Lower Respiratory Problems: Tuberculosis (PDF)

Ch. 30 Lower Respiratory Problems TUBERCULOSIS (TB) Caused by Mycobacterium tuberculosis  Gram +, aerobic, AFB Mostly affects LUNGS bc TB ❤️air (O2)  Lymph, brain, kidneys, liver, bone Airborne Spread from person to person by airborne droplets expecto...

Ch. 30 Lower Respiratory Problems TUBERCULOSIS (TB) Caused by Mycobacterium tuberculosis  Gram +, aerobic, AFB Mostly affects LUNGS bc TB ❤️air (O2)  Lymph, brain, kidneys, liver, bone Airborne Spread from person to person by airborne droplets expectorated when: Breathing Talking Singing Sneezing Coughing Droplets (1-5µm) stay suspended in the air for minutes to hours Cannot spread by touch or contact  Tuberculosis (TB) Occurs disproportionately in: Most at risk: Poor Homeless Underserved Inner-city neighborhoods Minorities Foreign-born people Those living or working in institutions (hospitals, LTC, prisons, shelters) IVDU Immunosuppression from any cause HIV, cancer, long-term corticosteroid use Rates of TB ↓ until the mid- Factors that influence 1980s transmission Ghon lesion or focus ↑ in TB 2/2: HIV + MDR-TB 1). Number of Once inhaled  TB lodge HIV:  TB leading cause of organisms expelled in bronchioles and aveoli into the air A local inflammatory rxn mortality MDR-TB 2). Concentration of occurs  Multidrug-resistant TB Calcified TB granuloma  Happens once a strain organisms = hallmark of primary TB develops resistance to 3). Length of time of = a defense mechanism the first-line meds: exposure to wall off infxn and  isoniazid or INH 4). Immuse system of prevent further spread  rifampin or Rifadin the exposed person TB CLASSIFICATION Presentation Primary, latent, reactivated Primary TB infection Whether pulmonary or Starts when bacteria are inhaled, trigger inflammatory extrapulmonary reaction Most people have effective immune response here Active TB infection Post-primary TB or reactivation TB Primary TB – active disease within 2 years of Occurs >2 years after initial infection infection Patient infectious if site of TB is pulmonary or People co-infected with HIV at greatest risk laryngeal Latent TB infection (LTBI) Occurs when there is not active TB disease Positive skin test but asymptomatic Cannot transmit TB; can develop active TB later Reactivation can occur with some diseases, stress Treatment is as important as it is for primary TB Clinical manifestation s Symptoms appear 2- 3 weeks after infection Initial: cough Late: Dyspnea Hemoptysis COMPLICATIONS OF TB Miliary TB Large numbers of organisms spread via the bloodstream to distant organs Occurs with primary TB or reactivation of LTBI Fatal if untreated Manifestations progress slowly and vary depending on which organs are infected Fever, cough, and lymphadenopathy May include hepatomegaly and splenomegaly Pleural TB—extrapulmonary Primary TB disease or reactivation of LTBI Pleural effusion Empyema Acute and long-term complications may occur when TB infects other organs Spine (Pott’s disease)—destruction of intervertebral discs and adjacent vertebrae CNS—bacterial meningitis Abdomen—peritonitis Other: kidneys, adrenal glands, lymph nodes and urogenital tract  TB: Diagnostics + Screening tests DIAGNOSTICS: Culture is the gold standard 3 consecutive sputum specimens Collected at 8-24 hour intervals Need 1 to be Early AM specimen Growth of mycobacterium can take up to 6 weeks Chest xray Cavitary infiltrates Upper lobe infiltrates Lymph node involvement Pleural effusion (+/- pericardial) Sarcoidosis and other dz mimic TB SCREENING TESTS: PPD: Purified protein derivative injected intradermally Called the Mantoux test is a tuberculin skin test Read at 48-72 hours 2 step process for initial or baseline screen Interferon-𝛄 Release Assays Positive reaction means exposed to Mycobacterium tuberculosis. IGRA: blood test QuantiFERON-TB Gold T-SPOT.TB Ready in a few hours  TB Treatment For the For the initial continuation phase phase 4 drugs 2 drugs 3 months 18 weeks Drug alert: ISONIAZID Major side effect ETOH ↑ Hepatic Tox Isoniazid Rifampin Non-viral hepatitis Pt edu: no ETOH use Obtain baseline INH competes with LFTs B6 or Pyridoxine  LFT q2-4 weeks peripheral Orange- neuropathy Pyrazinamid discoloration of Ethambutol Latent TB e bodily fluids Prevents active Ethambutol TB dz 1 drug regimen: EYE Isoniazid Exams live attenuated strain of Mycobacterium BCG vaccine can result in BCG vaccine: bovis false positive TST  TB DOT Treatment Directly observed therapy Used to ensure adherence Nonadherence major factor in MDR-TB Expensive Public health nurse @ a clinic site  TB: Nursing diagnoses and implementation Nursing diagnoses Acute care Ambulatory care Impaired AIRBORNE May go home even if cultures positive breathing ISOLATION Monthly sputum cultures Impaired airway Medical work-up Two consecutive clearance CXR negative cultures = noninfectious Risk for infection Sputum culture Teach patient how to Lack of knowledge Appropriate drug minimize exposure to others therapy Teach importance of Mask outside of adherence to patient and Health promotion NPR caregiver; provide strategies Screen Notify public health department Programs to Public health nurse address SDH follow-up DOT Teach symptoms of recurrence, factors that could reactivate TB Smoking cessation  Lung Abscess Etiology and pathophysiology Necrosis of lung Other: IV drug use, tissue from cancer, PE, lung Multiple abscesses aspiration of infarction, TB, Develops slowly multiple microbes —necrotizing bacteria from parasitic and pneumonia periodontal fungal diseases, disease (mouth) sarcoidosis Posterior upper lobes most often affected May erode into bronchi: foul- May grow into pleura: pleuritic pain smelling sputum 11  Nursing and Clinical Diagnostic Interprofessional If antibiotics not Complications: interprofessional manifestations: studies and nursing care effective: management occur slowly (weeks pulmonary abscess Chest x-ray Monitor for signs of Teach: effective Percutaneous to months) bronchopleural Other: CT scan; hypoxemia, coughing drainage of abscess Cough-producing fistula sputum, pleural respiratory distress; Supportive Surgery: lobectomy purulent sputum; fluid, and blood apply O2 measures: rest, or pneumonectomy Bronchiectasis foul smell and taste; cultures; IV antibiotics nutrition, fluids hemoptysis empyema bronchoscopy, WBC initially then switch Dental care Other: fever, chills, to oral therapy night sweats, Patient education— pleuritic pain, complete entire dyspnea, anorexia, prescription weight loss Decreased breath sounds; crackles Lung Abscess 12  Restrictive Respiratory Disorders Atelectasis Pleurisy Pleural Effusion + Empyema Restrictive Respiratory Disorders Disorders that impair movement of the chest wall and diaphragm Extrapulmonary2 categories: Intrapulmonary Lung tissue normal but caused by CNS, Abnormal pleural or lung tissue disorders neuro-muscular or chest wall disorders Hallmark characteristic PFTs best way to distinguish reduced FEV1 on PFTs restrictive from obstructive respiratory disorders 14   Collapsed, airless alveoli  Decreased or absent breath sounds  Dullness on percussion  Caused by: secretions obstructing small airways  At risk: bedridden and postop surgery patients  Prevention and treatment  Deep breathing exercises, incentive Atelectasis spirometry, early mobility 15 Atelectasis 16  PLEURISY Pleurisy is inflammation of the sheet-like layers that cover the lungs (the pleura). The most common symptom of pleurisy is a sharp chest pain when breathing deeply. Sometimes the pain is also felt in the shoulder. ETIOLOGY ASSESSMENT infectious diseases FINDINGS cancer, autoimmune PLEURAL disorders chest trauma FRICTION RUB GI disease heard peak of certain medications. inspiration Treatment underlying cause and pain management Teach splinting rib cage when coughing  PLEURAL EFFUSION CAUSES TYPES congestive Pleural fluid heart failure puncture (pleural cancer, tap) enables the pneumonia differentiation of pulmonary transudate embolism exudate Empyema Interprofessional and Clinical manifestations: nursing care Dyspnea, cough, sharp Treat underlying cause chest pain Chemical pleurodesis – Decreased chest obliterate pleural space a buildup of fluid movement; dullness, a procedure which decreased breath sounds involves putting a mildly between the layers of on affected side irritant drug into the tissue that line the Chest x-ray and CT— location and volume space between your lung and chest wall (the lungs and chest Empyema: above pleural space cavity manifestation and fever, night sweats, cough, weight loss EMPYEMA collection of purulent fluid in the pleural space. Caused by pneumonia TB lung abscess infected surgical wounds of the chest. Treatment options include antibiotic therapy (to eradicate the causative organism) percutaneous drainage chest tube insertion VATS intrapleural fibrinolytic therapy (instilled through the chest tube) to dissolve fibrous adhesions Decortication open window thoracostomy. Chest Trauma and Thoracic Injuries  Chest Trauma Traumatic injuries to chest contribute to many MECHANISMS OF INJURY traumatic deaths Blunt Simple rib Chest strikes or is struck by an object Range of fractures to Shearing and compression injuries of chest cardiorespirator injuries y arrest structures External appearance may be minor but may have severe internal organ damage Penetrating Classify primary Foreign object impales or passes through mechanisms of injury as body tissues creating an open wound either blunt or penetrating trauma 21  Fractured Ribs Most common ribs 5 through 9 – least protected by chest Blunt trauma muscles Can damage pleura, lungs, heart, and other internal organs Manifestations Complications Pain with inspiration and Atelectasis and pneumonia coughing Taping, using a thoracic binder Splinting not recommended Shallow respirations Treatment Patient teaching Reduce Pain: NSAIDs, opioids, Deep breathing and coughing nerve blocks Incentive spirometry Appropriate use of analgesics Early mobility when appropriate 22  Flail Chest Flail chest: 3 or more consecutive fractured ribs in 2 or more places or fractured sternum and several consecutive ribs Causes unstable chest wall and paradoxical movement with breathing Flail segment moves opposite Inspiration—sucked in Expiration—bulges out Inadequate ventilation;  work of breathing (WOB) Physical examination Rapid, shallow respirations Asymmetric and uncoordinated chest movement Inadequate ventilation Splinting Crepitus near fractures Diagnostic study Chest x-ray Treatment Ensure adequate ventilation/lung expansion Adequate oxygenation Pain management Other, if needed: Intubation and mechanical ventilation Surgical fixation 23 PNEUMOTHORAX  Caused by air entering pleural cavity  Positive pressure in pleural space causes lung to partially or fully collapse  Increased air in pleural space equals reduced lung volume  Open: opening in chest wall  Penetrating trauma—sucking chest wound  Closed: no external wound  Suspect pneumothorax with chest wall trauma Diagnostic Study: Chest x- ray Shows air or fluid in pleural space and reduced lung volume Pneumothorax Manifestations Small pneumothorax Mild tachycardia and dyspnea Large pneumothorax Respiratory distress Short, shallow, rapid respirations, dyspnea, low O2 saturation Absent breath sounds over affected area  Types of Pneumothorax Spontaneous— Iatrogenic —medical Tension Tension rupture of blebs procedures pneumothorax pneumothorax Hemothorax Can occur in Biopsies Accumulation of air Tension Blood in pleural healthy or subclavian catheter in pleural space pneumothorax = space chronically ill insertion that cannot escape medical emergency Treat with chest persons ventilator results in increased Manifestations tube COPD esophageal trauma intrapleural Severe asthma pressure dyspnea, cystic fibrosis Causes mediastinal tachycardia, Hemopneumothor pneumonia shift and tracheal ax Risk factors: Tall, hemodynamic deviation, instability: reduced decreased or thin, male, family venous return and Chylothorax history, or previous absent breath reduced cardiac sounds on Lymphatic fluid in pleural spontaneous output space pneumothorax affected side, Treat conservatively or with Can occur with neck vein Octreotide open or closed distention, Refractory options: surgery or pleurodesis pneumothorax cyanosis, diaphoresis May be fatal if pressure in pleural space not relieved Urgent needle decompression  TREATMENT OF PTX Treatments *Chest tubes with water-seal drainage Other: partial pleurectomy, stapling, or pleurodesis Emergency treatment consists of covering the wound with an occlusive dressing that is secured on 3 sides (vent dressing). Tension pneumothorax Needle decompression— immediate A needle decompression involves inserting a large bore needle in the second intercostal space, at the midclavicular line. Once this is done, there should be an audible release as the trapped air, and as the tension is released the patient should begin to improve Chest tube and water-seal drainage CHEST TUBES May be placed in ED, OR, or at bedside Standard insertion site: midaxillary HOB elevate 30 to 60 degrees; arm raised above head Antiseptic cleanse; local anesthetic Small incision over rib, chest tube inserted Sutured in place; occlusive dressing Connect pleural drainage system Chest x-ray to confirm placement CHEST DRAINAGE UNIT Chest drainage Bubblingunit. This unit has 3 chambers: in water-seal Tidaling in water-seal Chest drainage Wet suction unit. This unit Dry hassuction—no 3 chambers: water (1) collection chamber chamber chamber (1) collection chamber (less noise) Brisk at first, (2) water-seal chambereventually Fluctuation of water with (2) water-seal Amount chamber; of water in Dial regulator to disappears as lung pressure changes during chamber (3) suction (20control cm) pressure; control chamber. Suction visual alert chamber (3) suction expandscontrol chamber. Suction control chamber requires a respiration controls suction connection to a Intermittent withwall suction source that is dialed up higher Disappears as lung re- requires Excess a connection suction from to a wall suction source that is than the prescribed suction for the suction to work. In the dialed up higher than the prescribed suction for the exhalation, coughing, or expands source vented water suction unit, the suction control chamber controls the sneezing wall suction pressure. If stops suddenly, check suction Usual suctiontoorder work. = In the dry suction unit the wall suction is for occlusion −20 cm H2O (From Atrium Medical Corporation, Hudson, N.H.) controlled Adjust by using a regulator control dial. (From Atrium suction until Medical Corporation, Hudson, N.H.) gentle bubbling in third chamber Copyright © 2020 by Elsevier, Inc. All rights reserved.  Chest tube: nursing management Set-up and Insertion Drainage system Chest drainage Wet suction chest drainage Keep below chest Monitor: Consent/Aware of procedure Keep tubing loosely coiled Mark and measure drainage Water levels Gather and set-up Keep connections tight; Report greater than 200 mL/hr in Suction at—20 cm H2O equipment as per order taped first hour and 100 mL/hr thereafter; Gentle bubbling replace unit when full Observe: tidaling, Avoid overturning unit Dry suction chest drainage bubbling, air leak, fluid Breakage of unit Turn dial to ordered amount levels Place distal end of chest tube in 2 If decrease suction; depress high- cm water in sterile container; negativity vent and check water replace unit level in water-seal chamber No milking or stripping chest tubes Chest tube dressings Clamping chest tubes Monitor for Change according to Not advocated during Complications agency policy and transport or disconnection procedure due to risk for tension Reexpansion pulmonary Petroleum gauze pneumothorax edema Aseptic technique May clamp briefly to Hypotension Monitor for infection change drainage unit Severe subcutaneous Document emphysema THORACENTESIS Aspiration of intrapleural fluid for diagnosis and treatment 1000 to 1200 mL Larger volumes result in hypotension, hypoxemia, re- expansion pulmonary edema Chest x-ray: pneumothorax Monitor VS, pulse ox, and respiratory distress  PULMONARY EDEMA is an abnormal complication of left-sided HF. accumulation of various heart and fluid in the alveoli lung diseases and interstitial spaces of the lungs. Causes of Pulmonary Edema Goals include simultaneously Acute respiratory distress syndrome (ARDS) #1 Administer O2 to Altered capillary permeability of lungs: aspiration, improving oxygenation, keep SpO2 > 90% inhaled toxins, inflammation (e.g., pneumonia), severe ventilation, and cardiac hypoxia, near-drowning output. Anaphylactic (allergic) reaction Hypoalbuminemia: nephrotic syndrome, liver disease, nutritional disorders reduce preload IV morphine --> can Left ventricular (heart) failure (diuretics or NTG) reduce afterload Lymph system cancer (e.g., non-Hodgkin lymphoma) Overhydration with IV fluids O2 toxicity Unknown causes: neurogenic condition, opioid overdose, reexpansion pulmonary edema, high altitude  Pulmonary Hypertension Elevated pulmonary artery pressure (> 20 mm Hg) Five Classes (World Health due to an increase in resistance to blood flow Organization) based on through the pulmonary circulation causes Mean pulmonary artery pressures Group 1: Group 5: medication, Group 4: CV Multifactorial: Normal 12 to16 mm Hg specific Group 2: left- Group 3: lungs system and hematologic, sided heart Greater than 25 mm Hg at disease, genetic failure and hypoxia thromboembolis renal or link or m metabolic rest idiopathic involvement Greater than 30 mm Hg with exercises 33  Pulmonary Hypertension Idiopathic Pulmonary Arterial Secondary Pulmonary Arterial Cor Pulmonale Hypertension (IPAH) Hypertension (SPAH) Pulmonary hypertension Chronic increase in pulmonary Enlarged right ventricle without known cause results in artery pressures from another secondary to disorder of right HF and death if disease respiratory system; COPD untreated Parenchymal lung disease, LV Pulmonary hypertension Previously known as primary dysfunction, intracardiac preexists; HF pulmonary hypertension shunts, chronic PE, or Clinical manifestations Etiology and Pathophysiology systemic connective tissue Subtle and often masked by Uncertain; related to disease lung symptoms connective tissue disease, Symptoms: dyspnea, fatigue, Exertional dyspnea, cirrhosis, and HIV lethargy, chest pain; RV tachypnea, cough, fatigue, Insult to pulmonary hypertrophy and right-sided RV hypertrophy (ECG), endothelium results in heart failure increased intensity in S2 vascular scarring, endothelial Diagnosis—similar to IPAH heart sound, polycythemia dysfunction, and smooth Treatment—treat underlying HF: peripheral edema, weight muscle proliferation cause; if irreversible—IPAH gain, distended neck veins, Affects females more than therapies full, bounding pulse, enlarged males liver 34 Pathogenesis of Pulmonary Hypertension and Cor Pulmonale 35 Clinical Manifestations and Diagnostic Studies Clinical Diagnostics manifestations Classic: dyspnea on Right-sided heart exertion and fatigue catheterization Other: exertional ECG, chest x-ray, chest pain, PFTs, echo, CT scan dizziness, and Average time syncope, abnormal between onset and heart sounds (S3) diagnosis is about 2 Progression: years; disease is dyspnea at rest, advanced by that right ventricular point hypertrophy (cor pulmonale), HF 36  Early recognition—stop progression Report: unexplained shortness of breath, syncope, chest discomfort, edema of feet and ankles Drug therapy Pulmonary vasodilation, reduce right ventricular overload, and reverse remodeling Interprofession Manage edema Prevent thrombi al and Nursing Prevent hypoxia Care Goal – keep O2 saturation 90% or greater (Pulmonary Surgical interventions HTN) Pulmonary thromboendarterectomy (PTE) Atrial septostomy (AS)—palliative Lung transplant Disease recurrence has not been reported No cure Treatment can relieve symptoms, improve quality of life, prolong life Untreated, death can occur within a few years 37  LUNG TRANSPLANTATION Option for end-stage Postoperative Care: Prevent/treat Surgical procedures Rejection lung disease ICU complications— Treat diseases: Four types Ventilator and Acute: 5 to 10 days infection COPD, idiopathic Single-lung hemodynamic Fever, fatigue, Discharge pulmonary fibrosis, Bilateral lungs support dyspnea, dry planning/Coordinati cystic fibrosis, IPAH, Heart-lung IV fluids cough, O2 on of care 1-antitrypsin Lobes from living- Immunosuppression desaturation Self-care, deficiency related donor Tacrolimus, Chronic: medication Preoperative Care mycophenolate Bronchiolitis management, Evaluation mofentil, and obliterans (BOS) contacting Contraindications prednisone Progressive transplant team, Able to adhere Nutrition airflow obstruction pulmonary and cope with unresponsive to hygiene, postoperative bronchodilators rehabilitation regimen and United Network for corticosteroids Organ Sharing (UNOS) Lung Allocation Score (LAS)  LUNG CANCER BACKGROUND ETIOLOGY MANIFESTATIONS Leading cause of SMOKING 80-90% cancer-related deaths (28%) in United States Estimated 234,000 new cases in 2018; 154,000 deaths High mortality rate; low cure rate Advances in treatment improving response  LUNG CANCER DIAGNOSTICS Sputu Chest m CT Biopsy xray cytolog y 8 to 10 Smallest ID CT- Thorace cancer years for lesion location guided mediasti ntesis rare for cells not broncho a tumor detectab + extent needle noscopy for dx always scopy to reach le on x- of aspiratio VATS pleural present 1 cm ray masses n effusion  LUNG CANCER NSCLC Non-Small Cell Lung Cancer 85% Adenocarcinom Large cell Squamous cell a cancer cancer Most Highly Early sx: Moderate Rapid Slow 40% of common 10% of metatstati 25-30% of dry cough, growth growth growth lung ca in non- lung ca c  lymph lung ca hemoptysi rate rate rate smokers + blood s  LUNG CANCER SCLC Small Cell Lung Cancer Very Spreads 10-15% rapid Aggressi early  mets to of lung growth ve lymph + brain cancer rate blood  LUNG CANCER MANAGEMENT TARGETED + PROPHYLACTIC BRONCHOSCOP RADIOFREQUEN SURGERY RADIATION CHEMO IMMUNOTHERA CRANIAL IC LASER CY ABLATION PY RADIATION THERAPY Prophylactic NSCLC, Complications: radiation can treatment of chemotherapy esophagitis, skin decrease the choice in NSCLC may be used in TX FOR TUMORS irritation, nausea incidence of brain remove stages I to IIIA main treatment the treatment of OF NSCLC NEAR and vomiting, metastases and obstructing without for SCLC. nonresectable THE OUTER EDGE anorexia, and may improve bronchial lesions mediastinal tumors or as OF LUNGS radiation survival rates in involvement adjuvant therapy pneumonitis patients with to surgery. limited SCLC.  LUNG CANCER The nurse is preparing a patient for surgery and notices that the patient EVALUATIO looks sad. The patient says, “I am scared of having cancer. It is so horrible, and I brought it on myself. I N should have quit smoking years ago.” What would be the nurse’s best response? Convey a)It’s okay to be scared. What is it feelings about cancer that you are afraid of? openly and Have Maintain adequate adequate Have honestly, b)It’s normal to be scared. I would be minimal to with a breathing oxygenatio no pain realistic too. patterns n attitude c)Don’t be so hard on yourself. You about prognosis don’t know if smoking caused the cancer. d)Do you feel guilty because you smoked?