immune- compromised clients Reactions ≥5 mm considered positive  Diagnostic Studies (continued..) Interferon-γ release assays Chest x-ray** (IGRAs) Cannot make diagnosis Detects T-cell solely on x-ray lymphocytes in response Upper lobe infiltrates, to mycobacteria cavitary infiltrates, and Includes QuantiFERON-TB lymph node involvement and the T-SPOT suggest TB. Sputum Studies (Acid-fast Bacilli x 3 days) Confirmatory test  Collaborative Care for TB Pharmacotherapy Active disease Latent TB infection Four-drug regimen Usually treated with (RIPE) INH or Rifampin Rifampin (Rifadin) Isoniazid (INH) Pyrazinamide (PZA) Ethambutol What are the most (Table 23-4 First line antituberculosis common adverse effects agents p. 603) that you need to educate your clients for? Nursing Implementation  Question When should we discontinue the airborne isolation precautions?  Health Teaching 1. Teach client to prevent Ambulatory and Home Care spread. 1. Can go home even if Cover nose and mouth with cultures positive tissue when coughing, sneezing, or producing 2. Monthly sputum sputum cultures Hand washing after 3. Medication handling sputum-soiled compliance tissues 4. Infectious for first 2 2. client wears mask if outside weeks after starting of negative-pressure room, minimize exposure to others treatment if sputum + 3. Identify and screen close contacts.  Question The client has TB. He is placed on Airborne Isolation Precautions. Which intervention could the RN delegate to the assistive personnel (AP)? A. Administering oral TB medications once daily B. Collecting additional sputum specimens for TB bacilli C. Assisting the client to the bathroom D. Assessing the client’s diet preferences Ch. 19: Pneumonia Hospital Acquired Community Acquired  Pneumonia Etiology Occurs when defense Risk factors mechanisms are Over age 65, air incompetent or are pollution, altered level of overwhelmed. consciousness, prolonged immobility, malnutrition, smoking, resident of a long- term care facility, upper respiratory tract infection  Types of Pneumonia Community acquired (CAP) Acquired in the community and diagnoses within 48 hours post hospitalization. Causative agent: S. pneumonia Treat with empiric antibiotics Hospital Acquired (HAP): pneumonia in non-intubated client that starts 48 hours or longer after admission to the hospital not present at time of admission. Pneumonia (Clinical Manifestations) What is the adventitio us lung sound you will hear?  Atelectasis pleural effusion Pneumonia Pneumothorax Complicatio acute respiratory failure ns Sepsis lung abscess  Diagnostic Studies Sputum Studies (sputum culture and sensitivity, Chest X-Ray and gram stain) Diagnostic Studies History & Physical Serum (arterial blood gases, biological markers[CRP, procalcitonin used to differentiate for lung/cardiac causes], blood culture and sensitivity CURB-65  Diagnostic Studies Bronchoscop Bron y chos Do we copy need consent? Who explains the procedure?  Prevention: Pneumococcal vaccine (PCV13, Pneumovax 23) Collaborativ Treatment: e Care Antibiotics/Antiviral medication  Oxygen: hypoxia Analgesics: chest pain Antipyretics: elevated temp Collaborat Rest and activity as tolerated ive Care Nutrition therapy NOTE: If viral: supportive, hydration and oxygen Ch. 19: Lung Cancer  Lung Cancer Leading cause of cancer-related deaths (28%) Estimated 225,000 new cases each year in United States High mortality rate ~158,000 Americans Survival rate 17% (p. 620) Advances in treatment improving response  Etiology Most important risk factor in 80% to 90% of all lung cancers is smoking. Other causes: high levels of Contains 60 carcinogens that pollution, radiation and asbestos interfere with cell development Prolonged exposure: coal dust, Causes a change in bronchial nickel, uranium chromium, epithelium formaldehyde, arsenic Risk directly related to total exposure to tobacco smoke (direct and indirect) Total number of cigarettes smoked Age of smoking onset Depth of inhalation Tar and nicotine content Use of unfiltered cigarettes  Pathophysiology Primary lung cancers categorized Arise from mutated into two subtypes epithelial cells, genetics Non–small-cell lung cancer (NSCLC): 85% Tumor development Small-cell lung cancer (SCLC): promoted by epidermal 15% growth factor It takes 8 to 10 years for a tumor to reach 1 cm. Smallest lesion detectable on x-ray Occur primarily in segmental bronchi and upper lobes Non–Small-Cell Lung Cancer (NSCLC) Squamous Adenocarcino Large-cell cell ma carcinoma carcinoma Slow Moderate Rapid growing growing growing Early Most Highly symptoms common in metastatic non-smokers Small-Cell Lung Cancer (SCLC) Very rapid growth Most malignant Early metastasis Associated endocrine disorders Chemotherapy and radiation Poor prognosis Clinical Manifestations Symptoms appear late in disease. Pneumonitis May be masked by Persistent cough with chronic cough sputum (most common) Depend on type of Hemoptysis primary lung cancer, Dyspnea location, and metastatic Wheezing spread Chest pain Diagnostic Studies Chest x-ray: initial test CT Chest CBC Sputum cytology Chemistry panel Liver, renal, and pulmonary Lung biopsy for definitive function tests diagnosis Magnetic resonance Pleural fluid analysis imaging (MRI) Bone scans Positron emission tomography (PET) CT scans of brain, pelvis, Recommend at age 55-80 abdomen routine CT if history of smoking or quit < 15 years ago.  Staging Staging NSCLC staged according to TNM system T denotes tumor size, location, and degree of invasion. N indicates regional lymph node invasion. M represents presence/absence of Example;distant T3N2M0 would metastases. describe a large (T3) tumor that has spread to the nearby lymph nodes (N2) but has not spread to other parts of the body (M0). Staging of NSCLC Metastasis to liver, brain, bones, lymph nodes and adrenal glands Treatments Treatment of choice for early- stage NSCLC pneumonectomy lobectomy segmental, or wedge resections. Radiation Therapy Used as curative therapy, Stereotactic Radiotherapy (SBRT) palliative therapy, or adjuvant AKA stereotactic surgery or therapy radiosurgery Primary therapy for those unable High dose of radiation accurately to tolerate surgery delivered to tumor Palliative to relieve symptoms Smaller part of healthy lung such as dyspnea and pain exposed Preop to reduce tumor mass Outpatient therapy over 1-3 days Monitor for complications: Used in non- surgical option clients esophagitis, pneumonitis, pulmonary fibrosis Monitor nutrition, infection fatigue, psychosocial outlook p. 624 Chemotherapy, Biological & Targeted Therapy Biologic and Targeted Primary treatment for SCLC Therapy Treatment of nonresectable Block tumor growth tumors or adjuvant to surgery in Less toxic than NSCLC chemotherapy Variety of protocols Tyrosine kinase inhibitor Typically combination of two or Erlotinib (Tarceva) more drugs Kinase inhibitor Crizotinib (Xalkori) Angiogenesis inhibitor Bevacizumab (Avastin) Planning: Manage Symptoms Relieve breathing symptoms Effective breathing pattern Adequate airway clearance Adequate oxygenation of tissues Reduce Fatigue/Pain Minimal to no pain Provide psychological support Realistic attitude about treatment and prognosis  Nursing Implementation Health Promotion: Avoid Ambulatory and Home smoking, smoking Care cessation, smoke free environments Teach client signs and symptoms to Acute Intervention report. (teaching) Use of oxygen Symptom management Palliative Pain relief treatments vs Foster coping hospice strategies. NCLEX-RN Question: Multiple Choice An appropriate nursing intervention for a client with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be to: A. Perform postural drainage every hour B. Provide analgesics as ordered to promote client comfort C. Administer oxygen as prescribed to maintain optimal oxygen levels D. Teach the client how to cough effectively to bring secretions to the mouth.  NCLEX-RN Question: SATA A plan of care for the client with COPD could include (Select all that apply) A. Exercise such as walking B. High flow rate of oxygen administration C. Low-dose chronic oral corticosteroid therapy D. Use of peak flow meter to monitor the progression of COPD E. Breathing exercises, pursed-lip breathing that focus on exhalation  Peak Flow Meter for ASTHMA Peak Flow Meter Figure 20-11 Measures EXPIRATORY CAPACITY of your client or patency of airway Seal the device with their lips and blow as hard as they can Standing up 3 blows  Peak Flow Meter More info: https://www.lung.org/lung- health-diseases/lung-disea se-lookup/asthma/living-wi th-asthma/managing-asth ma/measuring-your-peak-f low-rate https://www.verywellhealth.com/thmb/669ESL_BopvVSl- uP_P65J_46r0=/1500x1000/ filters:no_upscale():max_bytes(150000):strip_icc()/200890_color- 5bd31a3446e0fb0026ee41f7.png  Peak Flow Meter GREEN YELLOW RED Asthma is “Good” GETTING WORSE BAD client is stable Take albuterol or Medical alert Take meds as both albuterol Call 911 usual and Take albuterol *take note before corticosteroids and they exercise or if Call their HCP for corticosteroids they anything med adjustments  NCLEX-RN NGN: Matrix/Grid Scenario: In order to maximize efficiency and safely accomplish care for a group of clients, the charge nurse must assign or delegate client care interventions to the nursing staff. Available staff includes an RN, LPN/ LVN, and an AP. All of these staff members are experienced and familiar with the routines of the unit. Indicate whether the action is best delegated or assigned to the RN, LPN/LVN, or AP.  Intervention RN LPN/LVN AP Take vital signs every 4 hours or as directed Check color and temperature of fingers for a client with a forearm cast. Assist clients to ambulate in the hallway, as ordered by the HCP. Give preoperative teaching to a client about client-controlled analgesia pump and measures to prevent postoperative complications Perform admission assessment on a client admitted for chest  EACH OF YOU HERE TODAY are the RN () BD = Unstable client requiring Rules of Comprehensive assessment. Delegatio Critical thinking/judgement, expected and unexpected client emergent n situations. ADPIE. What is your RN UAP BD = Stable client and unchanging task (SUT) role with each staff Delegate to UAP, noninvasive tasks, routine stable client member ambulation, bathing, client transportation, grooming, hygiene measure, positioning, of your ROM, skin care, and some specimen collections such as urine or stool team  LPN /LVN BD = NO initial Assessment or IV push & stable/predictable Your role In addition to the UAP tasks, the LPN can perform certain invasive with tasks and client care needs such LPN/LVN as: Administering oral meds, IM, SQ Delegation injections ( NO IV PUSH), changing basic dressings, irrigating wounds, monitoring an intravenous flow rate, suctioning. Questions? ?? Thank You =)