FONS EXAM N 1 PDF

Week 1 ====== Asthma attack --------------- ### What is asthma attack; Asthma attacks, or flare-ups, happen **when swelling or tightening narrows the airways, making it harder to breathe.** During an asthma attack, symptoms get much worse. Attacks can come on quickly or gradually and may be lif...

Week 1 ====== Asthma attack --------------- ### What is asthma attack; Asthma attacks, or flare-ups, happen **when swelling or tightening narrows the airways, making it harder to breathe.** During an asthma attack, symptoms get much worse. Attacks can come on quickly or gradually and may be life-threatening. People with asthma that is difficult to treat may get asthma attacks more often. **What is asthma:** - Is a chronic lung condition caused by narrowing of the airways when they become inflamed. - Can be controlled but not cured. Once people develop asthma, they\'re likely to have it for life. Even if they don\'t have any symptoms - even if they feel just fine - asthma is still there and can flare up at any time. **Asthma is characterised by:** - Chronic airway hyperresponsiveness. - Intermittent airway narrowing due to bronchoconstriction, congestion or oedema of bronchial mucosa or mucus. - More likely to be diagnosed as 'allergic asthma' if person has history of allergies including atopic dermatitis (eczema) or allergic rhinitis ('hay fever') and family history of asthma and allergies. (AIHW, 2024)  **Symptoms of asthma:**\ - The symptoms of asthma are different for different people. Most people who have asthma have one or more of these symptoms: - Coughing: Coughing from asthma is often worse at night, making it hard to sleep. Sometimes coughing brings up mucus. - Wheezing: Wheezing is a whistling or squeaky sound when you breathe. - Chest tightness: This can feel like something is squeezing or sitting on your chest. - Shortness of breath: Some people say they can't catch their breath, or they feel out of breath--- like they can't get enough air out of their lungs. Other conditions can cause these symptoms. But in asthma, the symptoms often follow a pattern: - They come and go over time or within the same day. - They start or get worse with viral infections, such as a cold. - They are triggered by exercise, allergies, cold air, or breathing too fast from laughing or crying. - They are worse at night or in the morning (WHO, 2024). ### Who is at risk; People who have - Frequent visits to the GP or emergency department with acute asthma or hospital admission in past 12 months. - Previous life-threatening attack or admission to an intensive care unit. - -No preventive medications/excessive reliance on inhaled bronchodilators. - Patient denial. - Poor adherence/insight. - Failure to perceive asthma symptoms. - Immediate hypersensitivity to foods, especially nuts. - Asthma triggered by aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs). - Poor access to health services. **[What causes asthma?]** The exact causes for developing asthma are unknown and may be different from person to person. However, asthma can also occur when the body's natural defenses against germs and sickness react strongly to a new substance in the lungs. Asthma **usually starts during childhood** when **the body's defense system is still taking shape**. However, some people **don't show signs of asthma until adulthood** --- this is known as **[adult- onset asthma]**. Certain factors can affect how a person\'s lungs develop or how the body fights germs.  Many factors may work together to cause people to develop asthma, such as: - **Things in the environment (called allergens**) that affected you as a baby or young child, including cigarette smoke or certain germs - **Viral infections** that affect breathing - **Family history,** such as a parent who has asthma (especially your mother) The following may also raise the risk of developing asthma. **The following may also raise the risk of developing asthma:** - **Allergies: **Asthma is usually a type of allergic reaction. People who have asthma often have other types of allergies, such as food or pollen allergies. - **Obesity: **Being overweight can raise the risk of developing asthma or make your asthma symptoms worse. - **Race or ethnicity: **Puerto Rican people and Black or African American people have a higher risk of developing asthma than people of other racial or ethnic groups. Black or African American and Hispanic children are more likely than non-Hispanic White children to die from asthma. - **Sex: **More boys than girls have asthma as children. In adults, asthma is more common among women. - **Occupational hazards: **Breathing in chemicals or industrial dust in the workplace can raise your risk of developing asthma. - **Climate change: **Air pollution and changing weather patterns contribute to asthma onset and exposure to allergens. (National Heart, Lung, and Blood Institution, 2024) ### What happens to the body during an asthma attack. **[How asthma affects people\'s airways: ]** The airways in people\'s lungs are very sensitive to substances such as tobacco smoke, dust, chemicals and pollen, or to getting a cold or the flu. These substances are called \"asthma triggers\" because people\'s immune systems overreact to them by triggering the release of cells and chemicals that cause asthma: The inner linings of the airways to become more inflamed (swollen), leaving even less room in the airways for the air to move through. The muscles surrounding the airways to get bigger and tighten. This squeezes the airways and makes them smaller. (This is called bronchospasm.) Glands in the airways to produce lots of thick mucus, which further blocks the airways. If asthma-related inflammation is not properly managed, repeated exposure to asthma triggers will exacerbate the inflammation, leading to worsening symptoms. (AIHW, 2024) #### Initial management of life-threatening acute asthma in adults and children.  Thunderstorm asthma --------------------- ### What is Thunderstorm asthma; Thunderstorm asthma **refers to episodes of asthma symptoms that occur when high pollen levels combine with a thunderstorm.** These episodes **require very specific weather conditions and are rare.** Only a few thunderstorms that occur during times of high pollen levels have a significant health impact. When these conditions happen near highly populated areas, many people can be affected simultaneously. **Occurrence in NSW** Thunderstorm asthma events have occurred in some areas of NSW, such as the region surrounding Wagga Wagga. However, the Sydney Metropolitan Region has not experienced a significant thunderstorm asthma event. ### Symptoms of Thunderstorm asthma; The symptoms associated with thunderstorm asthma can escalate quickly and may become life-threatening. They include: - Wheeze - Chest tightness - Difficulty breathing - Cough ### Causes of Thunderstorm asthma; The **exact cause of thunderstorm asthma is not fully understood**[. Exposure to high concentrations of very small pollen fragments appears to be an important factor]. During a thunderstorm, **moisture in the air swells pollen grains, causing them to burst and release tiny fragments**. Airflows in some thunderstorms can concentrate these fragments at ground level, where they may be inhaled and trigger asthma symptoms. In NSW, high levels of rye grass pollen are associated with thunderstorm asthma in some areas. ### Who is at risk. People at risk of thunderstorm asthma include: - Individuals with asthma - Individuals with undiagnosed asthma - Individuals with hay fever (allergic rhinitis) - Individuals who experience wheezing and sneezing during spring #### When are People Most at Risk? In NSW, the period from October to November is a time of higher risk for thunderstorm asthma. Being outside when pollen levels are high and thunderstorms are in the area increases the risk of exposure, potentially leading to thunderstorm asthma. Diagnostic test and management of asthma ------------------------------------------ #### Diagnosis in adult and children; **Diagnosis - Adults:** No single reliable test (\'gold standard\') and no standardised diagnostic criteria for asthma. Asthma cannot be diagnosed with a single test; instead, a combination of assessments is used to confirm the condition. The diagnosis is based on a detailed medical history and physical examination, focusing on the chest and airways #### Diagnostic tools;  **Lung Function Tests:**  Lung function tests, also known as pulmonary function tests, measure how well a patient can inhale (breathe in) and exhale (breathe out) air from their lungs. These tests are often conducted before and after the administration of a bronchodilator, a medication that opens the airways. If there is significant improvement in lung function after using a bronchodilator, it is indicative of asthma. Common lung function tests used to assess airways include: 1. **Spirometry:** Spirometry is the best lung function test for diagnosing asthma and for measuring lung function when assessing asthma control. This test measures the volume of air a patient breathes in and out and the speed at which they exhale. It helps to evaluate the overall lung capacity and airflow. Spirometry can: 1\) detect airflow limitation; 2\) measure the degree of airflow limitation compared with predicted normal airflow (or with personal best); 3\) demonstrate whether airflow limitation is reversible. This test is suitable for most adults and kids aged six and older.  **2. Peak Expiratory Flow (PEF) Tests:** PEF tests measure the speed at which a person can exhale air using maximum effort. These tests can be performed during spirometry or with a small handheld device. PEF tests provide valuable information about the patient\'s lung function and airway capacity. **3. Bronchodilator Responsiveness Tests:** These tests assess how much improvement in airflow a patient experiences after inhaling a fast-acting bronchodilator. This medication relaxes the muscles around the airways, helping to open them up. The test compares spirometry or PEF results before and after administering the bronchodilator. A significant improvement in airflow indicates a positive response to the bronchodilator, which is a strong indicator of asthma. **4. FeNO Test (Exhaled Nitric Oxide):** This test assesses the level of inflammation in the airways by measuring the amount of nitric oxide in the exhaled breath. **5. Bronchial Provocation or "Trigger" Tests:** These tests determine if the lungs are sensitive to specific irritants or triggers. They help in identifying substances that may provoke asthma symptoms. **Challenge Tests:** Challenge tests, also known as bronchial provocation tests, evaluate the sensitivity of the airways. These tests measure the speed of exhalation before and after exposure to a challenge agent. Challenge agents are substances or activities that may induce airway constriction in sensitive individuals, such as: - Inhaled medicines like methacholine, mannitol, or histamine - Allergens or irritants that do not affect individuals without asthma - Exercise, which can cool and dry the airways - Hyperventilation, involving rapid, shallow breathing **Other Diagnostic Tests:** - **Allergy Tests:** Consultation with an allergy specialist may be beneficial, as most individuals with asthma have allergies that can trigger or exacerbate their condition. Allergy tests can help identify specific allergens that need to be managed to control asthma symptoms. - **Blood Tests:** Blood tests are used to evaluate the immune system by checking the levels of certain white blood cells and antibodies. Specifically, the tests measure eosinophils and immunoglobulin E (IgE). Elevated levels of these markers may indicate severe asthma, providing additional information for diagnosis and treatment planning. #### Diagnosis - Children: - Difficult to diagnose in children under 5 years as: - Wheezing and cough are common in children, particularly under 3 years -- 'small airway syndrome'. - Many children who respond to bronchodilator treatment do not go on to develop asthma. - Infants (age 0 -12 months): asthma should not be diagnosed. - Preschool (age 1 -5years): Difficult to diagnose in this age group, because: - Episodic respiratory symptoms such as wheezing, and cough is very common in young children. - Spirometry is usually hard to perform in children. - Many children who respond to bronchodilator treatment do not go on to develop asthma #### Managing acute asthma in children and adults.  #### Managing acute asthma in children #### Medicines; Medications are a crucial component of asthma management. The primary goals of asthma medication are to control symptoms, prevent asthma attacks, and improve lung function. While there is no cure for asthma, proper medication and support can help individuals live symptom-free. Asthma medications are generally categorised into three main groups: 1. **Preventers**: These medications treat asthma to help maintain symptom-free periods. They include preventers, combination preventers, and non-steroidal preventers. 2. **Relievers**: These medications address symptoms triggered by asthma. They encompass relievers and dual-purpose relievers. 3. **Add-On Medicines**: These helps manage persistent asthma symptoms or severe asthma. They include long-acting bronchodilators, oral corticosteroids, and monoclonal antibodies (Asthma Australia, 2024).  #### Nursing management of asthma. **What are we looking for as nurses?** - Chest discomfort. - Dyspnea. - Chest tightness. - Cough. - Blue lips and fingers. - Tachypnea, tachycardia. - Tripod position. - Wheezing. **Nursing management of asthma** - Check oxygen status - Listen to lungs - Assess for respiratory distress - Position patient upright - Administer medications as prescribed **When To Seek Help** - Respiratory distress. - No air entry in lungs during auscultation. - Low oxygen saturation. - Patient cyanotic.  (Hashmi, Cataletto & Hoover, 2024) Week 1 lecture (Paediatric asthma) ================================== Intro to paediatric asthma -------------------------- υ Asthma is an inflammatory condition of the airways characterized by reversible airway obstruction and bronchospasm.\ υ One of the most common presentations to the Emergency Department\ υ Affects 10% (around 460,000) children in Australia.\ υ Asthma prevalence is higher in males, Indigenous children and those with a disability - Diagnosis of asthma is considered in children who present with wheeze, cough or difficulty breathing. - These episodic symptoms are very common in children under 3 years of age. - Asthma is difficult to diagnose in children under the age of 5 years. - Asthma exacerbations may increase in winter or when school returns ### ¬ Risk factors for serious exacerbation; - History of poorly controlled asthma - Previous ICU admission for asthma - Re-presentation after discharge from hospital - Recurrent admissions - Poor compliance with preventer medication eg. Flixotide - Overuse of reliever medication eg. Short Acting Beta Agonists such as Ventolin - Nocturnal symptoms - Two or more courses of oral steroids eg. Prednisoslone or one or more asthma hospitalisations in the last 12 months - Social factors and vulnerabilities eg. poor health literacy ### ¬ Assessment; - **Airway**- Patency, audible wheeze may be present, cough, ability to speak in\ sentences/cry - **Breathing-** Resp rate, work of breathing/use of accessory muscles, O2\ saturations, supplementary O2 requirement, air entry, adventitious breath\ sounds - **Circulation**- Heart rate, BP, colour, cap refill - **Disability**- GCS, pain - **Exposure-** Temperature - **Fluids-** Hydration status, intake/output - **Glucose-** BGL - **Holistic/social**- Parent/carer ### ¬ Initial management and discharge plan;   ### ¬ Discharge plan. - Asthma education - Asthma Action plan - Ventolin weaned to 3 hourly or less - Follow up with GP or High Risk Asthma Clinic https://files.nationalasthma.org.au/resources/NAC-Asthma-Action-Plan-2023-FILLABLE-HD.pdf A screenshot of a computer screen Description automatically generated Week 1 Tutorial =============== ### ¬ Acute problem with asthma Breathlessness\ Impaired oxygenation\ Impaired gas exchange\ Anxiety/distress ### ¬ Initial management of life-threatening acute asthma in adults and children;  https://www.asthmahandbook.org.au/static/files/Australian-Asthma-Handbook-v2.0-Acute-asthma.pdf ### ¬ Asthma & COPD medication; #### Salbutamol **What is Salbutamol?** - β~2~-Adrenoreceptor stimulant. Relief of bronchospasm (asthma, COPD); acute prophylaxis incl against exercise induced asthma **What does it do?** - fast-acting bronchodilator and reliever medication. Used to relax and open up your airways. It is used to relieve wheezing, coughing, chest tightness and breathlessness in people with [asthma](https://www.drugs.com/health-guide/asthma.html) and [chronic obstructive pulmonary disease](https://www.drugs.com/health-guide/chronic-obstructive-pulmonary-disease-copd.html) (COPD), including chronic bronchitis and emphysema. Salbutamol works by stimulating the beta-2 adrenoceptors in your bronchial muscles, which are the smooth muscles lining the two large tubes (bronchi) that carry air from your windpipe (trachea) to your lungs. This causes your bronchi to relax and dilate, widening your airway for a short period of about 4 to 6 hours and making it easier for you to breathe. It can also act on beta-2 adrenoceptors in your uterus (womb). **What are side effects?\ **- trembling, particularly in the hands, nervous tension, headaches, suddenly noticeable heartbeats (palpitations), muscle cramps #### Prednisolone **What is Prednisolone?** - Corticosteroid. Steroid responsive condition **What does it do?** - acts on the immune system to reduce inflammation in the airways of people with asthma.  **\ What are the side effects?** - fluid retention including bloating of the face and swelling of the abdomen. - weight gain. - irregular periods. - muscle cramps. - thin skin that bruises easily, and acne. - osteoporosis (thinning of the bones) - high blood pressure. ### ¬ Goal of asthma management Symptom control: - achieve good control of symptoms - maintain normal activity levels - Risk reduction- minimise: - risk of lung-attacks - fixed airflow limitation - medication adverse effects ### ¬ How do we mange asthma; - Medications - Self-Monitoring - Education and Skills - Knowledge, inhaler technique, adherence, written asthma action\ plans - Avoiding triggers - Regular review (every 6 months #### Self-monitoring Symptoms - Symptoms often deteriorate before PEF, therefore symptom monitoring can be more\ reliable than PEF  ### ¬ Action plan. - Facilitates early detection and treatment of an asthma exacerbation - Personalised instructions for self-management of deteriorating asthma - Example of asthma action plan\ https://d8z57tiamduo7.cloudfront.net/resources/NAC-Asthma-Action-Plan-\ 2023-Update-HD.pdf Main written factors to an effective action plan: 1. When to increase treatment 2. How to increase treatment 3. How long to stay on increased treatment 4. When to seek urgent medical assessment 5. Patient engagement and acceptance Week 2 ====== **Read from your textbooks:** 1. Levett-Jones, T. (Ed). (2018). *Clinical reasoning: Learning to think like a nurse.* Frenchs Forrest, NSW: Pearson. Chapter 6: Caring for a person experiencing respiratory distress and hypoxia. **Scenario 6.2: Caring for a person with respiratory distress. Pages 109-114.** 2. LeMone, P., Burke, K.M., Bauldoff, G., Gubrud-Howe, P., Levett-Jones, T., Dwyer, T., Moxam, L., Reid-Searl, K., Berry, K. et.al. (Eds.). (2020). *Medical-surgical nursing: Critical thinking for person-centred care* (4th Australian ed.). Frenchs Forrest, NSW: Pearson Australia. Vol 3 Chap 36: Nursing care of people with gas exchange disorders pages 1315-1327, pneumonia page 1254-1257 Pneumonia ----------- 1\. What is pneumonia; \- infectious disease of the lungs that can be caused by bacteria, viruses, or fungi. This infection leads to inflammation of the lung's air sacs (alveoli), which become filled with fluid or pus. This accumulation of fluid or pus impairs the transfer of oxygen into the bloodstream.\ The severity of pneumonia is influenced by factors such as the type of pathogen responsible, the patient\'s age, and their overall health status. Individuals at higher risk include infants, young children, adults aged 65 or older, and those with pre-existing health conditions. 2\. How pneumonia affects breathing; \- Pathogens such as bacteria, viruses, or fungi can enter the airways via mucus. The airways are equipped with cilia, which are hair-like structures that help expel mucus and pathogens, typically through coughing. When pathogens reach the air sacs (alveoli) in the lungs, the body\'s immune system responds by attacking these invaders. If the immune system is compromised, the pathogens causing pneumonia can proliferate. This immune response leads to inflammation, characterized by swelling in the air sacs. Consequently, the alveoli may become filled with fluid and pus, impairing oxygen exchange and making breathing difficult (National Heart, Lung and Blood Institute, 2022). 3\. Symptoms of pneumonia; range from mild to severe and may include cough, fever, chills, and difficulty breathing. The symptoms of pneumonia can vary in severity, ranging from mild to severe. Individuals at higher risk for more serious pneumonia or life-threatening complications include young children, older adults, and those with significant health conditions. Common symptoms of pneumonia include: - Chest pain during breathing or coughing; - Chills; - Cough, with or without mucus; - Fever; - Reduced oxygen levels in the blood, as measured by a pulse oximeter; - Shortness of breath. Additional symptoms may encompass headache, muscle pain, profound fatigue, nausea, vomiting, and diarrhea. In older adults and individuals with severe illnesses or compromised immune systems, symptoms may deviate from the typical presentation. These patients might experience a l**ower-than-normal temperature** rather than a fever, [and older adults may exhibit weakness or sudden confusion]. **Infants** may also present atypical symptoms, such [as vomiting, fever, cough, or signs of restlessness and lethargy.] Specific indicators of respiratory distress in infants include: - Cyanosis (bluish discoloration of the skin and lips); - Grunting; - Retraction of the muscles between the ribs during breathing; - Rapid breathing; - Nasal flaring with each breath. 4\. Risk factors of getting pneumonia; **Who is at risk of getting pneumonia?** Pneumonia can affect individuals of all ages; however, certain groups are at increased risk, including: - Individuals aged 70 years and older - Individuals with chronic medical conditions such as diabetes, cancer, or diseases affecting the lungs, heart, kidneys, or liver - Tobacco smokers - Indigenous Australians - Infants aged 12 months and under It is essential to recognise that risk for pneumonia increases with age due to the natural decline in immune system function, which diminishes the body\'s ability to combat infections and diseases effectively (Lung Foundation Australia, 2024). \ 5. Causes of pneumonia; What are the causes of pneumonia? Pneumonia is primarily caused by infectious microorganisms, which can be transmitted through inhalation of airborne droplets from an infected person\'s cough or sneeze. The main types of pathogens responsible for pneumonia are: 1. **Bacteria:** The most prevalent bacterial causes of pneumonia include *Streptococcus pneumoniae*, *Legionella pneumophila*, and *Haemophilus influenzae*. These bacteria can lead to severe infections that may affect localized areas or be more diffuse across the lungs. Bacterial pneumonia often follows a preceding cold or flu-like illness. 2. **Bacteria-like Organisms:** These include pathogens such as *Mycoplasma pneumoniae* and *Chlamydia pneumoniae*. Pneumonia caused by these organisms generally presents as milder compared to typical bacterial pneumonia. 3. **Fungi:** Fungal pneumonia, although less common in otherwise healthy individuals, is typically caused by environmental fungal organisms. It is more frequently observed in individuals with compromised immune systems or pre-existing lung damage due to other diseases. 4. **Viruses:** Viral pneumonia is a frequent cause of pneumonia and may be less severe than bacterial pneumonia. The influenza virus is one of the primary viral agents responsible for this type of pneumonia. - **Bacterial Pneumonia:** The most common bacterial cause of pneumonia, *Streptococcus pneumoniae*, can be spread through **[direct contact with contaminated surfaces or via respiratory droplets from coughing and sneezing.]** - **Viral Pneumonia:** Viruses responsible for pneumonia, such as those causing the common cold or influenza, are also **[contagious and can be transmitted from person to person.]** - **Fungal Pneumonia:** Pneumonia caused by fungi is not contagious. Fungal infections typically **[arise from environmental sources and are not spread through person-to-person contact as viral and bacterial infections are.]** #### Types of Pneumonia Identifying the specific type of pneumonia- to accurately describe the condition, to determine the most effective treatment strategy. - can vary in their aetiology, presentation, and response to treatment, making precise diagnosis essential for optimal patient care. - Pneumonia can be categorised based on the causative pathogen (virus, bacteria, or fungi) and the environment in which the infection was acquired. - The primary types include **community-acquired, hospital-acquired, healthcare-associated, ventilator-associated, and aspiration pneumonia**. ##### Community-Acquired Pneumonia (CAP): - **Bacterial Causes:** The most common cause of CAP is infection with ***Streptococcus pneumoniae*** (pneumococcal disease), which can also lead [to ear infections, sinus infections, and meningitis]. ***Mycoplasma pneumoniae*** causes atypical pneumonia with generally milder symptoms. Other bacterial agents include *Haemophilus influenzae*, *Chlamydia pneumoniae*, and *Legionella* (Legionnaires\' disease). - **Viral Causes:** Viruses responsible for the common cold[, influenza (flu), COVID-19, and respiratory syncytial virus (RSV)] can sometimes [progress to pneumonia.] - **Fungal Causes:** Although rare, fungi such as ***Cryptococcus*, *Pneumocystis jirovecii*, and *Coccidioide****s* can cause pneumonia, primarily in **immunocompromised individuals.** - **Protozoal Causes:** Protozoa like ***Toxoplasma* c**an occasionally cause pneumonia. ##### 2. Hospital-Acquired Pneumonia (HAP): - HAP occurs in patients **who are already hospitalized for another illness or procedure.** It is often more severe due to antibiotic-resistant bacteria such as methicillin-resistant *Staphylococcus aureus* (MRSA), making it harder to treat. ##### 3. Healthcare-Associated Pneumonia (HCAP): - HCAP can **develop in patients residing in long-term care facilities** (e.g., nursing homes) or **attending outpatient, extended-stay clinics**. Similar to HAP, it is commonly caused by antibiotic-resistant bacteria. **4. Ventilator-Associated Pneumonia (VAP):** - VAP affects patients on respirators or breathing machines in hospital settings, particularly in intensive care units (ICUs). It can be caused by the same bacteria responsible for community-acquired pneumonia, as well as the antibiotic-resistant strains found in hospital-acquired pneumonia. **5. Aspiration Pneumonia:** - Aspiration [pneumonia occurs when solid food, liquids, saliva, or vomit enter the trachea (windpipe) and reach the lungs]. Inability to effectively cough these substances out can lead to lung infection. ##### Diagnosis of Pneumonia - challenging due to the variability of symptoms, which often overlap with those of common respiratory infections like colds or influenza. - To accurately diagnose pneumonia and identify the causative pathogen, a **[comprehensive approach is employed, involving a detailed medical history, physical examination, and a series of diagnostic tests.]** **Medical History:** The [clinician will inquire about the patient's symptoms, including their onset, duration, and progression]. Specific questions may focus on potential exposure risks, such as: - Recent travel - Occupational hazards - Contact with animals - Exposure to ill individuals at home, work, or school - Recent illnesses **Physical Examination:** During the physical examination, the [clinician will auscultate the lungs using a stethoscope]. Pneumonia may be indicated by abnormal lung sounds, such as crackles, rales, or wheezing, heard during inhalation.   **Diagnostic Tests:** To confirm the diagnosis of pneumonia and ascertain the underlying pathogen, several tests may be recommended: - **Blood Tests:** These tests help confirm the [presence of infection and attempt to identify the pathogen responsible.] - **Chest X-ray:** This imaging modality assesses the location and extent of lung inflammation. - **Pulse Oximetry:** This test measures blood oxygen levels and [can indicate if pneumonia is impairing oxygenation.] - **Sputum Test:** Analysing [a sputum sample] obtained through a deep cough helps identify the infectious agent. For [high-risk patients], including those with **advanced age, compromised health, or those who are hospitalised,** additional diagnostic tests may be necessary: - **Chest CT Scan:** Provides [detailed imaging of the lungs to detect complications such as abscesses or pleural effusion]. - **Arterial Blood Gas Test[:]**[ Measures oxygen and carbon dioxide levels in a blood sample from an artery], offering a more precise evaluation of gas exchange compared to pulse oximetry. - **Pleural Fluid Culture:** [Involves analysing fluid extracted from the pleural space around the lungs to identify bacterial pathogens.] - **Bronchoscopy:** A procedure that allows direct visualisation of the airways. If standard treatments are ineffective, bronchoscopy can [help identify obstructions or other issues, and may involve sampling of lung tissue or fluid for further analysis] (National Heart, Lung and Blood Institute, 2022). #### Treatment of pneumonia The treatment of pneumonia depends **on the cause**---bacterial, viral, or fungal---and the **severity of the condition**. Often, the specific cause may not be identified, and treatment is focused on symptom management and preventing the condition from worsening. **Treatment Options:** 1. **Antibiotics:** - Used to treat bacterial pneumonia. - Ineffective against viruses but may be prescribed if a concurrent bacterial infection is present. 2. **Antifungal Medications:** - Used to treat pneumonia caused by fungal infections. **3. Antiviral Medications:** - Viral pneumonia frequently resolves on its own without the need for medication. - Antiviral drugs such as oseltamivir (Tamiflu®), zanamivir (Relenza®), or peramivir (Rapivab®) may be prescribed to reduce the duration and severity of viral infections. **4. Oxygen Therapy:** - Supplemental oxygen may be administered through a nasal cannula or face mask if blood oxygen levels are insufficient. **5. Intravenous (IV) Fluids:** - Administered to treat or prevent dehydration via direct infusion into the veins. **6. Fluid Drainage:** - In cases of significant fluid accumulation between the lungs and chest wall (pleural effusion), fluid may be drained using a catheter or through surgical intervention. The choice of treatment is tailored to the individual\'s specific condition, ensuring the most effective approach to managing pneumonia and preventing complications (Mattila et al., 2014). #### Impacts of Pneumonia Pneumonia can become life-threatening, particularly when complications arise. Notable complications include: - **Respiratory Failure:** Inadequate oxygen transfer or carbon dioxide removal due to fluid accumulation in the lungs. - **Sepsis:** A systemic response to infection that can lead to widespread inflammation and organ dysfunction. - **Bacteremia:** The presence of bacteria in the bloodstream, which can progress to severe systemic infections. - **Lung Abscesses:** Pus-filled cavities within the lung tissue. - **Kidney Failure:** Impaired kidney function resulting from reduced blood flow or systemic infection. - **Heart Rhythm Problems:** Irregularities in heartbeats that can be exacerbated by pneumonia. The risk of severe outcomes is higher in individuals under age 2 or over 65, those with pre-existing conditions such as heart or kidney disease, individuals with compromised immune systems, and patients who have had prior antibiotic treatments or hospitalisations. #### Bacteremia and Septic Shock **Bacteremia** refers to [the presence of bacteria in the bloodstream,] which may **occur due to various routine activities or infections.** Typically asymptomatic in healthy individuals, it can become [problematic if the immune system fails to eliminate the bacteria], potentially [leading to sepsis and septic shock]. **Septic Shock** represents a critical progression of bacteremia, characterized by a [significant drop in blood pressure and potential multi-organ failure]. Key symptoms of septic shock include: - - - - - - - Immediate medical intervention is required, involving blood cultures and antibiotic therapy. Hospitalisation may be necessary for managing severe cases. #### Lung Complications **Lung Abscesses:** These are [localised collections of pus within the lungs], more [common in individuals with prior gum disease, weakened immune systems, or excessive alcohol use.] **Symptoms include:** - Persistent fever - Productive cough with pus - Night sweats - Unexplained weight loss **Pleural Effusion:** This condition involves [fluid accumulation between the pleural layers surrounding the lungs], potentially [causing sharp chest pain and difficulty breathing.] **Symptoms include:** - Shortness of breath - Chest pain - Cough - Fever **Empyema:** An infection of the pleural fluid leading to symptoms such [as severe chest pain, fever, and difficulty breathing.] **Pleurisy:** [Inflammation of the pleura causing sharp chest pains], often [treated with antibiotics and anti-inflammatory medications.] #### Respiratory Failure Respiratory failure [occurs when pneumonia severely impairs lung function, leading to insufficient oxygenation and carbon dioxide elimination.] It is more common in hospitalised patients, the elderly, and those with pre-existing conditions. Symptoms include: - Difficulty breathing or rapid breathing - Cyanosis (bluish skin or lips) - Confusion - Extreme fatigue Treatment involves supplemental oxygen and addressing the underlying infection. #### Kidney Complications **Kidney Failure:** Pneumonia-related complications like [sepsis can lead to kidney failure], characterised by symptoms such as: - Itchiness - Swelling in extremities - Fatigue - Nausea and vomiting - Reduced urine output **Management may involve dialysis and, in severe cases, kidney transplantation.** #### Heart Complications Heart Failure: Pneumonia can exacerbate heart conditions, leading to symptoms such as: - Shortness of breath - Persistent coughing - Swelling in extremities - Fatigue Research indicates a significant risk of heart-related issues following pneumonia, particularly in elderly patients or those with pre-existing heart conditions. Coronavirus disease (COVID-19) ------------------------------ #### ♣ Overview of COVID-19; - the disease caused by the coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first confirmed case of COVID-19 in Australia was reported on January 25, 2020. COVID-19 is a highly contagious disease that spreads primarily through respiratory droplets or small airborne particles when an infected individual coughs, sneezes, talks, or is in close contact with others. - The majority of individuals infected with SARS-CoV-2 experience mild to moderate respiratory illness and recover without requiring special treatment. However, some individuals may become seriously ill and require medical attention. Older adults and those with underlying medical conditions such as cardiovascular disease, diabetes, chronic respiratory disease, or cancer are more likely to develop severe illness. It is important to note that anyone, regardless of age, can contract COVID-19 and potentially become seriously ill or die. - The virus can be transmitted through small liquid particles expelled from an infected person\'s mouth or nose when they cough, sneeze, speak, sing, or breathe. These particles vary in size, from larger respiratory droplets to smaller aerosols. Practicing good respiratory hygiene, such as coughing into a flexed elbow, and staying home to self-isolate if feeling unwell, are important strategies to reduce the spread of COVID-19 (Department of Health and Aged Care, 2024; WHO, 2024a). #### ♣ Symptoms of COVID-19; **Most Common Symptoms:** - Fever - Cough - Tiredness - Loss of taste or smell **Less Common Symptoms:** - Sore throat - Headache - Aches and pains - Diarrhea - Rash on the skin, or discoloration of fingers or toes - Red or irritated eyes **Serious Symptoms:** - Difficulty breathing or shortness of breath - Loss of speech or mobility, or confusion - Chest pain Immediate medical attention should be sought if serious symptoms are present. It is important to call ahead before visiting a doctor or health facility to ensure proper precautions are taken. Individuals with mild symptoms who are otherwise healthy should manage their symptoms at home. On average, it takes 5--6 days from the time of infection for symptoms to appear, although it can take up to 14 days (WHO, 2024). **Long-Term Effects of COVID-19** Most individuals who test positive for COVID-19 recover fully; however, some may develop a condition known as Long COVID. **Symptoms of Long COVID:** - Extreme fatigue (tiredness) - Shortness of breath, heart palpitations, chest pain, or tightness - Problems with memory and concentration - Changes to taste and smell - Joint and muscle pain These symptoms can persist for weeks or even months, differing significantly from the initial symptoms of COVID-19. #### ♣ Individuals at Higher Risk of Severe Illness from COVID-19; 1. **Individuals Aged 70 Years and Older**: This age group is at heightened risk due to age-related changes in immune function and overall health. 2. **People Aged 50 Years and Older with Additional Risk Factors**: This group includes individuals with underlying conditions such as: - Obesity - Diabetes - Cardiovascular disease - Chronic lung disease (including moderate or severe asthma requiring inhaled steroids) - Neurological disease - Severe chronic liver or kidney disease - Active cancer - Those who are not up to date with recommended vaccinations 3. **Aboriginal and Torres Strait Islander People Aged 30 Years and Over with Additional Risk Factors.** 4. **Individuals Who Are Moderately to Severely Immunocompromised.** 5. **People with Significant or Complex Disabilities.** 6. **Pregnant Women.** 7. **Children with Complex Chronic Conditions.** #### ♣ Diagnostic test for COVID-19; **SARS-CoV-2 Antigen Rapid Test (Self-testing)-** Rapid Antigen Tests (RATs) detect the presence of viral proteins associated with SARS-CoV-2. These tests are particularly effective when administered to individuals exhibiting symptoms of COVID-19, making it advisable to conduct the test promptly upon the onset of symptoms. **COVID-19 PCR TEST-** Polymerase Chain Reaction (PCR) tests are a type of nucleic acid test that detect the presence of the genetic material (RNA) of the SARS-CoV-2 virus, which causes COVID-19. PCR tests are highly sensitive and can identify the virus in its early stages, often before the individual exhibits any symptoms. #### ♣ NSW health recommend risk mitigation measures; **COVID-19 Vaccination Policy Update for NSW Health Workers** The policy regarding COVID-19 vaccination for NSW Health workers has changed. Vaccination is now strongly recommended, rather than required, for all workers in both Category A and Category B positions (NSW Government, 2024b). #### Droplet Precautions (Surgical Mask and Eye Protection) - Patients who are negative for COVID-19 and have no epidemiological link to COVID-19 but present with an acute respiratory infection (ARI) or recent onset of fever without an alternative clinical focus should adhere to droplet precautions. This includes the use of a surgical mask and eye protection (Clinical Excellence Commission, 2023).A green sign with a white circle with a logo on it Description automatically generated #### Airborne Precautions (P2/N95 Respirator and Eye Protection) Airborne precautions should be implemented for the following: - Confirmed COVID-19 cases. - Suspected cases, which include individuals who meet both clinical and epidemiological criteria or individuals identified as high-risk contacts, regardless of the presence of symptoms. These precautions involve the use of a P2/N95 respirator and eye protection to prevent the transmission of airborne pathogens (Clinical Excellence Commission, 2023). Use of gown/apron and gloves based on risk assessment, proximity, duration and intensity of exposure during care provision (Clinical Excellence Commission, 2023). Chronic Obstructive Pulmonary Disease (COPD) ---------------------------------------------- #### ♣ What is COPD? AIM 88-92% STATS for COPD pts  - encompasses a group of long-term lung conditions that progressively impair breathing.   - characterized by the narrowing of the bronchial tubes (bronchi or airways) in the lungs, which impedes airflow and makes breathing difficult. - This progressive disease is **[currently incurable.]** The primary conditions included under COPD are: - - - COPD is a progressive disease, meaning that it worsens over time, leading to increasing difficulty in breathing and a decline in lung function (Australian Institute of Health and Welfare, 2024). #### ♣ Understanding of ventilation perfusion coupling; - **Ventilation (V)-** amount of gas that moves into and out of an alveolus that can participate in gas exchange - **Perfusion (Q (Quantity))-** amount of blood in pulmonary arterial blood vessel that moves past the alveolus that can participate in gas exchange Normal- **[V/Q ratio or coupling]** needs to be as close to 1 to 1 ratio as possible. **There\'s a blockage in the alveolus**- the ventilation the air coming in and out of the alveolus it\'s not happening right cause there\'s no ventilation occurring So what happens to the gas that\'s inside of this LVL is well think about it the blood is still moving past and so that means whatever oxygen is inside the alveolus will jump into the bloodstream and that means oxygen levels will drop because it\'s not getting replenished what about carbon dioxide levels while the blood still moving past so he can throw carbon dioxide out into the alveolus and because it can\'t escape carbon dioxide levels go up There was a blockage at the alveolus which led to a decrease in ventilation right there\'s less ventilation happening that decrease in ventilation led to a decrease in oxygen in the alveolus an increase in carbon dioxide at the alveolus\--\> decrease in oxygen in the alveolus is the trigger to tell this pulmonary arterial to constrict decreased oxygen results in vasoconstriction now what does that mean for perfusion coming past if that\'s now constricting what does that mean for profusion coming past it drops we have matching ventilation dropped perfusion dropped let\'s now look at an example. Look at example where there\'s not a blockage in the alveolus there\'s a blockage at the blood vessel itself so let\'s take a look so we\'ve got a blockage here so let\'s think about what\'s happening is the blood moving past no So what happens the perfusion you have a drop in perfusion what\'s happening at the alveolus well what\'s happening in the LVL list is that gas is coming in to the alveolus think about what\'s happening here right gases coming in there\'s no blood going past some can\'t exchange anything so gas is going in gas is going out so that means whatever the concentration of gas is in the atmosphere ends up being that concentration inside the alveolus now if you think about it what you should probably be aware of is that inside the alveolus normally the oxygen concentration inside the alveolus is about 100 millimetres of mercury and the oxygen concentration outside the alveolus in the atmosphere is about 159 millimetres in mercury that means just in a normal alveolus I\'m not talking about blocked LDLS 100 and 59100 oxygen is lossed the pressure of oxygen partial pressure is lossed when it goes into the obiols for some reason normally why because some of that oxygen bonds with hydrogen to create water so there\'s some it\'s last and this is a normal blood vessel moving through so oxygen gets taken away pretty quickly so that\'s why in a normal LVL\'s oxygen levels are usually low well that carbon dioxide carbon dioxide in the atmosphere is quite low 0.2 millimetres in what is the in the lvoe list in the LV almost the carbon dioxide levels are 40 they are a lot higher why is that well because in a normal normal LDL in the blood is going past can throw carbon dioxide out boosting up the levels of carbon dioxide so now that I\'ve shown you what it\'s like normally what\'s happening now that this is blocked if this is blocked no bloods going past this i told you the concentration or partial pressure of these gases here concentration or partial pressure of these gases here now starts to reflect the partial pressure of gas outside So what does that mean for oxygen it means that the oxygen goes from 100 259 so oxygen goes up what happens to carbon dioxide goes from 40 to 0.2 that means carbon dioxide levels go down well competitor here it\'s the opposite right the opposite so here\'s the interesting point in this case the drop in CO2 is actually the trigger to tell the bronchioles to constrict what was the stimulus I\'ve dropped in perfusion that led to a drop in carbon dioxide which led to bronchial constriction which means what\'s the outcome a drop in ventilation it now matches you get the drop in confusion resulting in a drop in ventilation so at the end of the day how do you summarise all this this is how I\'ll do it you would say that decreased L Viola oxygen or you could put the pain in front the partial pressure decreased alveolar partial pressure oxygen equals pulmonary arterial viso construction you could also say that decrease L Viola partial pressure of carbon dioxide equals Bronco construction and this is basically summarising what\'s happening in that ventilation perfusion coupling process job #### ♣ Causes and symptoms of COPD; Several mechanisms can contribute to the narrowing of the airways, leading to COPD- may include the destruction of lung tissue, mucus accumulation obstructing the airways, and inflammation or swelling of the airway lining. - develops gradually over time, often as a result of a combination of **risk factors:** - - - - - - - A diagnosis of COPD should be considered in individuals presenting with typical symptoms. Confirmation of the diagnosis is typically achieved **[through spirometry]**, a test that measures lung function. However, in low- and middle-income countries, where spirometry may not be readily available, the diagnosis of COPD may be challenging to establish (World Health Organisation, 2023). #### **Symptoms of COPD include:** - - - - - characterised by symptoms that can exacerbate rapidly, known as flare-ups. These episodes typically persist for several days and may necessitate additional medical treatment to manage. Increased risk for a range of comorbid health conditions, including: **[COMPILACTIONS]**: - - - - - Onset of COPD symptoms often occurs from mid-life onwards, and as the disease progresses, individuals frequently experience increased difficulty in performing routine daily activities, primarily due to breathlessness. This progressive decline can **lead to significant financial implications due to reduced productivity in both workplace and home settings, as well as increased costs associated with medical care** (WHO, 2023). #### ♣ Types of COPD; +-----------------------------------+-----------------------------------+ | **Type** | **Explanation** | +===================================+===================================+ | **Emphysema** | - progressive group of lung | | | disorders characterised by | | | **obstructed airflow that | | | impairs breathing and worsens | | | over time**. | | | | | | - Many individuals with COPD | | | exhibit features of both | | | emphysema and chronic | | | bronchitis, though the | | | severity of each component | | | can vary significantly among | | | patients. | | | | | | - **Emphysema primarily impacts | | | the air sacs (alveoli) in the | | | lungs**. | | | | | | - Under **[normal | | | conditions], | | | these alveoli are elastic and | | | expandable, allowing them to | | | fill with air during | | | inhalation and deflate during | | | exhalation, much like small | | | balloons.** | | | | | | - **[In emphysema], | | | the structural integrity of | | | the alveolar walls is | | | compromised.** | | | | | | - **This damage results in the | | | loss of elasticity and the | | | destruction of the walls | | | between the alveoli, leading | | | to the formation of fewer, | | | larger air sacs.** | | | | | | - This alteration in alveolar | | | structure significantly | | | **impairs the lungs\' ability | | | to efficiently exchange | | | oxygen and carbon dioxide**. | | | | | | - Consequently, individuals | | | with emphysema **experience | | | difficulties in maintaining | | | adequate oxygenation and | | | removing carbon dioxide from | | | their bodies** (Goldklang | | | &Stockley, 2016). | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | **Chronic Bronchitis** | - characterised by **persistent | | | inflammation and irritation | | | of the bronchial tubes | | | (**airways responsible for | | | transporting air to and from | | | the air sacs (alveoli) in the | | | lungs) | | | | | | - The chronic irritation of | | | these airways **leads to an | | | increased production of | | | mucus, which accumulates due | | | to the swelling and | | | inflammation of the bronchial | | | tubes.** | | | | | | - This **buildup of mucus, | | | combined with the swelling of | | | the airways, obstructs | | | airflow and impairs the | | | lungs\' ability to | | | effectively exchange oxygen | | | and carbon dioxide.** | | | | | | - Result: **experience | | | difficulty in maintaining | | | adequate respiratory function | | | and managing efficient gas | | | exchange** (Dotan, So & | | | Kim, 2019) | +-----------------------------------+-----------------------------------+ #### ♣ Diagnosis and treatment of COPD; [**Spirometry**-] primary diagnostic test for COPD, capable of **detecting the condition before symptoms become apparent.** It **measures both the volume of air exhaled and the rate at which air is expelled from the lungs**. - During the test, the patient is instructed to inhale deeply and then exhale forcefully into a tube connected to a spirometer. **The results can help determine the severity of COPD and inform treatment strategies. In some cases, a bronchodilator may be administered to assess the reversibility of airway obstruction[, with pre- and post-medication results compared.]** **[Other Lung Function Tests]** - - - **Lung Imaging Tests** - - #### Treatment of COPD **[IRREVERSIBLE]** - various treatments can alleviate symptoms, slow disease progression, and enhance the ability to remain active- treatments are available to prevent or manage complications. Interventions used in the management of COPD: **Lifestyle Changes:** - **Smoking Cessation**: Quitting smoking is the most crucial step for COPD treatment. Avoiding exposure to second-hand smoke and other lung irritants is also essential. - **Nutritional and Physical Activity Guidance**: Consult with healthcare providers for a nutritional plan that meets your dietary needs and advice on appropriate physical activity. Physical exercise can strengthen respiratory muscles and improve overall well-being. **Pharmacological Treatments:** - **Bronchodilators**: These medications **relax the muscles around the airways, aiding in airway expansion and making breathing easier.** Typically administered via inhalers\-\-\--severe cases, inhalers may also contain steroids to reduce inflammation. - **Vaccinations**: Immunisations for **influenza** and **pneumococcal pneumonia** are vital, as individuals with COPD are at higher risk for severe complications from these infections. - **Antibiotics**: Prescribed in cases of bacterial or viral lung infections to combat infections and prevent exacerbations. **Oxygen Therapy:** - For [severe COPD with low blood oxygen levels]**, supplemental oxygen can help improve breathing.** The duration and necessity of oxygen therapy vary, with some patients requiring it continuously and others needing it only at specific times. **AIM 88% to 92% STATS** **Pulmonary Rehabilitation:** - A comprehensive programme designed to enhance the quality of life for individuals with chronic respiratory issues. It may include: - **Exercise Training**: Structured physical activity to improve respiratory muscle strength and overall fitness. - **Disease Management Education**: Training on managing COPD symptoms and complications. - **Nutritional Counseling**: Guidance on maintaining a healthy diet that supports respiratory health. - **Psychological Support**: Counseling to address mental health issues related to chronic illness. **Surgical Interventions:** - Surgery is generally considered a last resort for patients with severe COPD symptoms unresponsive to medical treatments. Surgical options include: - **Lung Volume Reduction Surgery**: Removal of damaged lung tissue to improve lung function. - **Bullectomy**: Removal of large air spaces (bullae) that form when air sacs are destroyed, which can hinder breathing. - **Lung Transplant**: For severe COPD cases, a lung transplant may be necessary to improve breathing and quality of life (Aaron, 2014). #### ♣ The impact of COPD on individuals. - Staying calm for the family- being positive- family support - Importance of lifestyle change and exercise at the age - Walking up hills- harder - Importance of pulmonary rehab Week 2 Lecture ================ https://canvas.uts.edu.au/courses/32044/pages/week-2-lecture?module\_item\_id=1895767 #### Respiratory anatomy and physiology;  #### Components of Respiration **[ Ventilation]** **[Gas exchange]** **[Gas transport]** **[Tissue gas exchange]**  Respiration is defined as the gas exchange between an Organism and its environment. The function of the respiratory system is to transfer oxygen from the atmosphere to the blood and remove the carbon dioxide from the blood. https://canvas.uts.edu.au/courses/32044/pages/week-2-lecture?module\_item\_id=1895767 #### Ventilation #### **Assessment of Cough** ***Does the cough occur at a specific time of the day?*** ***Is it a dry hacking cough (indicating inflammation, or is it a barking congested cough (indicating infection)?*** ***Is the cough related to cigarette smoke or an irritant?*** ***Is the cough mainly at night - nocturnal coughing can be associated with LVF or asthma?*** #### Sputum Note apperence and smell Sputum can be classified as: \* clear \* watery mucoid \* purulent, \* blood stained \* pink and frothy \* plugs Microscopically the sputum may have bacteria, pus or malignant cells #### Sputum Yellow sputum usually indicates a high cellular content due to bacterial infection but in asthma eosinophil clumps can produce a similar appearance Regular production of green sputum may indicate bronchiectasis due to long standing production of large volumes of sputum daily. #### Haemoptysis ***Is graded by its severity*** ***Slight streaking of sputum with blood can be caused by acute and chronic bronchitis or a large hemorrhage*** ***Frank haemoptysis is always significant*** ***Continuous haemoptysis should be considered to be carcinoma until proven otherwise***  #### Dyspnoea Assess the rate and progress of the breathlessness When has the person walked - around the shops - to the pub or park - to the end of the street to the garden gate, the front door - Around the house, one room, from bed to chair #### Dyspnoea *How severe is the dyspnoea* *Exercise tolerance may be graded as follows* *Grade 5 - SOB at rest* *Grade 4- SOB walking around the house Grade 3-SOB attending personal care Grade 2 SOB stops for a rest when walking at own pace on level ground* *Grade 1.- Asks friends of same age to slow down but can keep going at own pace on level ground* #### Dyspnoea *Characteristic* *Tightness may indicate airway obstruction or angina* *Gasping and panting suggest hyperpnoea (excessive but not necessarily laboured obstructed breathing)* #### Respiratory Chest Pain ***Classical respiratory pain is pleuritic*** *** Characterized by a sharp severe stabbing pain*** - ***Usually unilateral which is worse on inspiration and coughing (when the pleural spaces rub together)*** - ***It follows the line of the intercostal nerve*** #### Cardiac and other Chest pain - ***Cardiac**-May be retro-sternal dull crushing, radiating into the neck / arms not related to breathing* - *All chest pain should be considered cardiac until proven otherwise* - ***Oesophagitis**- chest pain has a burning sensation at the lower end of the sternum* - *Relieved by antacids* - ***Pericardial** retro-sternal chest pain is worse on inspiration and is provoked by swallowing and change of position.* - *It may be relieved by sitting forward* #### Stridor - *This is a harsh musical noise caused by obstruction of the trachea or the larynx on inspiration* - *It is caused by tracheal compression or laryngeal oedema* - *It is heard as bronchial breath sounds over the trachea* #### Wheeze - *Is a musical nosise which is due to an obstruction In the bronchial airways* - *It may be continuous , intermittent, generalized or localized* - *It can be heard in* - *Asthma* - *CCF* - *Tumour* #### What triggers the patient's asthma - *Dust* - *Dust mite* - *Animal Dander* - *Mould* - *Smoke* - *Perfume* - *Foods* - *Medications* #### Detailed and thoroughly description of respiratory assessment ¬ Collecting history;\ ¬ Inspection;\ ¬ Palpation\ ¬ Percussion;\ ¬ Auscultation.  **Stage 1- Inspection-** signs of increased work of breathing accessory muscle use, pursed lips and diaphoresis), PR, rate, rhythm and depth of respirations, symmetrical breathing - Take an overall view of the shape of the chest - Examine the thoraic spine and note any obvious kyphosis asymmetry - Observe for scars prominent veins - Flattening - Over inflation of the chest wall or diaphragm - Accessory muscles use: - Inter-costal muscles receding back and forth - Sterno-mastoids tight and pulled up to the ears with every breath - Abdominal muscles assisting the diaphragm - A diagram of a human skeleton Description automatically generated **Stage 2- Palpation-** perform in a systematic sequence so all areas are assessed- progress in a zig zag motion from side to side and top to bottom. Assess anterior, posterior and lateral chest wall, discomfort or pain. Lumps or bumps and any boney structure. Note the patient's moisture. Repeat words 99. Deep breathes- rise and fall of chest. Feel for crepitus- feels like rice bubbles under the skin- indicative of air in the sub-cutaneous tissue\-\--\> may result in chest trauma, pneumothorax, tracheostomy **Stage 3- Percussion-** produces audible sounds and palpable vibrations- help determine if the underlying lung tissue is filled with fluid, air or solid material. Percusses by striking your finger close to the nail in the interspaces of the ribs. **Types of sounds:** \-           **[Resonant-]** healthy lung tissue \-           **[Hyper-resonant]**- too much air is present-emphysema or pneumothorax \-           **[Dull-]** abnormal density in the lungs- pneumonia, pleural effusion or tumor   **Stage 4- Auscultation**- clean the stethoscope with alcohol wipe, back and front- listen to the intensity, pitch and duration of the inspiratory and expiratory sounds throughout the cycle. Compare left to right lung fields- avoid boney parts.  #### Central Cyanosis Due to inadequate oxygenation of blood during its passage through the lungs and implies either respiratory or right to left intra cardiac shunt Best observed in warm mucous membranes of mouth, lips, tongue. #### Peripheral Cyanosis - Is due to an increased uptake of oxygen to the tissues in previously normally oxygenated blood. - I occurs where there is any degree of peripheral stasis or low cardiac output with poor peripheral perfusion. A black and white image of a person Description automatically generated #### Understanding respiratory patterns **Tachypnoea** - increased regular rate above 20 / min **Bradypnea** - decreased regular respirations below 10 per min. This pattern is normal during sleep **Hyperpnea**- deeper than normal respirations occurring at a regular rate **Apnoea**- the respiratory pattern is marked by absence of respirations **Biots -** faster and deeper than normal respirations marked by abrupt pauses and breaths of unequal depth **Cheyne- Stokes -** Faster and deeper than normal, followed by a slower pattern which alternates with periods of apnoea **Kussmaul\'s -** faster and deeper than normal and continue without pause. The breathing sound laboured with deep sighs #### Hyperventilation Rate and depth of respiration is increased when there is a decrease in carbon dioxide Reasons include - Asthma, - Lobar Pneumonia - Severe Pain Ph 7.47, PC02 33, PO2 80, SaO2 92 #### Hypoventilation Rate and depth of respirations are decreased Always leads to a rise in CO2 Decreased minute volume and alveolar ventilation Ph 7.11, PCO2 80,PO2 55, SaO2 85 Week 2 Tutorial ================= #### Stepwise management of stable COPD; At admission - Respiratory assessment - Medical history - **[Social history]** **[Social Determinants of Health\ ]**- What is going on in her home environment, socially and at work?\ - Does she have carer responsibilities\ - What is her financial state?\ - Can she access a GP and pharmacy?\ - Does she live with a smoker? - Health literacy - What is Sarah's understanding of her illness? - How does she find out about new interventions? - Education - History and adherence - What has changed recently? - Can we talk to her family/partner - what do they think? - Planning for discharge at admission -- Assistance at home, GP, respiratory physician and pharmacist contact. - Community nursing options  #### Discharge plan for COPD; Discharge into the community\ Think about: - Improving ventilation - Promoting secretion removal - Preventing complications and progression of symptoms - Promoting Sarah's comfort and participation in care - Improving quality of life - Use the COPD Management Plan to assist you #### Review of respiratory assessment (e.g., auscultation points, adventitious sounds) ##### Palpation - Lumps or abnormal structures - Skin temp - Rise and fall of chest - Pain ##### Percussion - Sounds and vibrations - Resonant - Hyper-resonant - Dull ##### Auscultate 1.Position patient upright\ 2. Ask them to breathe through their mouths\ 3. listen to breath sounds with your stethoscope\ 4. Compare each side with the other\ 5. Listen for quality, intensity and adventitious sounds ##### Auscultation Points #### Adventitious sounds **Wheeze:** Resulting from distal airflow obstruction. They are continuous, high pitched, hissing sounds caused when air flows through narrowed airways **Crackles:** Interrupted, non-musical sounds caused by distal airways opening during inspiration and collapsing during exp. **Pleural friction rub:** grating sound as thickened pleural surfaces rub together during breathing. Indicative of pleurisy secondary to pneumonia or pulmonary infarction. **Stridor:** a loud strangulating sound during inspiration indicating obstruction of the\ trachea or larynx requiring immediate review by a senior doctor. Stridor is an upper airways obstruction and can be clearly auscultated over the patient's trachea. [A silent chest may mean total peripheral airway obstruction]  Week 3 ====== Readings: --------- Levett-Jones, T. (Ed). (2018). *Clinical reasoning: Learning to think like a nurse.* Frenchs Forrest, NSW: Pearson. **Scenario 7.2:** Caring for a person with heart failure  [ The Heart and its function:] #### *** Role of the heart in the human body;*** - responsible for pumping blood to every part of the body, supplying oxygen and nutrients to all cells, nerves, muscles, and vital organs. It is located in the chest between the lungs, slightly to the left of the centre, and is protected by the rib cage. #### Different parts of the heart; **Heart Walls** The heart walls are composed of strong muscle tissue that contracts and relaxes to pump blood throughout the body. This muscle tissue is organized into three distinct layers: 1. **Endocardium:** The innermost layer, which lines the interior of the heart chambers and valves. It is a smooth, thin layer that reduces friction as blood flows through the heart. 2. **Myocardium:** The middle, muscular layer, responsible for the contractile force needed to pump blood. It is the thickest layer and is composed primarily of cardiac muscle fibers. 3. **Epicardium: **The outer protective layer, which also serves as the visceral layer of the pericardium (the heart\'s surrounding sac). The epicardium contains blood vessels, nerves, and a small amount of fat, contributing to the heart\'s protection and structural integrity (National Heart, Lung and Blood Institution, 2022). **Heart chambers** The human heart consists of four chambers, organised into two on the right side and two on the left side, analogous to the rooms of a house: 1. **Atria**: The upper chambers are the left atrium and the right atrium. These chambers receive blood returning to the heart from the body and lungs. 2. **Ventricles**: The lower chambers are the left ventricle and the right ventricle. These chambers pump blood out of the heart to the lungs and the rest of the body. These chambers are separated by a thin muscular wall called the septum, which prevents the mixing of oxygenated and deoxygenated blood within the heart (National Heart, Lung and Blood Institution, 2022). **Heart Valves** The heart contains four valves that function like doors between its chambers, ensuring unidirectional blood flow as the heart pumps. These valves open and close in response to pressure changes within the heart. The heart valves include: 1. **Atrioventricular (AV) Valves**: Located between the atria and ventricles, these valves prevent the backflow of blood into the atria. - **Tricuspid Valve**: Positioned between the right atrium and right ventricle. - **Mitral Valve**: Positioned between the left atrium and left ventricle. 2. **Semilunar (SL) Valves**: Located at the exits of the ventricles, these valves prevent the backflow of blood into the ventricles. - **Aortic Valve**: Situated at the exit of the left ventricle, leading into the aorta. - **Pulmonary Valve**: Situated at the exit of the right ventricle, leading into the pulmonary artery. These valves only open in one direction, preventing blood from flowing backward and ensuring efficient circulation through the heart and to the rest of the body  **The Blood Vessels** Blood travels between the heart, lungs, and the rest of the body through an intricate network of blood vessels. There are three main types of blood vessels, each serving a distinct function: 1. **Arteries**: These vessels carry oxygenated blood away from the heart to the body\'s tissues and organs. They are characterised by thick, elastic walls that can withstand high pressure. 2. **Veins**: These vessels return deoxygenated blood back to the heart and lungs for re-oxygenation. Veins have thinner walls compared to arteries and often contain valves to prevent the backflow of blood. 3. **Capillaries**: These are the smallest blood vessels, where the exchange of oxygen, nutrients, and waste products occurs between the blood and the body\'s cells. Capillaries connect the arterial and venous systems, facilitating the transfer of oxygenated and deoxygenated blood (Heart Foundation NZ, 2024). ### The Conduction System of the Heart The heart\'s conduction system generates and transmits electrical signals that initiate the pumping action, circulating blood throughout the body and to and from the lungs. This system includes several key components: 1. **Sinoatrial (SA) Node**: Known as the body\'s natural pacemaker, it produces electrical impulses that initiate each heartbeat. 2. **Atrioventricular (AV) Node**: This node receives electrical signals from the atria (upper chambers) and relays them to the ventricles (lower chambers). 3. **Bundle of His, Bundle Branches, and Purkinje Fibers**: These structures act as electrical pathways, transmitting impulses from the AV node throughout the ventricles, ensuring coordinated contractions. The electrical signal pathway is as follows: - The SA node generates an electrical signal that causes the atria to contract, pushing blood into the ventricles. - The signal then moves to the AV node, which delays it slightly before passing it to the Bundle of His. - The signal travels through the right and left bundle branches and then to the Purkinje fibers, causing the ventricles to contract and pump blood to the lungs and the rest of the body. #### Coronary circulation. ##### Blood Circulation Blood that has depleted its oxygen supply returns to the right side of the heart via the inferior and superior vena cava. From the right atrium, it is pumped into the right ventricle and then sent to the lungs through the pulmonary artery for oxygenation. Once oxygenated, the blood returns to the left side of the heart via the pulmonary veins, entering the left atrium. It is then pumped into the left ventricle and subsequently distributed to the rest of the body through the aorta. This efficient system of electrical conduction and blood circulation is vital for maintaining the body\'s oxygen and nutrient supply, as well as for removing waste products  A diagram of a heart Description automatically generated ##### Coronary Circulation The heart possesses its own dedicated network of blood vessels, known as the coronary arteries, which supply the myocardium with the necessary oxygen and nutrients to sustain its pumping action. The coronary arteries originate from the aorta, the largest artery in the body, and are situated on the external surface of the heart. A narrowing or occlusion within these arteries can have serious clinical implications: - **Narrowing of a coronary artery** can lead to angina, characterized by chest pain due to reduced blood flow to the heart muscle. - **Complete blockage of a coronary artery** can result in a myocardial infarction, commonly known as a heart attack, which occurs when blood flow is entirely obstructed, causing damage to the heart tissue (Heart Foundation NZ, 2024). Heart failure ------------- ##### What is heart failure Heart failure is defined as the inability of the heart to supply peripheral tissues with the required amount of blood and oxygen to meet their metabolic demands. It is a chronic condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen, essentially failing to keep up with its workload (Tanai & Frantz, 2015). **Mechanisms of Compensation in Heart Failure** Initially, the heart attempts to compensate for its reduced pumping capacity through several mechanisms: 1. **Enlargement**: The heart stretches to contract more forcefully, attempting to meet the body\'s demand for more blood. Over time, this leads to an enlargement of the heart. 2. **Increased Muscle Mass**: The heart muscle cells (myocytes) grow larger, increasing the heart\'s muscle mass and initially enabling it to pump more strongly. 3. **Increased Heart Rate**: The heart beats faster to enhance cardiac output. The body also employs other compensatory mechanisms: 1. **Vasoconstriction**: Blood vessels narrow to maintain blood pressure and compensate for the heart's reduced power. 2. **Fluid Retention**: The kidneys retain more salt and water, increasing blood volume to help maintain blood pressure and allow the heart to pump more effectively. However, this added volume eventually overburdens the heart, exacerbating heart failure. These compensatory mechanisms temporarily mask the underlying issue but do not resolve it. As heart failure progresses, these processes become less effective, leading to worsening symptoms such as fatigue and breathing difficulties, which usually prompt medical attention. Heart failure can affect the heart's left side, right side, or both, but it typically starts with the left side. Heart failure is a serious condition for which there is no definitive cure. Congestive heart failure, a specific type of heart failure, requires timely medical intervention. Although the terms \"heart failure\" and \"congestive heart failure\" are sometimes used interchangeably, they refer to different clinical scenarios (Heart Foundation, 2024). Classification of heart failure based on pumping ability Heart failure can be classified based on the heart\'s ability to pump blood effectively: 1. **Heart Failure with Reduced Ejection Fraction (HFrEF)**: - Also known as systolic failure, this type occurs when the [heart muscle has weakened and can no longer pump sufficient blood through the body]. - Consequently, the organs do not receive adequate oxygen. - Medical professionals may further categorise this condition into mildly and severely reduced ejection fraction (EF). 2. **Heart Failure with Preserved Ejection Fraction (HFpEF)**: - Also known as diastolic failure, this type [occurs even though the heart muscle remains strong.] - [The heart tissue **becomes stiffer** than in a healthy heart, limiting its ability to expand sufficiently and fill with enough blood after contraction]. - As a result, insufficient blood flows through the body, particularly during physical exertion (Heart Foundation, 2014). Classification of Heart Failure Based on the Affected Side of the Heart Heart failure can be classified according to which side of the heart is affected, although it sometimes involves both sides (biventricular heart failure): 1. **Left-Sided Heart Failure**: - This type occurs when the left ventricle fails to pump enough blood throughout the body. - Blood accumulates in the blood vessels leading away from the lungs, causing shortness of breath, difficulty breathing, or coughing, especially during physical exertion. - Left-sided heart failure is the most common form and is typically caused by coronary artery disease (CAD), heart attacks, or long-term high blood pressure. 2. **Right-Sided Heart Failure**: - This type occurs when the right ventricle is too weak to pump sufficient blood to the lungs. - Blood builds up in the veins, leading to increased pressure and fluid leakage into surrounding tissues. - This results in fluid accumulation in the legs, or less commonly, in the genital area, organs, or abdomen. - Right-sided heart failure often develops due to advanced left-sided heart failure and is treated similarly. It can also be caused by high blood pressure in the lungs, pulmonary embolism, or lung diseases such as COPD. 3. **Biventricular Heart Failure**: - This type affects both sides of the heart, leading to symptoms of both left-sided and right-sided heart failure, such as shortness of breath and fluid accumulation (Tanai & Frantz, 2015). Pressure-Overload versus Volume-Overload Heart Failure Heart failure can be classified according to the underlying pathophysiological factor: **1. Pressure-Overload Heart Failure:** - This type of heart failure is characterised by left ventricular dysfunction due to adverse left ventricle chamber remodeling and decreased myocardial contractile function. - It primarily occurs in conditions such as aortic valve stenosis and arterial hypertension. - The heart experiences increased resistance against which it must pump, leading to hypertrophy and decreased function over time. **2. Volume-Overload Heart Failure**: - This type occurs when the heart chambers are overfilled with blood, which the heart attempts to transmit into the systemic circulation. - Various conditions can cause volume overload, including: - **Arteriovenous Malformations and Fistula**: Abnormal connections between arteries and veins. - **Congenital Heart Diseases**: Conditions such as persistent ductus arteriosus and ventricular septal defect. - **Valvular Heart Diseases:** Issues like aortic regurgitation and mitral regurgitation lead to backflow of blood into the heart chambers. - Volume overload also affects the pulmonary circulation in conditions such as: - **Tricuspid Regurgitation and Pulmonary Regurgitation**: Valvular diseases affecting the right side of the heart. - **Congenital Atrial Septal Defect:** An opening in the atrial septum that allows blood to flow between the atria (Tanai & Frantz, 2015). Systolic versus Diastolic Heart Failure Heart failure can be categorized based on the underlying mechanisms affecting the heart\'s pumping ability: systolic heart failure and diastolic heart failure. **1. Systolic Heart Failure** - **Definition**: Characterised by impaired left ventricular contractility, resulting in a reduced ejection fraction (EF), hence referred to as heart failure with reduced ejection fraction. - **Pathophysiology**: The heart muscle becomes weaker and cannot pump enough blood through the body, leading to insufficient oxygen supply to organs. This condition often involves eccentric remodeling, where the heart chamber dilates progressively, resulting in volume overload and forward heart failure. - **Common Causes**: The most common underlying causes of systolic heart failure include ischemic heart disease, cardiomyopathies, and heart valve diseases. - **Structural Changes**: The primary structural change is an increase in muscle mass and chamber dilation, which initially helps maintain cardiac output but ultimately leads to heart failure progression. **2. Diastolic Heart Failure** - **Definition**: Characterised by impaired ventricular relaxation and filling, increased ventricular stiffness, and elevated filling pressures, with a normal EF. This is known as heart failure with preserved ejection fraction. - **Pathophysiology**: The heart muscle remains strong but becomes stiff, preventing adequate filling of blood. This leads to increased filling pressures and backward heart failure due to pressure overload. - **Common Causes**: Diastolic heart failure is commonly related to chronic hypertension and ischemic heart disease. It can also result from restrictive, infiltrative, or hypertrophic cardiomyopathies. - **Structural Changes**: The structural changes include concentric remodeling or ventricular hypertrophy, leading to increased ventricular stiffness and elevated filling pressures (Tanai & Frantz, 2015).  Signs and symptoms of heart failure People with heart failure can experience one or more of the following symptoms: - Bloated stomach.  - Chest pain. - Coughing and wheezing . - Difficulty with breathing or shortness of breath, especially when doing physical activity. - Discomfort when lying flat, due to difficulty with breathing. - Dizziness. - Heart pounding or racing (i.e. palpitations). - Loss of appetite or nausea. - Swollen ankles or legs (i.e. oedema). - Tiredness, fatigue, and weakness..  - Waking overnight due to difficulty with breathing (Heart Foundation, 2024). Risk factors contributing to heart failure Heart failure often develops as a consequence of pre-existing heart conditions. The following factors significantly increase the likelihood of developing heart failure: - **Coronary Artery Disease (CAD):** This condition arises from the accumulation of cholesterol and fatty deposits in the heart\'s arteries, known as atherosclerosis. This buildup reduces blood flow to the heart muscle, potentially leading to chest pain (angina) or a heart attack if blood flow is completely obstructed. Atherosclerosis also contributes to high blood pressure, which can further exacerbate heart failure. - **High Blood Pressure (Hypertension):** Chronic elevated blood pressure forces the heart to work harder to circulate blood. Over time, this strain causes the heart chambers to enlarge and weaken, eventually leading to heart failure. - **Type 2 Diabetes:** Diabetes often leads to high blood pressure and atherosclerosis due to elevated lipid levels in the blood, increasing the risk of heart failure. - **Metabolic Syndrome:** Characterised by three or more of the following risk factors---abdominal obesity, high fasting triglycerides, low HDL (good) cholesterol, high blood pressure, and high fasting blood sugar---metabolic syndrome contributes significantly to the development of heart failure. - **Hyperthyroidism:** Overactive thyroid conditions can lead to sustained increases in heart rate and thickening of the heart muscle, contributing to heart failure. - **Aging:** As individuals age, the heart can weaken and stiffen, increasing the risk of heart failure, particularly in those over 65. Additional Risk Factors Include: - **Smoking:** Tobacco use accelerates cardiovascular damage and increases the risk of heart failure. - **Obesity or Overweight:** Excess body weight places additional strain on the heart. - **Alcohol or Drug Abuse:** Excessive use of alcohol or drugs can lead to heart damage and heart failure. - **Certain Types of Radiation and Chemotherapy:** Cancer treatments can adversely affect heart health. - **Faulty Heart Valves (Heart Valve Disease):** Abnormalities in heart valves can impair heart function. - **Heart Rhythm Problems (Arrhythmias):** Irregular heart rhythms can strain the heart and contribute to heart failure. - **Heart Conditions Present at Birth (Congenital Heart Disease):** Structural abnormalities present from birth can lead to heart failure. - **Inflammation of the Heart Muscle (Myocarditis):** This condition can weaken the heart muscle and impair its function. - **Pregnancy-Related Stress:** Increased cardiovascular demands during pregnancy can contribute to heart failure. - **Chronic Conditions:** Conditions such as HIV and thyroid disorders, if not managed properly, can also lead to heart failure. - **Damage to the Heart Muscle (Cardiomyopathy):** Causes of cardiomyopathy include infections, alcohol abuse, and certain medications. Certain populations face higher risks: - **Black Individuals:** Have approximately a 19% higher risk of developing heart failure compared to white individuals. This condition may present more severely and at a younger age. - **Hispanic Individuals:** Research indicates multiple heart failure risk factors and healthcare disparities, suggesting an elevated risk within this population (American Heart Association, 2024; Heart Foundation, 2024). Diagnostic Tests for Heart Failure To accurately diagnose heart failure, it is crucial to conduct specific tests that will reveal the underlying causes and severity of the condition. The diagnostic process typically involves a thorough evaluation of symptoms, medical history, and physical examination by a healthcare provider. The following tests may be employed to confirm a diagnosis of heart failure and assess its impact on the heart: 1. **Chest X-ray**: This imaging technique allows for the visualisation of the heart\'s size and can help identify any fluid accumulation in the lungs, which is indicative of heart failure. 2. **Echocardiogram**: Utilising ultrasound waves, this test provides a detailed view of the heart\'s pumping action, blood flow, and valve function. It is instrumental in assessing the efficiency of the heart\'s contractions and the condition of the heart\'s valves. 3. **Electrocardiogram (ECG)**: An ECG records the electrical activity of the heart. This test helps identify abnormal heart rhythms and other electrical irregularities that may be contributing to heart failure. 4. **Blood Tests**: These tests evaluate how well other organs, such as the kidneys and liver, are functioning. They can also measure biomarkers related to heart failure, such as B-type natriuretic peptide (BNP) levels. 5. **Coronary Angiogram**: This procedure involves injecting a contrast dye into the coronary arteries to visualise blood flow. It helps detect any blockages or narrowing of the arteries that supply blood to the heart muscle (St Vincent\'s Hospital Heart Health, 2024). Treatment approaches for heart failure Effective management of heart failure involves a comprehensive approach tailored to the individual's needs. The primary objectives of treatment are to alleviate symptoms, enhance quality of life, improve cardiac function, and address underlying causes. **Lifestyle Changes:** - **Smoking Cessation:** - Seek support from healthcare professionals, including nurses, pharmacists, or doctors. - **Fluid Intake Limitation:** - Restrict fluid consumption to no more than 1.5 liters (6 cups) per day, including water, tea, juice, and coffee. - Utilise a fluid balance chart to track daily fluid intake. - **Salt Reduction:** - Decrease dietary salt to prevent fluid retention and reduce cardiac strain. - **Daily Weight Monitoring:** - Daily weight to detect fluid accumulation. - Report any sudden weight increase of 2 kg within 2 days to the healthcare provider. - **Symptoms Monitoring:** - Regularly check for signs of fluid retention such as increased shortness of breath or swelling of the ankles. - **Annual Flu Vaccination:** - Obtain the flu shot to prevent respiratory infections that could exacerbate heart failure symptoms. - **Alcohol Intake Reduction:** - Limit alcohol consumption as it can contribute to heart failure.  - **Regular Exercise:** - Engage in consistent physical activity to enhance overall wellbeing and heart function St Vincent\'s Hospital Heart Health, 2024). Ischaemic stroke ---------------- #### What is ischaemic stroke; Ischaemic strokes are the most common type of stroke. An ischaemic stroke occurs when a blood vessel supplying the brain becomes obstructed, impairing blood flow to specific areas of the brain. This blockage can be due to a blood clot or other factors. The interruption in blood supply leads to a rapid depletion of oxygen and nutrients, causing brain cells and tissues to begin dying within minutes. Ischaemia stroke can lead to the loss of function in the affected brain regions, which can result in significant deficits in motor, sensory, or cognitive functions. Prolonged ischaemia can cause permanent brain damage or death. An ischaemic stroke is a critical medical emergency. Immediate intervention is crucial, as the longer the brain remains deprived of blood, the greater the risk of irreversible damage or death (Walter, 2022). ### Different groups of ischaemic stroke; ##### Thrombotic strokes Thrombotic strokes occur due to a blood clot that forms within the blood vessels of the brain. In a thrombotic event, blood flow to the brain is obstructed within a blood vessel due to a thrombus (clot) forming within the vessel itself. This typically occurs secondary to conditions such as atherosclerotic disease, arterial dissection, fibromuscular dysplasia, or inflammatory conditions. Thrombotic strokes are caused by these thrombi developing in the arteries that supply blood to the brain. This type of stroke is commonly observed in older individuals, particularly those with high cholesterol, atherosclerosis (the buildup of fats and lipids within the walls of blood vessels), or diabetes. Symptoms of a thrombotic stroke can manifest suddenly, often during sleep or in the early morning. Alternatively, the onset may be gradual, occurring over several hours or even days. Thrombotic strokes may be preceded by one or more transient ischemic attacks (TIAs), also referred to as \"mini-strokes.\" TIAs can last from a few minutes to up to 24 hours and serve as a warning sign that a stroke may occur. Although the symptoms of a TIA are typically mild and transient, they are similar to those caused by a stroke (Hui et al., 2024). ##### Embolic Stroke Embolic strokes are typically caused by a blood clot (embolus) that forms elsewhere in the body and travels through the bloodstream to the brain. These strokes frequently result from heart disease or heart surgery and tend to occur suddenly without any warning signs. Approximately 15% of embolic strokes occur in individuals with atrial fibrillation, a type of abnormal heart rhythm where the upper chambers of the heart do not beat effectively. In an embolic event, debris from another part of the body obstructs blood flow through the affected vessel. The source of emboli can be a proximal artery, such as an atherosclerotic plaque in the internal carotid artery, leading to an artery-to-artery embolic stroke. These strokes often originate from the heart, but occasionally, the source may be from the right side of the circulation, passing through a right-to-left shunt, such as a patent foramen ovale, and into the cerebral arterial system (Hui et al., 2024). ### Causes of ischaemic stroke; #### Large artery disease A common cause of ischaemic strokes is atherosclerosis, where cholesterol builds up as plaques on the inner walls of arteries. When these plaques become too large, they can cause a clot to form. These clots often develop in the carotid arteries in the neck, which are the brain\'s main supply of blood, but they can also form in arteries within the brain. Strokes resulting from large artery blockages can cause significant damage because they affect a larger area of the brain. However, these strokes can often be prevented by addressing risk factors such as high blood pressure and high cholesterol (Stroke Foundation 2024). #### Heart conditions Clots can also form in the heart due to several conditions: - **Atrial Fibrillation (AF)**: This irregular heartbeat causes one of the smaller heart chambers to pump in an uncoordinated way, **leading to stagnant blood and clot formation.** - **Patent Foramen Ovale (PFO)**: This condition connects the two sides of the heart, allowing clots that form in v