Respiratory Disorders - Epistaxis, Tuberculosis, Pneumonia - PDF

Chapters 29,30 31 Respiratory Disorders 317  Epistaxis Tuberculosis Pneumonia Primary concern Topics Pleural effusion Oxygenation & Ventilation Pulmonary embolism Asthma...

Chapters 29,30 31 Respiratory Disorders 317  Epistaxis Tuberculosis Pneumonia Primary concern Topics Pleural effusion Oxygenation & Ventilation Pulmonary embolism Asthma COPD  Risk Factors Trauma (surgery) Low humidity Infection Allergies Overuse of decongestant sprays Tumor Medications that affect bleeding (aspirin, NSAIDS, warfarin)caumadin Epistaxis blood cominges of the nose Anterior Bleeds (nosebleed) Most common Easy to visualize Usually stop with self treatment Posterior Bleeds pose a risk for blood clots Closer to throat Unable to assess how much blood loss May need medical intervention Concern for aspiration of blood  Initial Treatment Apply pressure tip head forward Secondary Treatment if needed Cauterize the capillaries burns them Apply internal pressure Gauze, balloon Focused Assessment Respiratory Status (RR, O2 Saturation, any dyspnea) I Neuro status (LOC) levels of consciousness VS (BP) Epistaxis To Swallowing (any dysphagia) cough giration worries for Expected Outcomes Gasping Controlled bleedingchoking symptoms Difficulty drinking Lots Normal focused assessments Pt Education (Respiratory, fooling Neuro, VS, Swallowing) Focused on the cause (may use humidification, stop nasal sprays, treat infection) Avoid NSAIDS, Aspirin, Vigorous nose blowing  Social Determinates of Health Mycobacterium Most frequently a pulmonary problem Homelessness Can effect kidneys, bones, meninges and other tissues Poor neighborhoods Tuberculosis Close proximity living (long Active most term care, prisons, shelters, hospitals) risk to pass on IV drug users infection Latent have Poor access to care bacteria immunocompromised and acquiring pneumonia  Nursing Assessment Nursing Interventions Airborne isolation Single room Slow onset of symptoms 2-3 weeks Negative pressure after exposure N-95 masks/ HEPA Dry cough that becomes productive Tate Appropriate drug therapy Night sweats Active TB 4 drug combo therapyautisiceria ftp.gie The Fever At least 2 months Tuberculosis Weight loss Fatigue Non-adherence contributes to multi drug resistance Risk for reinfection or resistant Put patient Malaise organisms r/t non-compliance into a negative Pleuritic chest pain contactstrace for 3 Teaching Prevent spread (cover cough, sneeze) pressure isolation Lung Assessment Crackles Wash hands Patient wears mask outside of neg room and keep Dyspnea pressure room door closed Hemoptysis Infectious for 2 weeks after starting treatment Identify and screen close contacts Discontinue airborne isolations with 3 neg sputum tests on 3 different days.  Test Normal Results Abnormality with Condition Explanation Fluorochrome Negative Positive; 3 samples obtained on 3 Mycobacterium tuberculosis or Acid fast different days is a bacterium that resists Bacilli Sputum decolonizing chemicals after staining Tuberculin 10 mm considered positive induration and the risk placed and Response in Recent Immigrants ( 48hrs Routine oral care significantly decreases risk of HAP/ VAP  Clinical Presentation Cough Green/ yellow sputum Fever Change in level of consciousness [confusion or stupor] Chills Diaphoresis Tachycardia Headache Pleuritic chest pain Myalgias Pneumonia Fatigue Focused Resp Assessment Rhonchi or crackles Bronchial breath sounds Increased fremitus Egophony Dyspnea Change in O2 saturation Decreased O2 saturation with activity Right lower lobe pneumonia  Treatment Interventions Prevention Curative Antibiotics (ASAP) Keep HOB @ least 30 Expect response 48-72 degrees hrs Antivirals (viral pneumonia) Assist eating as needed Pneumonia Supportive Assess gag reflex Most are bacterial Oxygen (if needed) Monitor gastric residuals if Antipyretics NG present Analgesics Mobilize Hydration Promote activity allow for Cough, Deep Breathe, IS frequent rests Oral hygiene  Test Normal Results Abnormality with Explanation Pneumonia Chest X-Ray Clear Lung Infiltrates Findings reflect areas of Fields consolidation CBC with 3.5-10.5 /μL leukocytosis, (WBC) Findings will be reflective of active differential count is usually greater infection than 15,000/μL, bands (immature neutrophils) Diagnostic Studies PNA Bronchoscopy, Normal Washings positive for Used to view the pulmonary broncho-alveola pulmonary infective agent on structures and obtain pocket of r lavage structures and immuno-fluorescent broncho-alveolar washings (more fluid will negative stain sensitive then standard sputum usually resolve cultures specimens) with pneumonia on its own Other tests: Blood cultures, Thoracentesis  Direct visualization of bronchi Indications Earmens Diagnostic procedure Obtain biopsy or specimens Treatment: foreign body removal Nursing Interventions Position in fowlers or semi fowlers Bronchoscopy Must remain NPO until gag reflex returns Monitor VS during conscious sedation slows signsdown vital Outcomes Expected Blood tinged mucus post procedure Maintain adequate VS [O2 sat, RR] Eight's Unexpected Outcomes New (dyspnea, SOB, tachycardia) decreased O2 sat, a lot is not alright  Abnormal amount of fluid in pleural space look at this slide with Transudative (watery fluid) Exudative (protein rich fluid) chest tubes Common Causes Pneumonia slideshow Heart failure Cancer Pulmonary embolism Pleural Cirrhosis Pulmonary embolism effusion Post op chest surgery Kidney disease Heart surgery Inflammatory disease Treatment interventions Diuretics if r/t heart failure Chemotherapy, radiation or medications r/t malignancies Thoracentesis to drain fluid 1-1.2 L removed at one time Risk to drain too much at once (hypotension, hypoxemia)  Assessment 4 D’s Dyspnea; cough; and occasional sharp, non-radiating chest pain that is worse on inhalation. Decreased movement of the chest on the affected side Dullness to percussion Pleural Diminished breath sounds over the affected area. Effusion Diagnostic Tests Chest X-Ray CT Scan Ultrasound Thoracentesis w/ fluid analysis  Insertion of large bore needle through the chest wall into the pleural space Indications Obtain specimen for diagnostic Removal of fluid Instill medications Nursing Interventions Position pt sitting up, leaning over table Prepare local anesthetic Thoracentesis Prepare for Chest Tube insertion want patient Expected Outcomes to sit up Maintain VS, Oxygenation, RR If removal of fluid improved respiratory status for this Unexpected Outcomes Decrease O2 saturation Bleeding Decreased BP Increased HR  Cause & Assessment Risk Factors Clot lodges in the pulmonary Immobility circulation Often clot is from DVT Recent surgery Focused Assessment History of DVT Pulmonary Abrupt- Sudden- SOB, Cancer sotachypnea, Embolism (PE) Dyspnea, tachycardia, dry cough, Obesity hemoptysis, pleuritic chest pain Oral Contraceptives/ hormones Cyanosis, Hypotension, Smoking Acute PE prevents Syncope, abnormal heart sounds, abnormal ECG Prolonged air travel 02 from Fever, petechiae, flu like symptoms Pregnancy moving Clotting disorders across the Hypercoagule lung membranes Bloodclotsfaster than expected  Test Normal Abnormality Explanation Results with Condition ABG PaO2: 80-100 PaO2: 90% Avoid triggers Supplemental oxygen to treat hypoxia Monitor signs & symptoms Follow ABG’s if appropriate Use Peak Flow at home Monitor Cardiac & Pre-medicate if exercise Respiratory status closely induced asthma Asthma Priority SABA have ceiling effect Correct hypoxia Seek medical help if no Improve ventilation relief from inhalers Give Short Acting Recognize asthmatic patients Brochodilators (MDI or frequently do not perceive Nebs) urgency with changes in IV Steriods [Need the breathing profound systemic anti-inflammatory properties] Have emergency airway equipment  ⚫ Peak flow results ⚫ Green Zone ⚫ Usually 80% to 100% of personal best ⚫ Remain on medications ⚫ Continue to monitor ⚫ Yellow Zone ⚫ Usually 50% to 80% of personal best Peak Flow ⚫ Indicates caution Meter ⚫ Something is triggering asthma. ⚫ Administer quick relief medication Visual objective ⚫ Red Zone meter about ⚫ 50% or less of personal best ⚫ Indicates serious problem breathing ⚫ Definitive action must be taken with health care provider. ⚫ Rescue medications must be administered! How to use a Peak Flow Meter  Limited Airflow not fully reversible c Generally progressive chronic disease Gradual onset diagnosis typically >55 yrs old sometimescloser Includes chronic bronchitis & emphysema to 60 Chronic Result of chronic inflammation, consistent exposure to noxious stimulus [smoking, pollutants, particles, gases] Obstructive Risks related to living in highly polluted areas, family history of disease, alcoholism, SMOKING Pulmonary Permanent structural changes Disease [barreled chest, destruction of alveolar spaces] Result of long Often co-exists with heart disease term exposure to 4th leading cause of death affecting 15 million people smoking or pollutants  Assessment Dyspnea [exertion & rest] Fatigue that interferes with ADL’s Underweight Barrel chest COPD Accessory muscles SOB fatigue See pursed lip breathing with every Wheezing day activities Skin color changes (cyanosis) Blood changes (polycythemia) d/t chronic hypoxia too many redblood cells due to kidneys 4921 1981  Spirometry- Gold Standard red foodcells Baseline- bronchodilator- retest 19 8intahamoff Reduced FEV1/ FVC ratio Decreased amt of exhaled air in 1st second/Amt of air exhaled after max less air exhaled inspiration than inhaled Increased residual volume Amount of air left at the end of expiration 6 min walk test O2 sat drops 88% or lower, qualify for home O2 COPD Diagnostics CXR Not really a diagnostic- but may see hyperinflation of lungs; flattened diaphragm ABG: What might you expect to see for a patient diagnosed with COPD 2 years ago? pH: High Low or Normal CO2: High Low or Normal comEnsatory respiratory acidosis  Primary Causes Bacterial/ Viral Infections Associated with poorer health outcomes Assessment: COPD Uncompensated ABG Increased work of breathing Exacerbations Altered level of consciousness (new/ worse confusion) Unstable Blood Pressure (hypotension) New/ worse edema Right sided heart failure Increased cyanosis  Short acting bronchodilators, Steroids & antibiotics (if bacterial infection) Low Flow Supplemental O2 NC 1-6 L/min [24-44%] Facemask 6-12 L/min [35-50%] Non-Rebreather 10-15 l/min [60-90%] Treatment High Flow Venturi mask High flow nasal cannula Ventilator Bipap Goal 88-92% O2 saturation How much O2 can we give in an emergency? 110 151 min  Remove triggers (if possible) Vaccinate Influenza Pneumovax Smoking cessation Seek prompt treatment Decreased reserve/ may decompensate quickly ADL’s consideration Space activities Collaborative Allow for adequate rest Gradually increase duration of walks Care Breathing Training pursed lip breathing Teach O2 safety RN’s can titrate LPN’s can adjust for stable patients ULAP can not administer or titrate Nutrition High calorie see Frequent small meals  Respiratory disorders are the #1 cause of death for people with IDD IDD patients have more frequent & longer admissions IDD have increased incidence of Impaired swallowing & dysphagia which increases risk aspiration or asphyxiation Neuromuscular dysfunction (ALS, MS..) IDD & Anticholinergic effects (drying) Pulmonary Assess droolingmore than coughing constantly annually for overt or silent aspiration problems Difficulty swallowing (choking or throat clearing, drool, aversion to food, weight loss, frequent chest infections, asthma) Collaborate Refer to speech and language pathologist for function m sdf  Asthma COPD Asthma & COPD IDD785mind Need to screen for asthma Also, consider other causes Screen for smoking/ exposure to 2nd hand smoke Both are more of cough/ wheeze Screen for obstructive sleep prevalent in IDD pts Spirometry/ pulmonary apnea compared to general function tests may need to be Especially if there are population adapted craniofacial abnormalities IDD pts may not be able to Genetic abnormalities complete tests as directed (downs syndrome)