RESPIRATORY SYSTEM NOTES.docx.pdf

RESPIRATORY SYSTEM - injection of radioisotope, scans are taken with scintillation camera MODULE 4: CARE OF CLIENTS - measure blood perfusion to lungs...

RESPIRATORY SYSTEM - injection of radioisotope, scans are taken with scintillation camera MODULE 4: CARE OF CLIENTS - measure blood perfusion to lungs - confirm pulmonary embolism WITH RESPITRATORY SPUTUM EXAM DISORDERS - C&S - AFB staining DIAGNOSTIC TESTS - Cytologic exam *REVIEW PHASES OF VENTILATION* RESPIRATION: exchange of O2 & CO2 NURSING CONSIDERATION: EXTERNAL: Alveolar & capillaries (mimute vessels) - early morning INTERNAL: From tissue to cellular level rinse mouth with plain water VENTILATION: movement of air in & out use sterile container - sputum exam for C&S is collected before first dose of 97% of O2: goes to Hgb antibiotic 3% of O2: goes to plasma - AFB (acid fast bacilli) stain: collect for 3 connected mornings. (* 3 specimen) MANTOUX TEST OR PPD OR TUBERCULIN SKIN TEST - PPD (PURIFIED PROTEIN DERIVATIVES) * sputum should be examine first before giving abx. - intradermal - Read 48-72 hours BIOPSY OF LUNGS - + Montoux Test = induration of 10mm - Transbronchoscopic biopsy – done during - HIV positive = induration of 5mm bronchoscopy - (+) = exposure to Mycobacterium tubercle - Percutaneous needle biopsy - Open lung biopsy - usually in forearm - indicates exposure to TB; not positive LYMPH NODE BIOPSY - Assess metastasis of lung cancer CHEST X-RAY - all metallic objects should be removed PULMONARY FUNCTION TEST - Deep breath; & hold breath *Nose clipped & heavily & blow hard FLUOROSCOPY VITAL CAPACITY – maximum volume of air after - studying lungs while in motion exhaled at maximum capacity TIADAL VOLUME – volume of air at normal breathing BRONCHOGRAPHY (500mL) Nursing Intervention Before: INSPIRATORY RESERVE VOLUME – max vol. Secure written consent following a normal breathing Check for allergies to iodine or seafood EXPIRATORY RESERVE VOLUME – max of air that NPO for 6-8 hours can be exhaled following normal breathing Pre-op meds- Atropine sulfate, valium, topical FUNCTIONAL RESIDUAL – air that remains after a anesthesia sprayed, local anesthesia injected to larynx normal breathing Have O2 and antispasmodic available RESIDUAL VOLUME – volume of air that remains after forceful exhalation (1,200 mL); prevents lung from Nursing Interventions after: collapsing Side lying TOTAL LUNGS CAPACITY: NPO until gag reflex return Cough & deep breathe ARTERIAL BLOOD GASES - Radial artery is common site for blood withdrawal - radio opaque medium instillation on trachea and bronchi - Allen’s test - needs informed consent - Use 10 ml pre-heparinized syringe - low grade fever anticipated - Container with ice to prevent hemolysis of specimen BRONCHOSCOPY * used to assess ventilation & acid base balance Nursing Intervention Before: * Edgar Allen; assess adequacy of collateral Informed consent * Clinch fist; put pressure on radial & ulnar arteries; open fist; Pre-op meds – Atropine sulfate, valium, topical if it turns back from pallor to normal (5-15 seconds) – means anesthesia sprayed, local anesthesia injected to larynx. adequate blood supply. NPO 6-8 HRS Remove dentures, prosthesis, contact lenses PULSE OXIMETRY * index finger; SPO2 Nursing Intervention After: Side lying THORACENTESIS NPO until gag reflex return * fluid removal from pleural space - until bronchi - needs informed consent Nursing Interventions before - after: watch for bronchial tree perforation (s/s: cyanosis, - Secure consent hemoptysis, increased HR, dyspnea, hypotension). - Take initial v/s - Position: Upright leaning over bed table LUNG SCAN - Instruct to remain still, avoid coughing during insertion (* movement can puncture lungs) NOTES  - Pressure sensation is felt on insertion of needle Nursing intervention after: - Turn on affected side - Bed rest until v/s is stable - Check for expectoration of blood, notify doctor RESPIRATORY PROBLEMS CHOANAL ATRESIA * done when pt. has pleural effusion; for culture & sensitivity Atresia: Congenital absence or abnormal narrowing of a test; for palliative procedure. body opening * REVIEW ASSESSMENT* Choana: A funnel - shaped opening, particularly either of CHIEF COMPLAINT the openings between the nasal cavity and the pharynx - Dyspnea - Cough Signs and Symptoms - Sputum Production Respiratory distress at birth - Hemoptysis They are quite for the first time and attempt to breathe - Wheezing through the nose - Stridor Infant struggle and become cyanotic at feedings - Chest pain Simultaneously or difficulty feeding Past medical hx Family Hx Danger signs: Psychosocial hx and lifestyle Persistent cry and difficult breathing Occupational or environmental exposure - Geographic location Medical-Surgical management - Personal habit – smoking Medical management o YEARS OF SMOKING x NO. OF PACK oral airway insertion* PER DAY= PACK YEARS Surgical management PHYSICAL EXAMINATION For bilateral atresia INSPECTION - Local piercing of the obstruction membrane - Note signs respiratory distress (s/s: RR, nasal Surgical removal of the bony growth flaring, use of mouth, use of accessory muscles & etc.) INFANT RESPIRATORY DISTRESS SYNDROME (IRDS) - Note client’s speech pattern A hyaline - like membrane lines the terminal - Head and Neck bronchioles, alveolar ducts and alveoli, preventing the - Chest wall exchange of oxygen and carbon dioxide - Chest deformities - Fingers and toes Clinical manifestations Nasal flaring PALPATATION Expiratory grunting - Trachea (ex. Deviated trachea due to lung collapse) Tachypnea or more than 60 bpm - Chest wall Sternal and substernal retractions - Thoracic excursion Fine crackles and diminished breath sounds - Tactile Fremitus Respiratory acidosis Hypothermia PERCUSION - Resonance (normal lung fields) Diagnostic evaluation - Hyperresonance (means air trapping in pleural ABG analysis space; emphysema & pneumothorax) Chest X-rays - Dullness Nursing care AUSCULATION Assess cardiovascular, respiratory, and neurologic status Normal breath sounds Monitor continuous electrocardiography and vital signs 1. Bronchial (tracheal) – heard over the manubrium; Initiate and maintain ventilator support status high pitch & loud Administer medications including endotracheal surfactant, 2. Bronchovesicular – heard over the bronchi; high as prescribed pitch Initiate and maintain I.V. therapy 3. Vesicular – heard over lung fields Provide adequate nutrition through enteral feedings, if possible, or TPN ADVENTITOUS BREATH SOUNDS Maintain thermoregulation 1. Crackles/ rales fine – soft, high pitch, like popping Obtain blood samples as necessary sound when hair is touched with fingers. 2. Crackles/ rales coarse – Loud, bubbling; like open SIDS/SUDDEN INFANT DEATH/CRIB DEATH a wallet with velcro Possible causes: 3. Pleural friction rub – low pitch, grating sound Abnormality in the control of ventilation causing prolong 4. Wheeze high-pitch, squeaking, moaning apneic period with profound hypoxia and arrhythmias (sibilant rhonchi) – similar to rhonchi; narrowed Immature respiratory system & respiratory function airway Sleep in prone position 5. Wheeze low- pitched, musical snoring, moaning sound (sonorous rhonchi) Clinical manifestation Sudden, unexplained death of an infant under 1 year of age Death takes place during sleep without noise or struggle NOTES  Parents or caregivers usually discover that the child has Ineffective breathing pattern died in her sleep Ineffective airway clearance Frothy, blood - tinged fluid fills the infant’s mouth and Risk for imbalanced fluid volume nostrils Anxiety The infant maybe lying-in secretions The diaper is filled with the urine and stool Diagnostic evaluation Implementation Autopsy Assess airway obstruction by evaluating respiratory status Is the only way to diagnoses SIDS Keep emergency equipment* Autopsy findings indicate pulmonary edema intra thoracic Administer oxygen therapy and maintain the child in cool Petechiae or hemorrhage and other minor changes mist tent, if needed suggesting chronic hypoxia Administer medications as ordered, and note effectiveness to maintain or improve child's condition Nursing management Promote desired fluid's intake Avoid implying wrong doing, abuse, or neglect Provide emotional support for the parents to decrease Evaluate family coping and grieving patterns anxiety Provide anticipatory guidance for typical feelings Provide age-appropriate act for the child confine to mist Allow the parents verbalize, listen and validate feelings tent to ease anxiety Be non-judgmental about parent's attempts at resuscitation Monitor for rebound obstruction when administering Support parents racemic epinephrine Refer family for counseling, if needed Provide child & family teaching Refer to community self-help group When the child's awakens with a bark like cough, Monitor infant at risk for apnea tell them to place the child in the bathroom and run Teach parent how to minimize the risk of SIDS hot water Avoid implying wrong doing, abuse, or neglect Instruct the parent's to stay in the bathroom with Evaluate family coping and grieving patterns the child to prevent accidental injury Provide anticipatory guidance for typical feelings change the clothing frequently and bedding Allow the parents verbalize, listen and validate feelings Be non-judgmental about parent's attempts at resuscitation BRONCHIOLITIS An infection of the lower respiratory tract (bronchioles), CROUP produces inflammation obstruction by thick mucus and a general term referring to a group of disease involving edema. inflammation of the larynx, trachea and major bronchi - common in toddlers CLINICAL MANIFESTATION Atelectasis Clinical manifestations Tachypnea* Acute LTB Dyspnea Gradual onset* Sternal retractions, wheezing, crackles, rhonchi on Hoarseness (due to inflammation) auscultations, thick mucus Inspiratory stridor, retractions Signs of a mild upper respiratory infection, such as nasal Low - grade fever (possible) drainage or pharyngitis Restlessness and irritability Lower grade fever- 101F- 102F (38.3C - 38.93C) Pallor/ cyanosis Sneezing, dry and persistent cough Wheezing, rales, ronchi, and localized areas of diminished Air hunger, cyanosis, anorexia breath sounds Signs of otitis media Apprehensive, irritable and restless DIAGNOSTIC EVALUATION Dehydration Throat cultures Laryngoscopy DIAGNOSTIC EVALUATION Neck X-ray Clinical findings Bronchial mucus culture MEDICAL MANAGEMENT -Shows RSV Cool humidification during sleep with a cool mist tent or humidifier MEDICAL MANAGEMENT Inhaled epinephrine and corticosteroids* Provide cool mist tent humidification Tracheostomy Administer humidified oxygen therapy Oxygen administration Administer and maintain I.V. therapy Drug therapy options Drug Therapy Options Bronchodilator * Antipyretic* RSV immune globulin (I.V.) Inhaled epinephrine* Corticosteroids* (methyprednisolone sodium succinate) NURSING MANAGEMENT Monitor vital signs and pulse oximetry NURSING MANAGEMENT Assess respiratory and cardiovascular status Assessment Early signs of respiratory distress, Anxiety, dyspnea, Assess respiratory and cardiovascular status restlessness, tachypnea Use gloves, gowns aseptic hand Note color, respiratory effort evidence of fatigue washing as secretion precautions Monitor vital signs* and pulse oximetry Administer physiotherapy after edema has abated Nursing diagnoses NURSING DIAGNOSES Impaired gas exchange Impaired gas exchange NOTES  Ineffective breathing pattern r/t mucus accumulation and Provide high calorie, high protein foods with added food respiratory tract edema salt and salt intake Ineffective airway clearance r/t increase tracheobronchial secretions TONSILITIS/ADENOIDITIS Drug Therapy is the term commonly use to refer to infection and Mucolytic (dornase alfa) [pulmozymel] inflammation of the palatine tonsils Bronchodilator Antibiotic nebulizer inhalation CLINICAL MANIFESTATIONS.I.V. antibiotics Mouth breathing/ difficulty breathing Oral pancreatic enzymes replacement with pancrealipase Frequent sore throat (pancrease) Anorexia, decrease growth velocity Low - grade fever Surgical management Obstruction to swallowing Lobectomy Nasal or muffled voice Resection of sympatomatic lobar bronchiectasis to retard Night cough progression of lesion to total lung capacity Offensive or foul odor Nursing care DIAGNOSTIC EVALUATION Assess respiratory and cardiovascular status Ears, nose and throat exam & appropriate cultures Monitor vital signs and I&O Pre-operative blood studies Monitor pulse oximetry CBC Encourage physical activity Teach parent to have a thorough understanding of dietary Medical management regimen and special needs for calories, fat and vitamins Bacterial tonsillitis Appropriate antibiotics is given Penicillin/azithromycin* Viral tonsillitis RESPIRATORY DISORDERS No therapy other than comfort or fever reduction strategies COMMON AMONG Surgical management Tonsillectomy ADOLESCENT & YOUNG Adenoidectomy ADULTS CYSTIC FIBROSIS FRACTURE OF THE NOSE/ NASAL FRACTURE Is a generalized dysfunction of the exocrine glands that Septal dislocation/fracture due to minor trauma the most affects multiple organ system common facial fracture and third common fracture of the Is a generalized multisystem disorder affecting the exocrine skeleton overall. glands so the substances the secrete are abdominally viscous, affecting primarily pulmonary and G. I. function CLINICAL MANIFESTATION Nose pain CLINICAL MANIFESTATIONS Swelling of the nose. Bulky, greasy foul - smelling stool that contain undigested A crooked or bent appearance. food Bruising around the nose or eyes. Distended abdomen and thin arms and legs from A runny nose or nosebleed. steatorrhea or partial or complete intestinal obstruction A grating sound or feeling when the nose is touched rubbed Thick intestinal secretions Blocked nasal passages. Meconium ileum in the new born (earliest sign) Salty taste on the child's skin Diagnostic Evaluation Sweat that contains 2-5 times the normal levels of sodium Physical exam and chloride Axial and Coronal CT scan Voracious/increase appetite. Obstruction of pancreatic ducts SURGICAL MANAGEMENT Rectal prolapse Rhinoplasty* Closed reduction DIAGNOSTIC EVALUATION Open reduction Chest X-ray Sweat chloride test DEVIATED SEPTUM* Stool specimen analysis Is an abnormal configuration of the cartilage that divides Pulmonary function studies (after 4 y.o.) the sides of nasal cavity, which may cause problem with Prenatal diagnostic tests proper with breathing or nasal discharge. Medical management CLINICAL MANIFESTATION CPT Nosebleeds Postural drainage Sinus infections or sinusitis Coughing and DBE Postnasal drip* Broncho-pulmonary lavage Loud breathing in children Administer pancreatic enzymes with meals and snacks Nasal congestion Provide zinc and iron supplements and water - soluble and Pain in the face fat soluble vitamins NOTES Surgical management PHARYNGITIS/SORE THROAT Septoplasty Is an inflammation of the pharynx including palate, tonsils surgery to correct a deviated nasal septum* and posterior wall of the pharynx. 3 FORMS Acute bacterial pharyngitis Viral pharyngitis Chronic pharyngitis NASAL POLYPS CLINICAL MANIFESTATION The end product of the ongoing inflammation that may Throat soreness and dryness result from viral or bacterial infections, from allergies or from Pain on swallowing* an immune system response to fungus. Fever Cough CLINICAL MANIFESTATIONS Mild to severe redness of the throat* Difficulty breathing/mouth breathing Nasal discharge Runny nose Lymph node enlargement in the neck Persistent stuffiness Chronic sinus infections MEDICAL MANAGEMENT Loss or diminishment of your sense of smell For streptococcal pharyngitis, penicillin V 25 mg qid orally, Dull headaches for penicillin G benzatine (Bicillin) in a single intramuscular Snoring dose of 2.4 million units Erythromycin for patient who is allergic to penicillin MEDICAL MANAGEMENT Other penicillin, macrolides, and cephalosporin are also DRUG THERAPY used Oral corticosteroids or corticosteroid nasal spray Fluticasone (Flonase) NURSING INTERVENTIONS & PATIENT EDUCATION Triancinolone (Nasacort) Advise patient to have any sore throat with fever evaluated Budisonide (rhinocort) & encouraged compliance with full course of antibiotic Medications to control allergies or infections therapy Antifungal medications Lukewarm saline gargles and use of antipyretic/analgesics as directed SURGICAL MANAGEMENT Encourage bed rest with increased fluid intake during fever Polypectomy Inform the patient of good hand washing Endoscopic sinus surgery LARYNGITIS RHINITIS/RHINOSINUSITIS Is an inflammation of the mucus membranes lining the Is an inflammation of nasal mucusa (allergens) larynx and may/ may not include edema of the vocal cords TYPES CLINICAL MANIFESTATIONS Acute rhinitis/common colds/coryza Hoarseness of voice Allergic rhinitis Dry cough Non-allergic rhinitis Difficulty in swallowing Drug induce rhinitis Complete but temporary voice loss* may occur Vasomotor rhinitis Rhinitis of pregnancy DIAGNOSTIC EVALUATION Laryngeal mirror CLINICAL MANIFESTATION X-ray Hypersecretion or increase nasal drainage Computed tomography Nasal obstruction symptoms - nasal congestion stuffiness Fiber trophic laryngoscopic exam or paroxysmal sneezing Headache MEDICAL MANAGEMENT Antibiotic is prescribed if a bacterial infection is suspected MEDICAL MANAGEMENT In severe cases, systemic steroids (methyl prednisolone 1. Treatment of underline cause [Medrol]) Allergy - anti-histamines Supplemental humidification Infection or acute rhinitis Mucolytic agents may also prescribed supportive care for viral antibiotics for bacterial NURSING MANAGEMENT* 2. Topical decongestants (for short-term use) 1. Treatment consist of voice rest, steam inhalations, 3. Intranasal corticosteroids increase fluid, throat lozenges 2. Inform the client and the family about the relief measures, NURSING INTERVENTIONS infection prevention, in avoidance of tobacco and alcohol and Avoid irritating inhalants pollutants Do not overused topical nasal sprays or drops 3. Preventive therapy is aimed toward increasing the client's Don't blow nose to frequently or too hard and family's awareness of the hazards of tobacco and Blow through both nostrils at the same time alcohol use. Side effect of systemic decongestant is stimulation of SNS 4. Long term voice retraining may be necessary if improper Intranasal corticosteroids do not cause significant systemic use or overuse of the voice is the main cause absorption SINUSITIS NOTES  Inflammation of the sinuses.* MEDICAL MANAGEMENT CLINICAL MANIFESTATION Antibiotic therapy for 7-10 days Acute sinusitis Hydration and humidification Pain* Secretion clearance interventions* Nasal congestion and discharges Bronchodilators* Anosmia* Red and edematous nasal mucosa NURSING INTERVENTION Fever Establishing effective airway clearance Administer or teach self - administration of antibiotics as ordered Chronic sinusitis Encourage mobilizations of secretions, though hydration Persistent nasal obstruction, chronic nasal discharge, clear Educate patient that beverages with caffeine or alcohol or purulent discharge should be avoided Cough* Teach self - administration of inhaled bronchodilators Feelings of facial fullness/pressure Headache LEGIONAIRE'S DISEASE Fatigue Is an acute bronchopneumonia, an inflammation of the lungs, that begins in the terminal bronchioles* DIAGNOSTIC EVALUATION Sinus X-rays and CT scan July 19, 1976. Peculiar event wherein during the american Antral puncture and lavage: making puncture on wall of legion convention in Philadelphia 182 people, 29 died due to maxillary sinus & lavage symptoms related to pneumonia Nasal sinus endoscopy CLINICAL MANIFESTATION MEDICAL MANAGEMENT Cough that's initially non productive but that can Topical decongestant spray or drops/systemic eventually be productive decongestant Grayish, nonpurulent, blood - streaked sputum Topical nasal corticosteroids High fever, recurrent chills Antibiotic: Malaise, generalized weakness Trimethoprim - sulfamethoxazole (Bactrim) Headache, diffuse myalgias Penicillinase - resistant penicillins Anorexia, diarrhea Cephalosporins or macrolide antibiotics Chest pain, tachypnea Analgesics Respiratory distress Warm compresses, cool vapor humidity for comfort DIAGNOSTIC EVALUATION SURGICAL MANAGEMENT Blood tests Functional endoscopic sinus surgery (FESS): non Chest X-ray invasive; discloses sinus air opening & insertion of Direct immunoflourescence of L. pneumohilia and indirect endoscope fluorescent serum antibody testing Sputum test Caldwell LUC procedure (radical antrum surgery): clearing block & infected sinus. Enters max sinus through MEDICAL MANAGEMENT mouth. Canine fossa is incised to reach maxillary sinus. The Oxygen therapy* sinus will then be cleared & creation of an enlarge opening Drug therapy options drainage through the nose - for maxillary sinus only. o Antibiotic ▪ Erythromycin (erythrocin) External sphenoethmoidectomy: used to clear secretion ▪ Rifampin (rifadin) in ethmoid sinus. ▪ Tetracycline (achromycin) o Antipyretic NURSING MANAGEMENT o Acetamenophin (Tylenol) Maintaining a patent airway o Aspirin Promoting comfort o Inotropic agent Promoting communication o Dopamine (intropin) Encouraging fluid intake NURSING MANAGEMENT ACUTE BRONCHITIS Closely monitor the client's respiratory status continually, Is an infection of the lower respiratory tract that is generally v/s, pulse oximetry or ABG values, LOC, and dryness and an acute sequel to an URTI color of the lips and mucus membranes watch for signs of shock CHRONIC BRONCHITIS Keep the client comfortable* a productive cough lasting at least 3 months and occurring Provide mouth care frequently for 2 consecutive years Replace fluids and electrolytes as needed Provide mechanical ventilation and other respiratory CLINICAL MANIFESTATION therapy Dyspnea, fever, tachypnea Give antibiotics as necessary Productive cough, clear to purulent sputum Pleuritic chest pain, occasionally PULMONARY EMBOLISM INFARCTION Diffuse rhonchi and crackles heard on auscultation Refer to obstruction of one or more pulmonary arteries by thrombus Infiltrates & consolidation (nang-gahi): means there is necrosis of lung tissue that can result from interference with pneumonia. blood supply NOTES  Clinical picture of open or tension pneumothorax ETIOLOGY Air hunger, agitation, hypotension, cyanosis THROMBUS Mild to moderate dyspnea and discomfort may be present with spontaneous pneumothorax CLINICAL MANIFESTATIONS Dyspnea, pleuritic pain, tachypnea, apprehension HYPERESONANCE: heard during percussion due to air chest pain with apprehension & a sense of impending RESONANCE: normal percussion sound. doomed occurs when most of the pulmonary artery is obstructed DIAGNOSTIC EVALUATION Cyanosis, tachyarrhythmias, syncope, circulatory collapse, Chest X-ray and possibly deaths encountered in patients with massive pulmonary embolism subtle deterioration in patients conditions with no explainable cause pleural friction rub MEDICAL MANAGEMENT DIAGNOSTIC EVALUATION 1. Spontaneous pneumothorax: ABG's Non-operative if non extensive Chest X-ray Observe and allow for spontaneous resolution Ventilation - perfusion lung scan Needle aspiration or chest tube drainage MEDICAL MANAGEMENT 2. Tension pneumothorax Oxygen* Close the chest wound immediately An infusion is started to open an I.V. route for drugs/fluids Chest tube is inserted and water - seal drainage set Vassopressors, inotropic agents such dopamine (intropin) & up or antidysrhythmic agents ECG is monitored continuously for right ventricular failure, SUGICAL MANAGEMENT may have a rapid onset Pleurodesis Small doses of I.V. morphine* Thoracotomy Pulmonary angiography, hemodynamic measurements, ABG determinations, and other studies are carried out COMPLICATIONS Subsequent management - anticoagulation and Acute respiratory failure thrombolysis: Cardiovascular collapse.I.V. heparin Oral anticoagulation with warfarin (Coumadin) NURSING INTERVENTIONS Thrombolytic agents- streptokinase (streptase) 1. Achieving effective breathing pattern Newer clot specific thrombolytics Provide emergency care as indicated Apply petroleum gauze to sucking chest wound Assist SURGICAL MANAGEMENT with emergency thoracentesis or thoracotomy Interruption of vena cava Be prepared to performed CPR or administered medication Embolectomy if cardiovascular collapse occur Maintain patent airway, suction needed NURSING INTERVENTIONS: Position upright if condition permits Correcting breathing pattern Maintain patency of chest tubes Improving tissue perfusion Assist patient to splint chest while turning or coughing and Relieving pain administer pain medication as needed Reducing anxiety 2. Resolving impaired gas exchange Encourage patient in the used of inspiratory spirometer CHEST TRAUMA/INJURIES Monitor oximetry and ABG's to determine oxygenation Provide oxygen as needed 1. PNEUMOTHORAX Air in the pleural space occurring spontaneously after a 2. RIB FRACTURE trauma Most common chest injury Result of laceration to the lung parenchyma May interfere with ventilation and may lacerate underlying tracheobronchial tree, or esophagus lung *PNEUMO: presence of air. CLINICAL MANIFESTATION * usually have deviated trachea Pain fracture site Painful, shallow respirations CLASSIFICATION Localized tenderness and crepitus (crackling) over fracture Spontaneous pneumothorax: formation of small site sacs of air/ pleb in the lung ruptures - causing air leaking. 3. HEMOTHORAX Open pneumothorax: caused by stab/sucking Blood in the pleural space as result of penetrating or blunt chest wound. chest trauma* Tension pneumothorax: accumulation or build up of air due to lung laceration. CLINICAL MANIFESTATION Dyspneic, apprehensive, or in shock CLINICAL MANIFESTATION Hyperesonance, diminished breath sounds 4. FLAIL CHEST Reduced mobility of affected half of thorax Loss of stability of chest wall as a result of multiple rib Tracheal deviation away from effected side in tension fractures, or combined rib & sternum fractures pneumothorax NOTES  one portion of the chest has lost its bony connection to the - Unstable patient following blunt or penetrating rest of the rib cage trauma During respiration, the detached part of the chest will be - Non trauma pulled in on inspiration and blown out on expiration o Pleural effusion, chylothorax, emphyema (paradoxical movement). post operative CLINICAL MANIFESTATION CONTRAINDICATION Dyspnea and cyanosis - Diaphragm disruption Lung effusion, lung laceration TECHNIQUE - Local anesthetic - Sterile field - Scalpel, Kelly or hemostat forcep - Chest tube and pleurevac device 5. PULMONARY CONTUSION - Securing suture Bruise of the lung parenchyma that results in leakage of Nursing Care blood edema & fluid into the alveolar and interstitial spaces Check patient status-encourage deep breathing deep of the lung* breathing and shoulder range of motion Never elevate drainage system above level of chest CLINICAL MANIFESTATION Do not strip or milk routinely Maintain aseptic technique Tachypnea, tachycardia when changing dressings Crackles on auscultation Clamp tubes only for special procedures as changing Pleuritic chest pain drainage, air leaks or before removal of chest tubes Copious secretions If drainage system breaks, place distal end of tubing in Cough - constant, loose, rattling sterile water container at 2 cm level 6. CARDIAC TAMPONADE *prepare Kelly on the bedside to clamp for any leaks Compression of the heart as a result of accumulation of *document the quantity (level) and characteristics of the fluid within the pericardial space drainage in the bottle system. If bloody ba siya or pus or Caused by penetrating injuries unsay color niya. CLINICAL MANIFESTATION Falling BP CHRONIC OBSTRUCTIVE Distended neck veins, elevated CVP Muffled heart sounds Pulsus paradoxus PULMONARY DISEASES Dyspnea, cyanosis, shock (COPD’s) MEDICAL & SURGICAL MANAGEMENT FOR CHEST - mainly characterize by chronic airflow limitation because of TRAUMA the chronic obstruction in the airway passages which can The goal is to restore normal cardio -respiratory function as lead to pulmonary insufficiency. quickly as possible. 1. EMPHYSEMA Rib fracture - Enlargement and destruction of the alveolar, bronchial Give analgesics and bronchiolar tissue Encourage deep breathing - Caused by smoking, infection, inhaled irritants, heredity, Assess with intercostal nerve block allergic factors, aging, deficiency of alpha 1 antitrypsin For multiple rib fractures, epidural anesthesia may be used Signs and symptoms: Hemothorax Anorexia, fatigue, weight loss Assist with thoracentesis Feeling of breathless, cough, sputum production, flaring Assist with test tube insertion and set up drainage system of the nostrils, use of accessory muscles for breathing, Auscultate lungs and monitor for relief of dyspnea increased rate & depth of breathing, dyspnea, barrel Monitor amount of blood loss in drainage chest Replace volume with I.V. fluids or blood products Decreased respiratory excursion, resonance to hyperresonance, decreased breath sounds with NURSING RESPONSIBLITIES FOR CHEST TRAUMA prolonged expiration, normal -decreased tactile fremitus, Suction as indicated through nose or mouth or pursed-lip breathing endotracheal tube PCO2 elevated or normal, pO2 normal or slightly Prepare for tracheostomy decreased Secure one or more I.V. lines for fluid replacement, and obtain blood for baselines studies 2. CHRONIC BRONCHITIS Monitor CVP readings. ABG/SpO2 - Excessive production of mucus in the bronchi with Obtain urinary output hourly accompanying persistent cough Continue to monitor thoracic drainage to provide - Caused by cigarette smoking, infection, inhaled irritants, information about rate of blood loss. Whether bleeding has hereditary, allergic factors, aging stopped, whether surgical Signs and symptoms CHEST TUBE THORACOSTOMY Productive (copious) cough, dyspnea on exertion, use of INDICATIONS accessory muscles for respiration, wheezing and - Pneumothorax rhonchi - Hemothorax Feeling of epigastric fullness, slight cyanosis, distended neck veins, ankle edema NOTES  Increased pCO2, decreased pO2 Administer bronchodilators, corticosteroids, and Finger clubbing later in the disease, weight gain, edema, antibiotic, mucolytic as prescribed jugular venous distention PULMONARY HEART DISEASE (COR PULMONALE) What obstruct the patient with chronic bronchitis is the thick - An alteration in the structure or function of the right sputum ventricle resulting from disease affecting lung structure or function or its vasculature heart disease caused by 3. BRONCHIECTASIS lung disease - Chronic abnormal dilation of the bronchi with destruction - complication of COPD of muscular elastic structure of the bronchial wall - Caused by bacterial infection, congenital defects, Signs and Symptoms: tenacious secretions, obstruction of bronchi, foreign Increasing dyspnea and fatigue bodies Distended neck veins, peripheral edema, hepatomegaly Bibasilar crackles and split second heart sound -Carbon dioxide narcosis - headache, confusion, somnolence, coma Decreased pO2 and pH, increased pCO2 Signs and Symptoms Diagnostics Examination Chronic cough that produces copious, foul - smelling, ABG's decreased PaO2 and pH, increased PaCO2 mucopurulent (very yellow) secretions, possibly totaling PFT's may show airway obstruction several capfuis daily Blood test show HCT greater than 50% Coarse crackles during inspiration over involved lobes or Electrocardiogram changes are consistent with right segments ventricle hypertrophy Dyspnea Chest X-ray shows right heart enlargement Occasional wheezes Echocardiogram shows right heart enlargement Sinusitis Weight loss Nursing Interventions Finger clubbing Improving gas exchange Recurrent fever and bouts of pulmonary infection o Monitor ABG Obstructs the airway: the tenacious secretions o Use continuous low -flow oxygen o Avoid central nervous system depressants COPD Complications o Monitor for signs of respiratory Respiratory failure Attaining fluid balance Pneumonia, overwhelming respiratory infection o Watch alterations in electrolyte levels Right heart failure, dysrhythmias o Employ ECG monitoring Depression o Limit physical activity Skeletal muscle dysfunction o Restrict sodium intake Diagnostic Evaluation Stopping cigarette smoking Chronic Bronchitis and Emphysema Recognize and treat infectious immediately o PFT demonstrate airflow obstruction Treat hypoxemia with supplemental oxygen o ABG's - decreased PaO2, pH and increased CO2 Chronic lung disease - continuous low-flow oxygen o Chest X-ray - in late stages, hyperinflation, therapy at home flattened diaphragm, increased retrosternal space, decreased vascular markings PLEURISY o Alpha 1 - antritypsin assay useful in identifying - Inflammation of the visceral & parietal membranes genetically determined deficiency in emphysema Assessment findings Bronchiectasis Knife - like pain that is aggravated on deep breathing o Bronchoscopy and coughing o Chest X-ray Dyspnea o CBC Pleural friction rub heard on auscultation brought by the o PFT pressure of the inflamed pleura plus the lung tissue. o Sputum culture and Gram stain Apprehension Nursing Care for COPD Diagnostic Evaluation: Low concentration of oxygen (2-3 L/min) Chest X-ray Monitor pulse oximetry Sputum exam Provide respiratory treatments and chest physiotherapy Thoracentesis Diaphragmatic or abdominal and pursed - lip breathing Pleural biopsy technique Record the color, amount and consistency of sputum Nursing Interventions Suction the client as needed if ineffective ang Identify and treat cause pagpagawas sa sputum Monitor lung sounds Monitor weight Administer analgesics, NSAID Indomethacin as Encourage small, frequent meals prescribed High calorie, high protein diet with supplements Apply hot or cold application as prescribed Encourage Encourage fluids up to 3000 ml/day coughing and deep breathing High - Fowler's and lean forward Instruct the client to lie unaffected side to splint chest Allow activity as tolerated PNEUMOCONIOSIS NOTES - Non neoplastic alteration of the lung resulting from Monitor BP inhalation of mineral or inorganic dust (dusty lung) Comfort measure to alleviate discomforts - Most common pneumoconiosis are: Monitor closely for any manifestation of airway o Silicosis – inhaling large amounts of crystalline obstruction & bleeding from anterior and posterior nares. silica dust. (daghan kaayo ug silicon fragments sa Inspect oral cavity for presence of blood and soft palate lungs), necrosis and proper placement of posterior plug o Asbestosis – long-term exposure to asbestos Prophylactic antibiotics - are used to prevent toxic shock (fibre-like material) syndrome and sinusitis. o coal worker's pneumocontosis – "black lung Instruct client to minimize activity for approximately 10 disease," occurs when coal dust is inhaled days. NO VALSALVA MANUEVER - nasal pack: no blowing for 2 days following removal; Clinical Manifestation no sneezing/ open mouth when sneezing; no Chronic cough and sputum production extraneous exercise; no lifting; no stooping; no Dyspnea straining. Melanoptysis (black-pigmented sputum caused by exposure to coal dust) Oral hygiene (half strength Hydrogen peroxide mixed with water or saline) Nursing Interventions Use of humidifier or vaporizer - adds supplemental Promote measures to reduce the exposure of workers moisture to prevent dryness and crusting secretion. to industrial products Don’t blow nose for 2 days after removal of nasal pack o Dust control When sneezing, mouth should be open Ventilation o Spraying an area with ether BRONCHOGENIC CANCER/LUNG CA Floor cleaning - 31% deaths in men than in woman 25% o Toxic substances should be enclosed and placed in restricted areas Etiology: Workers must wear protective devices Tobacco smokers (active or passive) Ongoing educational programs Environment and occupational Exposure o Stop smoking Genetics o Receive an influenza vaccination Dietary factors o Responsibility for their own health Types: EPISTAXIS (NOSEBLEED) 1. Small Cell Lung Cancer (SCLC) – about 10-15% of lung - Hemorrhage from the nose, caused by the rupture of cancers. Most aggressive. tiny, distended vessels in the mucous membrane of any o Oat cell cancer – it is named for the small and oval area of the nose. shape cell (appearance of the cancer cell) which look - 90% are anterior portion occurring in children and like a grain of oat. Originates in the large central adults, 10% posterior are common in older (50+) bronchi. Major risk factor is cigarette smoking - SEPTUM: 3 major blood vessels meet 2. Non-small cell lung cancer (NSCLC) – most common Causes lung cancer accounting for about 85% of all cases Trauma Types: Infection o Squamous cell cancer – as good prognosis Drugs (anticoagulants) especially if detected early. Accounts 25-30% of Cardiovascular disease (atherosclerosis, HPN) lung cancer cases. Known as EPIDERMOID Blood dyscrasias CARCINOMA, because this usually arises in central Nasal tumors chest area in bronchi. Low humidity Foreign body in nose o Adenocarcinoma good prognosis; most common Deviated nasal septum lung cancer; 40% of lung cancer cases. Can also be seen in non smokers. Arise in outer or peripheral Medical Management areas of the lungs. With tendency to spread to Pinch the anterior portion of the nose for a minimum of lymph nodes or beyond. 5-10 minutes. Ice compress application o Undifferentiated cancer – has poor prognosis. Cauterization of the bleeding vessel with application of known as large cell carcinoma. least common type. Silver Nitrate 10-15% of all lung cancer cases. High tendency to Nasal packing (Posterior and Anterior) - antibacterial spread in Lymph nodes. Has high tendency to ointment is applied to half- inch gauze which is then metastasize. gently but firmly inserted into the anterior nasal cavity. o Nasal Balloon-substitute of nasal packing (rubber Clinical Manifestation inserted dayun ipaburot to compress the nasal Any change in respiration pattern mucous membrane) Persistent cough o Should remain in place for a minimum of 48-72 Sputum streaked with blood hours. Frank hemoptysis Diet-liquid to soft diet. (do not offer mga solid foods) Rust colored or purulent sputum Chest, shoulder, arm pain Surgical Management: Recurring episodes of pleural effusion, pneumonia, 1. Artery ligation (internal maxillary & ethmoidal artery). bronchitis, dyspnea, unexplained or out of proportion Nursing Management: Diagnostic Evaluation Monitor for hypoxia Chest X-ray NOTES  CT Scan Express feelings about fear of suffocation Sputum cytology Allow activity as tolerated with rest periods Fiberoptic bronchoscopy Turning, coughing, deep breathing, & breathing retraining Medical and Surgical Management High Fowlers position Chemotherapy Provide chest physiotherapy, postural drainage, Radiation therapy incentive spirometry and suction (not during the attack) Surgery Small frequent feedings, encourage fluids (not during o Pneumonectomy the attack) o Lobectomy o Segmentectomy *only use “bulsita” during hyperventilation; NOT during o Decortication/Pleurectomy asthma attacks o Thoracoplasty * Don’t give water during attack; patient will have a tendency o Wedge resection* of aspiration. INFLUENZA *after removal of the portion of the lungs, it will involve chest - acute viral infection of the respiratory tract (both upper tube insertion post-operatively and lower respiratory tract)* *post-operatively, positioned pt on the unaffected side INFLUENZE an italian word - used for various causes of ASTHMA widespread epidemic. - form of chronic obstructive airway disease in which the FLU VIRUS: 1930; first identified bronchial linings overreact to various stimuli, causing episodic spasms and inflammation that severely restricts People who are most at risk: airway. very young children older adults Classification: people who are living in institutional setting Extrinsic asthma – outside source (pollen, dust) people with chronic diseases Intrinsic asthma* – temperature, stress health care personnel Mixed asthma - combination of extrinsic and intrinsic Aspirin induced asthma Causative Agent: Exercise-induced asthma Type A virus – is the most prevalent and is associated Occupational asthma- related to exposure to with the most serious epidemics; wild birds are natural chemicals hosts; transmitted through individuals and animals Type B virus – outbreaks also can reach epidemic level Precipitating factors: but disease is generally milder than type A; only found in Exercise human Emotional stress Type C virus – never been connected with large Endocrine changes epidemics; milder than Type A; not easily transmiable Atmospheric changes Inhalation of irritant *no symptoms, can't transfer yet. Family history Mode of Entry: According to severity: direct contact through droplet spread Mild intermittent – symptoms < 2 times a week airborne spread following coughing or sneezing by an Mild persistent – symptoms > 2 times a week but < infected person 1time a day Moderate persistent – daily symptoms Incubation Period Severe Persistent – continual symptoms 1 to 3 days Clinical Manifestation: Period of Communicability Non-productive cough about 3 to seven days from onset of symptoms. Dyspnea Wheezing- because of the narrowing or constrictions of Clinical Manifestations: the airway onset of sudden chilly sensation Peak flow variability fever Chest tightness myalgias* (muscle pain) *cough Triad Symptom of Asthma Headache 1) severe dyspnea 2) excessive mucus secretion Complications: 3) expiratory wheezes viral bronchitis pneumonia Diagnostics Evaluation: bacterial pneumonia ABG's in acute severe asthma *superinfections Blood test Chest X-ray Management: PFT during attacks 1. Usually symptomatic. Skin test *SYMPTOMATIC- treat only the symptoms. For cough give muculytic; if fever & pain give analgesics. Nursing Interventions: Administer Low-flow humidified Oxygen 2. Antiviral drugs* Administer medications as prescribed ANTIVIRAL- INFLUENZA (1999) NOTES  Zanamivir (Relenza) – discovered in 1999; "adults Diagnostics: and children > 7 years old who have been Sputum culture analysis and sensitivity testing symptomatic for < 2days*; available in powder in a Skin test blister form Blood and urine culture o Nsg. Respon – monitor for bronchospasm and ABG measurements decline in lung function Chest X-ray used in uncomplicated influenza. Available form is powder C&S: most definitive test for diagnosis. form in a blister for inhalation (5 mg). Can cause Blood & urine culture: to rule out other conditions. BRONCHOSPASM. Oseltamivir phosphate (Tamiflu) – used for Management: influenza virus A or B in adults and in children > 1year Antibiotic therapy old who have been symptomatic for < 2 days Respiratory support o Nsg. Respon – Must be taken with meals to o O2 therapy decrease GI Effects o Bronchodilators o Tracheal Suctioning available in capsule (75 mg) & Oral suspension (12mg/mL). Nutritional support Should be taken with meals because they're gastric irritants. Fluid and electrolyte management *Both should be administered within 24 hour of onset Complications *considering viruses are self-limiting, they could die on their Pleural effusion due to increase fluid in pleural space. own, but in order to decrease/stop the multiplication of the Sustained hypotension and shock especially in gram virus – antiviral drugs are given negative bacteria disease, particularly in the elderly *they will not kill virus, only stops multipication of virus. Superinfection: pericarditis, bacteremia & meningitis Delirium Rimantidine (flumadine) - prophylaxis and Atelectasis treatment of illness caused by type A virus in adults Delayed resolution but no effect in type B; available in tablet form at 100mg also in syrup form at 50mg/ml Nursing Diagnosis and Intervention: o Nsg. Respon.-use cautiously in patient with Ineffective airway clearance related to excessive renal and hepatic impairment and in patients secretion and weak cough with history of seizures. o Increase fluid o Effective coughing & DBE reduces duration of fever and other symptoms when taken o Frequent turning sides first 48 hrs of the onset of illness. Available in tablet form o Chest physiotherapy, suctioning & artificial airways (100 mg); syrup (50mg/mL). Causes renal & hepatic o Collaborative: Brochodilators administration problems; it can also cause seizure attacks. Ineffective Breathing pattern r/t tachypnea Amantadine HCI (Symmetrel) – available in o Positioning for comfort powder in a blister form at 5mg/pack o Teach client on splinting of chest wall with pillow during coughing and the use of incentive spirometry 3. Immunization o Cough supressants and analgesics if prescribed 4. Prevention of spread of infection o Auscultate chest and record findings o Monitor ABGs - observe for hypoxemia, Vaccine: given yearly. In U.S. given during winters. hypercapnia, and acid-base imbalance) prevention: - isolation Sitting; semi or high fowlers to increase lung expansion. - handwashing Encourage early ambulation: to prevent secretions pooling. - wear mask - proper coughing & sneezing etiquettes. Activity intolerance related to decrease oxygen levels PNEUMONIA o Assess client's baseline level and response to - is an inflammatory process in lung parenchyma usually activity associated with a mark increased in interstitial and o Schedule activity after treatment or medication alveolar fluid. o Oxygen as needed - Due to increase interstitial or alveolar fluid, it will lead to o Gradual increase in activity on basis of tolerance lung consolidation o Teach client to avoid conditions that increases oxygen demand *lung consolidation. Decrease lung excursion & decrease o Instruct on pursed lip and diagphragmatic breathing fremitus. o Psychological support and quite environment Classification: ATELECTASIS Community acquired pneumonia (CAP) – common in - collapse of lung tissue at any level (segmental, basilar, elderly, causative agent is streptococcus pneumoniae lobar or microscopic) Hospital acquired pneumonia (HAP) – causative agent is staphylococcus aeroginosa Increase elastic recoil: decrease surfactants lower surface Pneumonia in Immunocompromised Host tension; the lungs would rebound during inhalation (like a Aspiration pneumonia rubberband). NOTES Risk Factors: headache, fatigue, dizziness, shortness of breath, pallor, Reduction in lung distention forces (lung compression) palpitation, brittle spoon shaped nails (koilonychia), cheilosis Localized airway obstruction & pica Insufficient pulmonary surfactant Increased elastic recoil Management: Correction of chronic blood loss Diagnostic Examination Oral iron supplements may be diagnose through PE o Given between meals for maximum absorption chest radiograph o Vitamin C enhances its absorption o May result to constipation and black stools Assessment findings: low level of oxygen in the blood Parenteral Iron maybe given IM using Z-track technique dyspnea (Dextran or Sorbitex) tachypnea, tachycardia, increase temperature o For intolerance with oral preparation cyanosis o Has high risk for allergic reaction bronchial or diminished breath sounds and crackles over involved area Increase diet of iron-rich foods o meat, egg yolk, whole grain breads/cereal Nursing Interventions:* Frequent positioning B. VITAMIN B12 DEFICIENCY ANEMIA Early ambulation - Vitamin B₁₂, also known as cobalamin, is a Deep-breathing and effective coughing* water-soluble vitamin involved in metabolism Oxygen administration - "Pernicious Anemia" – body's inability to absorb Vit. Postural drainage, chest physiotherapy B12 due to lack of intrinsic factor, substance secreted by Tracheal suctioning parietal cells of gastric mucosa Drug therapy - Impairs cellular division and maturation especially in Encourage the patient to stop smoking, lose weight or proliferating RBC both as needed. - RBCs are macrocytic (megaloblastic) Humidify inspired air and encourage adequate fluid - Inevitably develops after total gastrectomy; 15% in intake partial gastrectomy Provide reassurance and emotional support - Lack of Vit. B12 alters structure and disrupts function of Relaxation technique peripheral nerves * beefy-red tongue HEMATOLOGIC DISORDERS Nursing Assessment Diagnostic: ANEMIA Collect 24 hr. urine for Schilling Test also known as - Condition where the hemoglobin content of blood is B12 absorption test insufficient to deliver oxygen to tissues Given vitamin b12 (radionucleide b12) then measures it 3 Major Causes: through urine (24 hrs). Excessive blood loss Decrease RBC pdxn Manifestations: Increase RBC destruction Pallor, weakness, dyspnea, smooth sore beefy red tongue, diarrhea, indigestion, weight loss, paresthesia Erythropoieten: liver produces this & even kidney in the extremities liver problems: usually has anemia Management: - Anemia reduces the oxygen carrying capacity of blood, Parenteral replacement with cyanocobolamin (B₁2) is producing tissue hypoxia necessary by I.M.injection Basic Classifications: C. FOLIC ACID DEFICIENCY ANEMIA Nutritional Anemia – due to decrease in specific - Folic Acid is required for DNA synthesis and normal nutrients/minerals that’s needed for RBC formation maturation of RBC Hemolytic Anemia – increase in RBC destruction - Caused by dietary deficiency, associated with alcohol Bone Marrow Depression Anemia – decrease/abn abuse; impaired absorption and some medications that function of bone marrow impedes absorption (oral contraceptives, phenytoin, broad spectrum antibiotics, ) NUTRITIONAL ANEMIA - Macrocytic (megaloblastic) anemia A. IRON-DEFICIENCY ANEMIA o RBC greater than 8mm in diameter - Inadequate iron content in the body affecting hemoglobin synthesis Manifestations - Caused by chronic blood loss, decreased dietary intake Pallor, progressive weakness, fatigue, shortness of or malabsorption breath, palpitations - RBCs are small (microcytic) and pale (hypochromic) Gl symptoms are similar to B12 deficiency but more - Menstruation is the most common cause of iron severe (glossitis, cheilosis and diarrhea) deficiency in women while GI bleeding in men Neurological symptoms are not seen Symptoms: Management: Oral folic acid supplements indefinitely with malabsorption NOTES  Foods high in folic acid such as green leafy vegetables, broccoli, organ meats, eggs & milk B. HEREDITARY SPHEROCYTOSIS - Increase number of spherocytes BONE MARROW DEPRESSION ANEMIA - Defective cellular membrane where the biconcave A. APLASTIC ANEMIA shape of cell become spherical and is easily destroyed. - Characterized by bone marrow hypoplasia resulting in - deficient G6PD can lead to destruction of RBC pancytopenia (insufficient RBCs, WBCs, and platelets) - May be idiopathic; possible causes exist, including S/S: spherical large RBC, enlarge spleen chronic exposure to myelotoxic agents (agents toxic to Treatment: Splenectomy bone marrow), infection, autoimmune disease - Definitive diagnosis is determined through bone marrow aspiration Symptoms: C. SICKLE CELL ANEMIA pallor, weakness, palpitation, fatigue, exertional - Caused by autosomal genetic defect (one gene dyspnea, gum bleeding, petechiae, ecchymosis affected) that results in the synthesis of hemoglobin S prone to infection - During decreased oxygen tension, hemoglobin S causes the cells to elongate, become rigid, and assume Nursing Management crescent sickle shape causing it to clump together Therapeutic management focuses on restoring bone obstructing capillary blood flow causing ischemia marrow function through: o immunosuppressive therapy Conditions That Precipitate Sickling o bone marrow transplant o Emotional and physical stress Anti-lymphocyte or anti-thymocyte globulin is prescribed o Dehydration, infection, hypoxia, fever to suppress autoimmune response Sickling response is reversible with normal oxygenation Supportive treatment includes platelet and RBC and hydration transfusion, antibiotics and antifungals Repeated episodes of sickling weaken cell membrane Implement reverse isolation causing it to hemolyze Prevent infection and bleeding Manifestations are primarily the result of obstruction of sickle cells and increased RBC destruction BONE MARROW TRANSPLANT o pallor, fatigue, painful and swollen joints (due to Types: eschemia) Allogeneic: donor is a sibling/parent with similar tissue type Diagnostic Test: Syngeneic: marrow is from identical twin Hemoglobin electropheresis - determine the presence Autologous: donor is also the recipient and percentage of Hgb S Procedure: Sickle Cell Crisis 1. Marrow is harvested through multiple aspirations from a) Vaso-occlusive – vasospasm causes stasis of blood in iliac crest microcirculation leading to ischemia and infarction of 2. Conditioning regimen provides a state of local tissue b. immunosuppression b) Splenic Sequestration – life-threatening caused by 3. Transplantation: marrow is administered through central pooling line over 30 minute period c) Aplastic Crisis – reduced production and increased 4. Engraftment: transfused marrow cells move to destruction of RBC, triggered by viral infection or marrow-forming sites of recipient bone depletion of folic acid Complications: Management Failure to engraft Maintain adequate hydration through IV fluids and oral o When the RBC, WBC, and platelet cour does not intake begin to rise Administer oxygen and blood transfusion decrease o Infection and severe thrombocytopenia are major painful crisis episodes Medications include analgesics concerns and folic acid supplements Provide rest and comfortable position by elevating Graft-versus-host disease extremities to promote venous return o Occurs when immune competent graft cells Prevent exposure to infection or treat with antibiotics recognize host tissue as foreign and mount promptly cell-mediated immune response D. POLYCYTHEMIA VERA HEMOLYTIC ANEMIA An increase in the number of circulating erythrocytes A. G6PD DEFICIENCY ANEMIA and the concentration of hemoglobin in the blood - Characterized by deficiency in G6PD -an enzyme that Bone marrow stimulate an overproduction of helps metabolize 10% of glucose inside the RBC erythrocytes, leukocytes and thrombocytes thereby Treatment is Supportive increase blood viscosity, blood volume and congestion of tissues and organs with blood G6PD (Glucose 6 Phosphate Dehydrogenase) Occurs at 7-12 days problem. Primary Polycythemia - Unknown etiology; a neoplastic stem cell disorder - the cell cannot withstand the oxidative process. characterized by erythrocytosis Ex. thiazide diuretics, vitamin k, antibiotics, chlorampenicol, anti-malarials, aspirin, sulfonamides. Include NSAIDs Secondary polycythemia (internet) NOTES - Abnormal high levels of erythropoietin is produced - A group of hereditary clotting factor disorders because of hypoxemia leading to excessive characterized by prolonged coagulation time that results erythropoiesis in excessive and prolonged bleeding Manifestations Hemophilia A and B are X-linked recessive disorders Plethora (engorged blood vessels causing ruddy color of transmitted by female carriers and displayed exclusively in face, hands, feet, ears) males Splenomegaly and hepatomegaly Headache, dizziness, visual disturbance, hypertension Signs and symptoms: Vascular disease: angina, claudication, thrombosis Prolonged clotting times Subcutaneous ecchymosis and hematomas Gum bleeding, hematemesis, hematuria, Abdominal pain, hemarthrosis, paralysis Management Maintain adequate oxygenation Clotting factors - are inactive enzymes that become Manage underlying chronic conditions (CHF, COPD) that activated in a sequence. affect oxygenation Encourage smoking cessation CLOTTING FACTORS Phlebotomy Factor I - Fbrinogen o 500ml of blood is withdrawn once or twice a week Factor II - Prothrombin Avoids foods rich in iron Factor III - Tissue thromboplastin (tissue factor) Administer myelosuppressive agents Factor IV - Ionized calcium ( Ca++ ) Factor V - Labile factor or Proaccelerin E. THROMBOCYTOPENIA Factor VI - UNASSIGNED - Platelet count less than 100,000/mm³ and the common Factor VII - Stable factor or Proconvertin cause of abnormal bleeding Factor VIII - Antihemophilic factor Factor IX - Plasma thromboplastin component/ Causes maybe unknown, infection, chemotherapy or Christmas factor radiation, medications Factor X - Stuart-Prower factor Factor XI - Plasma Thromboplastin Antecedent Diagnostic Test: CBC, platelet count, coagulation Factor XII - Hageman factor studies includes prothrombintime (PT), partial Factor XIII - Fibrin-stabilizing factor thromboplastin time (PTT) Assessment Symptoms: fatigue, purpura, ecchymosis, petechiae, Hemophilia A - "classic hemophilia" hemorrhage, epistaxis, hematuria, Gl bleeding, - Deficiency of Factor VIII menorrhagia Hemophilia B - "Christmas disease" Assessment - Deficiency of Factor IX Idiopathic Thrombocytopenic Purpura - Destruction of platelets is greatly accelerated Von Willebrand's disease caused by body’s immune system therefore - Deficiency of the von Willebrand factor categorized as Autoimmune - Factor VIII has 3 properties: pre-coagulant activity, - Platelets are coated with antibodies, recognized by antigenic activity and von Willebrand factor activity the spleen as foreign and destroys them - Autosomal dominant trait factor VIII defect Secondary Thrombocytopenia Management - Defect in platelet production as a result of Replacement of deficient factor medications: thiazide diuretics, ASA, ibuprofen, o Hemophilia A: cryoprecipitate containing 8-100 units sulfonamides, digitalis, heparin of factor VIII per bag at 12 hrs. interval - Caused by: viral/bacterial infection, bone marrow o Hemophilia B: plasma or factor IX concentrate given disorders, chemotherapy, radiation every 24 hrs until bleeding ceases o Von Willebrands diseases: same with hemophilia Management Steroids or immunoglobulin to suppress the immune Referral for genetic counseling response Stop topical bleeding by applying direct pressure Platelet transfusions may be given In joint bleeding, totally rest joint, apply ice & administer Treatment may consist of spleenectomy in ITP hemostatic agents Initiate thrombocytopenic precautions: *done for pts risk in bleeding due to decrease number of thrombocytes o Avoid IM or SQ injections o Avoid use of aspirin- containing products o No use of toothbrush and razors o Prevent invasive or traumatic procedures o Assess signs of bleeding (e.g. Guaiac test) o Avoid venipuncture (use of 3 lumen central line) o Administer stool softeners as necessary F. HEMOPHILIA NOTES