MS1 Unit 2 Lecture PDF

UNIT 2: 4. Internal Respiration NURSING CARE OF AT RISK AND SICK ADULT CLIENTS WITH Cellular respiration; the oxygen and carbon dioxide we keep ALTERATIONS OR PROBLEMS WITH OXYGENATION...

UNIT 2: 4. Internal Respiration NURSING CARE OF AT RISK AND SICK ADULT CLIENTS WITH Cellular respiration; the oxygen and carbon dioxide we keep ALTERATIONS OR PROBLEMS WITH OXYGENATION on exchanging must reach the cells on our body to continue (THE LOWER RESPIRATORY SYSTEM AND ITS DISORDERS) living. The diffusion of gases between the blood of the systemic LESSON 1: RESPIRATORY PHYSIOLOGY: A CLOSER LOOK capillaries and cells. The Respiratory Physiology A. Four (4) Distinct Events During Respiration B. Mechanics of Breathing 1. Inspiration (Inhalation) 2. Expiration (Exhalation) 3. Non-respiratory Air Movements Examples: coughing hiccups, yawning, sneezing, crying, and laughing. C. Respiratory Volume and Capacities 1. Pulmonary Ventilation Inhalation (inspiration) or exhalation (expiration). The movement of air into and out of the lungs. The diaphragm and intercostals muscles promote lung expansion for ventilation 2. External Respiration Gas exchange occurring at the alveolar level. The diffusion of gases between lung fields, particularly the alveoli and the blood of the pulmonary capillaries. 3. Respiratory Gas Transport Transportation of gases such as oxygen and carbon dioxide to different blood vessels (either veins, artery, or capillaries) all over the body. The transportation or exchange of oxygen and carbon dioxide between the lungs and tissues.  Tidal Volume (TV) D. Respiratory Sounds The volume of air inhaled and exhaled with Sounds generated by the air movement through the normal/simple quiet breathing (500 ml). respiratory system are as follows: Inspiratory Reserve Volume (IRV) 1. Bronchial Sounds – sounds that comes from under the Forceful inhalation bronchi. The maximum volume that can be inhaled following a 2. Vesicular Sounds – sounds from the vesicles particularly normal quiet inhalation (2100 - 3200 ml) the alveoli. Expiratory Reserve Volume (ERV) E. Factors Influencing Respiratory Rate and Depth Forceful exhalation 1. Physical factors The maximum volume that can be exhaled following a Example: measuring respiratory rate and depth after normal quiet exhalation (1200 ml) running for 30 minutes continuously. Residual Volume (RV) 2. Volition (Conscious Control) The volume of air that remains in the lungs after forceful Examples: inhalation and exhalation while exercising, exhalation (about 1200 ml) breathing techniques while swimming, and managing breath Note: It is impossible to empty all the gases in the lungs during singing. after series of forceful exhalation. 3. Emotional factors Vital Capacity (VC) Examples: rapid and faster breathing when angry, The maximum volume of air that can be exhaled after a hyperventilation when scared or shocked. maximum inhalation. 4. Chemical factors The sum of the TV, IRV, and ERV (4800 ml) This pertains to respiratory gases like oxygen and carbon VC = TV + IRV + ERV dioxide including other gases related to it such as Inspiratory Capacity (IC) bicarbonate (HCO3) and carbonic acid (H2CO3). Total maximum amount of air that can be inhaled Table 2.2 Summary of Age-Related Respiratory Changes following normal quiet exhalation. The sum of TV and IRV (3,600 ml) IC = TV + IRV Total Lung Capacity (TLC) The total volume of the lungs at maximum inflation; sum of TV, IRV, ERV and RV (6,000 ml) TLC = TV + IRV + ERV + RV F. Neurologic Control of the Respiratory System LESSON 2: The nervous system is associated with the respiratory system MANAGEMENT OF PATIENTS WITH since it gives commands to the respiratory organs to function. LOWER RESPIRATORY TRACT DISORDERS 1. Medulla Oblongata – center for respiration; responsible to give commands for inhalation and exhalation. A. Atelectasis 2. Pons – controls rate, speed, and depth of respiration Refers to closure or collapse of the 3. Phrenic Nerve – located in the spinal structure and controls alveoli; or simple “lung collapse”. diaphragmatic movement Most complicative disease among 4. Pneumotaxic Center – controls pattern of respiration LRTI disorders; if LRTI remain Example: Kussmaul’s Respiration (type of hyperventilation uncontrolled or untreated, it results related to acidosis) to atelectasis. 5. Apneustic Center –stimulate medulla to create prolonged Causes of Atelectasis: and deep respiration. 1. Chronic Obstructive Pulmonary Disease (COPD) o Examples are chronic bronchitis and emphysema 2. Lung distention/compressing forces o Such as pleural effusion (fluids in pleural space), pneumothorax (air in pleural space), hemothorax (blood in pleural space), ascites (fluid collection in abdomen) which hinders full lung expansion. 3. Chest wall disorder (Scoliosis) o Misalignment of spinal area must be reported immediately as if it remains untreated, it could hinder full lung expansion and lead to atelectasis. 4. Immobility o Post-operative patients (if there is no restriction to move) are encouraged to walk or deambulate or perform ROMs especially if patient has lung disease. 5. Pain (Chronic and Excruciating) o Unbearable or intolerable pain directly affects vital signs and become chaotic which may lead to stoppage or sudden cessation of lung function by not allowing full expansion. 6. Trauma and Surgical Procedure in the Lungs o Accidents, internal and external forces trauma including surgeries in the upper half of the body that requires general anesthesia are encouraged to do ambulation and ROM. 7. CNS dysfunction/coma o Nursing responsibility for this are passive ROM exercises. 8. Duration of Anesthesia Pathophysiology of Atelectasis o Patients underwent surgery with general anesthesia are Causes encouraged to do deep breathing exercises. Prior to operation, there must be a health teaching that you compose and Altered breathing Blocks / impedes passage of air to cannot seen by implemented it to the patient as full disclosure regarding and from the lungs. naked eye, it can only general anesthesia can lead to physiological depression of the be observed by functions of the body momentarily. Decrease altered breathing pattern, mechanical ventilator, depth and volume. Continuous Positive Airway Pressure Prevention is Better Than Cure! (CPAP), and Bilevel The best way to prevent atelectasis is that to prevent all of ↓ Tidal volume, diaphragm function, Positive Airway Alveoli also relies on and lung compliance or expansion Pressure (BiPAP) the aforementioned diseases above. oxygen to continue its function to supply Signs and Symptoms of Atelectasis: oxygen also in all ↓ Alveolar ventilation tissues of the body. If ✓ Fever deoxygenated alveoli o 1st clinical manifestation or universal sign; must report occurred, it will hardly Alveolar collapse / Atelectasis immediately especially if suspected with lung disfunction. inflate and deflate ✓ Cough and becomes atelectasis. Manifestations ✓ Diminished breath sounds and crackles o This is alarming as it indicates weakening respiratory function. Diagnostic Tests for Atelectasis: ✓ Sputum production 1. Chest X-ray o Productive secretions from coughing. o It reveals patchy infiltrates or ✓ Dyspnea consolidated areas (due to inflammatory o DOB or SOB exudation processes) that marks as ✓ Tachycardia hazy appearance in the image between o Compensatory mechanism by the heart from hypoxia. thoracic cages. ✓ Pleural pain 2. Pulse oximetry ✓ Central cyanosis o Low oxygen saturation (< 90%) o Bluish discoloration observed from mouth, lips, and Medical Management for Atelectasis: eyelids/conjunctiva as manifestation of hypoxic impending 1. First Line Measures alveolar collapse. Frequent turning on bed ✓ Anxiety Early ambulation (especially with post-operative patients) o Uncomfortable; uneasy feeling. Deep Breathing Exercises or DBE (for induction of anesthesia) Incentive spirometry (inhaling equipment to enhance full expansion of lungs) Coughing exercise 2. Positive – end expiratory pressure (PEEP) Nursing Management for Atelectasis “Pressure in the lungs above 1. Preventive measures are the focus atmospheric pressure that 2. Review and reinforce first line measures to prevent atelectasis exists at the end of expiration”. Note: Learn about the causation of atelectasis and know about It helps to prevent escaping of causation of each of them. extra residual volume pressure and air. B. Acute Tracheobronchitis A simple mask and one-way A sequel of URTI that causes inflammation of the trachea and valve system that provides bronchial tree (in worst cases, down to bronchioles). varying amounts expiratory Developed from URTI like tonsillitis, pharyngitis, and laryngitis. resistance, usually 5 to 15 cm H2O attached to a mechanical Causes of Acute Tracheobronchitis ventilator. 1. Smoking 3. Intermittent Positive Pressure Breathing (IPPB) 2. Environmental pollutants “An apparatus-controlled delivery of 3. Bacterial infection positive pressure into the airway o S. pneumoniae, H. influenzae, M. pneumoniae until a preset pressure is achieved”. 4. Fungal infection It is necessary that lungs always o Aspergillus have positive pressure. 5. Viral infection It improves lung volume expansion. o Adenovirus Signs and Symptoms of Acute Tracheobronchitis CPAP vs. BiPAP ✓ Dry, irritating cough Continuous Positive Airway Pressure (CPAP) is a device that o Due to presence of foreign secretions. maintains one constant positive pressure within the airway throughout ✓ Scanty mucoid sputum the respiratory cycle. It has a face mask that must be attached to a ✓ Sternal soreness from coughing portable ventilator that pumps air under pressure to keep the windpipe o Chest constriction because of excessive coughing. open. It is generally worn at night to maintain oxygenation for a person ✓ Fever who experiences sleep apnea (periods during which the client stops o Due to infection breathing) which can lead to high blood pressure or HPN and heart ✓ Night sweating ailments. ✓ Headache Bilevel Positive Airway Pressure (BiPAP) is more way effective for ✓ General malaise sleep apnea than CPAP as it can provide higher positive pressure in ✓ Difficulty of Breathing (DOB) two distinct values throughout respiratory cycle. It has also a face mask that attached on a machine that helps push through the air into the lungs ✓ Purulent (pus-filled) sputum that aids also in complex breathing pattern problems. o Whitish or yellowish color ✓ Blood-streaked sputum o Due to repetitive coughing that leads to trauma in the airway tract in which blood escapes where it can be called “hemoptysis” (presence of blood in the sputum).  Pathophysiology of Acute Tracheobronchitis Nursing Management for Acute Tracheobronchitis 1. Increase fluid intake to liquefy secretions and easily expectorate. Smoking, RTI, Environmental Pollutants 2. Positioning techniques (Fowler’s position) to allow full lung Inflammatory chemicals such as Inflammatory Process expansion. Bradykinin, 3. Deep breathing exercises (DBE) and coughing exercises if patient Histamine, and Bradykinin, Histamine, Prostaglandin The fluid exudation is not showing ventilatory patterns or breathing rates. Prostaglandin causes from capillary vasodilation of permeability will 4. Advise adequate rest periods to conserve energy. vasculature or blood ↑ Capillary Permeability move to the airway vessels wherein tract and become C. Pneumonia fluids escape called mucus secretions Fluid / Cellular Exudation that will harbor An inflammation of the lung parenchyma (lung fields) caused by capillary permeability. infection and cause infectious agents (mycobacteria, chlamydiae, mycoplasma, fungi, Mucus Hypersecretion coughing. parasites, and viruses) which can be communicable and non- infectious agents (toxic gases, chemicals, foreign matter, etc.) Medical Management of Acute Tracheobronchitis which can be possibly non-communicable and later become 1. Pharmacologic treatment infectious as it attracts microbes since patient is a. Antibiotic immunocompromised. If causative agent is bacteria. b. Antihistamine, usually not prescribed Because it tends to dry secretions, making it more difficult to expectorate. Instead of antihistamine, mucolytic drugs are prescribed which reduces viscosity of sputum like Guaifenesin, Acetylcysteine, and Carbocisteine. c. Expectorants These are agents that aid to expel mucus secretions like Guaifenesin and Robitussin. d. Analgesics and antipyretics Analgesics relieves pain and body malaise; antipyretics for fever. Classification According to Etiology 2. Suctioning and bronchoscopy 1. Community-Acquired Pneumonia (CAP) Suctioning removes excessive secretions if patient is It occurs either in community setting or within the first 48 hours unconscious or in comatose. of hospitalization (because pneumonia infection has Bronchoscopy helps determine to rule out disease process of incubation period or full-blown occurrence of disease). patient and decide best treatment for patient. 2. Hospital-Acquired Pneumonia (HAP) Also known as “nosocomial pneumonia”; occurs more than 48 hours after admission in patients with no evidence of infection at the time of admission.  Stages of Pneumonia 3. Pneumonia in the Immunocompromised Host 1. Congestion – 1 day with marked vasodilation (which makes It occurs with the use of immunosuppressive agents and airway tract thickened or swelling) leading to congestion of the conditions like use of corticosteroids (used when antihistamine lungs. does not work to patient), broad-spectrum antibiotics, 2. Red Hepatization – 2 days with marked exudation (increased chemotherapy, AIDS, etc. capillary vasculature wherein plasma escapes from blood vessel 4. Aspiration Pneumonia and move into airway tracts and cause adventitious breath sounds It refers to the pulmonary consequences resulting from entry like crackles) and presence of RBCs (redness). of endogenous (such as airway secretions) and exogenous 3. Grey Hepatization – 4 days with engulfment of bacteria by substances (like contrast materials) in the lower airway. hyperactivity of WBCs (e.g., macrophages) wherein WBC dies after the activity together with the bacteria and forms a pus. Knowledge Bonus! 4. Resolution / Recovery – 8 days with few WBCs on site of Know your common medical adjectives for disease infection; near-to-normal lung structures causations: ❖ Congenital – means “at birth” ❖ Juvenile – means “young-age onset” or “youthful” Signs or Symptoms and Manifestations of Pneumonia ❖ Nosocomial – means “hospital-acquired” ✓ Fever with chills ❖ Iatrogenic – means “acquired from or associated with medical- o Due to infection and inflammatory process surgical procedures” (medical error or negligence). ✓ Shortness of Breath (SOB) and chest pain ❖ Autoimmune – means “self-destructing” ✓ Signs of respiratory distress ❖ Idiopathic – means “unknown causation” ✓ Cyanosis o Due to consolidated areas in the lungs which hinders the Classification According to Degree and Site of Affectation respiratory gas exchange. 1. Lobar Pneumonia ✓ Fatigability Infection of a o Due to decreased oxygenation. substantial portion of ✓  WBC level one or more lobes of o Above 10,000 cells / cu mm wherein overproduction happens the lungs to fight inflammatory infections. Common among ✓ Cough with greenish/yellowish sputum adults o Indication of active infection wherein discoloration due to Unilateral affectation harboring of microorganisms. 2. Bronchopneumonia ✓ Cough with rusty sputum Infection distributed in a patchy fashion or consolidation in the o Indication for late-stage pneumonia; must be reported. lung parenchyma (both lungs affected). o Pathognomonic sign for pneumonia. Common among extreme ages (too young /too old) Usually bilateral Pathophysiology of Pneumonia 2. Supportive treatment a. Oxygen therapy – as response to cyanosis Infectious agents (Mycoplasma, etc.) Non-infectious agents (foreign matter) b. Mechanical ventilation – if more aggressive support is required especially if there is impending risk of alveoli collapse Inflammatory process Nursing Management for Pneumonia Release of inflammatory agents like 1. Maintain patent airway histamine, bradykinins, WBCs, etc. 2. Teach deep breathing exercises (DBE) 3. Proper disposal of secretions (if infectious agent). Hypersecretions of mucus, mucosal 4. Reinforce compliance of therapeutic regimen edema, marked consolidation due to WBCs activities. Summary! Alveolar hypoventilation Lobar Pneumonia Bronchopneumonia ✓ Fever with chills ✓ SOB and chest pain ✓ Signs of respiratory distress ✓ Cyanosis ✓ Fatigability ✓  WBC level ✓ Cough with greenish/yellowish sputum ✓ Cough with rusty sputum Diagnostic Test to Detect Pneumonia 1. Chest X-ray 2. Sputum exam – best diagnostic option 3. CBC (reveals WBC level) – above 10,000 cells / cu mm Medical Management for Pneumonia 1. Pharmacologic treatment a. Antibiotics Amoxicillin, Clarithromycin (CAP treatment) Vancomycin, 3rd and 4th generation of Cephalosporins (HAP treatment) Rimantidine, Amantidine (Viral treatment) b. Antipyretics Fibrile and fever symptoms c. Antihistamine Reduces sneezing and rhinorrhea D. Pulmonary Tuberculosis Pathophysiology of Pulmonary Tuberculosis An infectious disease that affects the lung parenchyma caused by Mycobacterium tuberculosis and other gram (+) acid fast bacilli. Can be transmitted via airborne droplet. Associated with poverty, malnutrition, and inadequate health care. Why poverty and malnutrition are associated with PTB? In a third world country like the Philippines, poverty is the number one problem. It is the root of many societal issues and complications such as hunger that can result to malnutrition. If malnutrition occurred, it could lead to immunodeficiency which becomes an individual prone to infection such as Mycobacterium agent that could give pulmonary tuberculosis. Diagnostic Test for Pulmonary Tuberculosis Risk Factors of Pulmonary Tuberculosis 1. Mantoux test (Pirquet Test or PPD or Tuberculin Test) Close contact with active PTB patient 0.1 mL ID, 4 inches below the dorsal elbow. Immunocompromised status Above 10 mm induration is positive result; 5 mm positive Substance abuse result for HIV patients. Environment (immigration in area with high prevalence) 2. Sputum examination Positive (+) acid fast smear Overcrowding More definitive of PTB Being a healthcare worker 3 different sputum specimens should be collected in 3 consecutive mornings. Signs and Symptoms of Pulmonary Tuberculosis ✓ Fever (low-grade, late afternoon) Why three early morning sputum specimens are needed to ✓ Loss of appetite diagnose pulmonary tuberculosis? ✓ Easy fatigability Morning sputum is needed because the overnight secretions ✓ Night sweating are usually from the lungs. Therefore, it determines the real ✓ Dry cough, laisoter productive with hemoptysis causative agent for LRTI diseases like PTB. It is collected three times consecutively to increase chances of accurate findings. Common in late PTB stages Hence, avoid false positive or false negative results. ✓ Weight loss ✓ Chest pain 3. Chest x-ray Not confirmatory but very supportive evidence for PTB. Ghon tubercle (hazy consolidated white spots) seen on Chest X-ray.  What are the signs and symptoms of hepatotoxicity? Classification of Pulmonary Tuberculosis (PTB) Some signs and symptoms of hepatotoxicity include: a. Class 0 – no exposure; no infection ✓ Weakness or fatigue b. Class 1 – with exposure; no infection ✓ Fever c. Class 2 – latent infection; no infection; no s/sx; (+) PPD ✓ Pruritis (itchiness) d. Class 3 – with infection; clinically active; (+) all tests ✓ Nausea ✓ Swelling of feet e. Class 4 – with infection; not clinically active; (+) all tests ✓ Jaundice (yellow discoloration) f. Class 5 – suspected disease; pending diagnosis Medical Management for Pulmonary Tuberculosis 2. Oxygen therapy Treated primarily with 6-12 months To maintain oxygenation 1. Pharmacologic treatment 3. Isolation techniques a. Anti-TB drugs (Remember mnemonic RIPES): Be careful and open minded that it has limitations; be i. Rifampicin considerate since an isolation such as personal belongings SE: red orange color of body secretions, hepatotoxicity, should not be isolated. thrombocytopenia (low platelet count) 4. BCG vaccination of newborn infants Bacillus Calmette–Guérin vaccine is a vaccine primarily What IF? used against tuberculosis, leprosy, and other If thrombocytopenia gets worse, client poses a high risk for bleeding (if external) and hemorrhage (if internal) because platelets microbacterial infections. play a major role in blood clotting all throughout our body and if it is in Nursing Management for Pulmonary Tuberculosis lower count or amounts, it could affect its major function as it should. 1. Maintain airway patency 2. Educate proper nutrition ii. Isoniazid (INH) 3. Break the mode of transmission SE: peripheral neuritis (inflammation of peripheral 4. Reinforce preventive measures – wear face mask, hand hygiene nerves with numbness), hepatotoxicity Learn more about PTB! Administer Vit B6 to prevent peripheral neuritis Watch video here: https://youtu.be/H3DplxYLBbc iii. Pyrazinamide (PZA) SE: hepatotoxicity iv. Ethambutol E. Pleurisy SE: optic neuritis, skin rash Inflammation of the pleural space by air, fluid, bacteria, or v. Streptomycin associated diseases resulting in a severe sharp, knife-like pain. SE: ototoxicity, nephrotoxicity Classified either pleural effusion or pneumothorax. ✓ Anti-TB drugs must be taken in combination to avoid bacterial resistance ✓ Drugs to be taken on empty stomach for maximum absorption Modern Treatment to PTB Now, all Anti-TB drugs except for Streptomycin is now combined in one tablet called “Quadtab”. Streptomycin is given separately since it is usually injectable. Signs and Symptoms of Pleurisy Signs and Symptoms of Pneumothorax and Pleural Effusion ✓ Pleuritic pain, usually occurring in one side only ✓ Sudden, sharp chest pain ✓ Pleural friction rub ✓ Shortness of breath (SOB) Diagnostic Findings for Pleurisy ✓ Anxiety or restlessness 1. Chest X-ray ✓ Diminished / absent breath sounds 2. Sputum exam The more pleural space expands, the more and harder for 3. Thoracentesis the stethoscope to heard the sound that penetrate from the 4. Pleural Biopsy lungs. Medical Management for Pleurisy ✓ Increased RR 1. Analgesics (NSAIDs) ✓ Chest tightness 2. Corticosteroids ✓ Chest asymmetry 3. Warm or cold pack on the affected side ✓ Cyanosis Nursing Management for Pleurisy ✓ Tympanic sound on chest percussion 1. Turn frequently on the affected side to splint chest wall and reduce stretching of the pleura Medical Management for Pneumothorax and Pleural Effusion 2. Splint the rib cage while coughing 4. Chest Tube Thoracostomy (CTT) 3. Warm and cold application Evacuate fluids from pleural space if patient needs longer time to fully treat the patient. F. Pneumothorax and Pleural Effusion 5. Thoracentesis Immediate evacuation of fluids for shorter duration. Accumulation of air in the pleural space. 6. Surgical Pleurectomy Pleural Effusion Removal of only infected parts of the pleura. Accumulation of fluids in the pleural space 7. Pleuroperitoneal shunt Types of Pleural Effusion: Re-routing or changing the route of fluid from the pleura to Hemothorax – blood the peritoneum. Pyothorax / Empyema – pus or purulent discharges 8. Oxygen therapy Hydrothorax – excessive pleural fluids 9. Analgesics Causes of Pneumothorax and Pleural Effusion Trauma – any accidents that may injure thoracic wall of patient Nursing Management for Pneumothorax and Pleural Effusion Thoracic Surgery – post-operative complication 1. Positioning technique – High Fowler’s position Positive Pressure Ventilation 2. Record thoracentesis output Thoracentesis 3. Monitor and report ABG results 4. Kink tube of drainage bottle of CTT when transporting patient CVP line insertion (e.g., going to x-ray) Emphysema – abnormal distension of alveoli wherein it is overinflated wherein patients have problems with their exhalation phase. G. Pulmonary Edema Signs and Symptoms of Pulmonary Edema Abnormal accumulation of fluid ✓ Difficulty of Breathing (DOB) in the lung tissue, alveolar Sites for gas exchange are not working. space, or both. A severe, life- ✓ Abnormal breath sounds threatening condition. Lungs are now filled with fluids (crackles/rales sound) Causes of Pulmonary Edema ✓ Central cyanosis 1. Congestive Heart Failure (CHF) Specifically on oral and nasal mucosa; eyelids (conjunctiva) Both right and left heart can cause pulmonary edema; but ✓ Productive cough, frothy and blood-tinged sputum specifically, the causation is more at the left heart and left Because of the reflux of systemic blood in the lungs. ventricles. ✓ Confused and stuporous 2. Left Ventricular Failure Hypoxia affects brain function; altered level of consciousness Ventricles are the one who pumps the heart that is more likely to have complications. Medical Management of Pulmonary Edema Pathophysiology of 3. Arrhythmias or Dysrhythmia 1. Vasodilators and inotropic drugs Pulmonary Edema Irregular pattern of heart beats; too much oxygenated blood Given to improve cardiac makes the lungs to have strenuous activities while too low function if the cause is cardiac make the lungs inactive for gas exchange. in origin. They usually given 4. Hypertension (HPN or HTN) IV/parenterally for immediate 5. Pericardial Effusion effect. Accumulation of fluids in the pericardium (layer that encloses Vasodilators expands blood the heart) vessels for good oxygenation 6. Fluid Overload (e.g., if chest pain, anti-anginal Strenuous for the heart and lungs instead of transporting fluids drugs like isordil, isosorbide) in the body, they accommodate excess fluids inside the lungs. Inotropic drugs strengthen 7. Multiple Blood Transfusion pumping activity of the heart Can lead also to fluid overload wherein blood should not be (e.g., dopamine, dobutamine, transfused drastically in short period of time. It should be within epinephrine) the recommended rate and hour to avoid fluid overload. 2. Diuretics Given if fluid overload is the cause 3. Morphine (Opioid analgesic) Remembering the association To reduce anxiety and control pain between the heart and lungs… 4. Oxygen therapy “A weak left side of the For hypoxia heart leads to reflux of the blood 5. Intubation and mechanical ventilation, in severe cases into the lung fields hence pulmonary edema becomes imminent”.  Nursing Management for Pulmonary Edema Pharmacology Flashback! 1. Oxygen administration 1. Loop Diuretics 2. Assisting in intubation and mechanical ventilation, if respiratory It reduces sodium chloride reabsorption in the thick ascending limb of the loop of Henle in renal tubule. It is used in the management and failure occurs treatment of fluid overload conditions such as heart failure, nephrotic 3. Monitor VS especially RR when administering Morphine syndrome or cirrhosis, and hypertension, in addition to edema. Opioids like Morphine has side effects of respiratory Examples include torsemide (Demadex), furosemide (Lasix), and depression. bumetanide. 4. Restrict fluid intake if hypervolemia is the cause 2. Potassium-Wasting Diuretics The Nursing Oxygen Administration It is used to remove extra potassium in the body specifically, Initially, a nurse can set the oxygen tank without the doctor’s hyperkalemia. Examples are chlorothiazide (Diuril), chlorthalidone order at the flow rate of 2-3 L/min. It is the safest method to avoid (Hygroton), and hydrochlorothiazide (Esidrix, HydroDiuril, oxygen toxicity. In Bulacan Medical Center, nurses follow their Microzide) tend to deplete potassium levels. health policy in setting their oxygen sources at fixed 2 L/min. 3. Potassium-Sparing Diuretics Potassium-sparing diuretics reduce fluid levels in the body without H. Acute Respiratory Failure (ARF) causing to lose potassium, an important nutrient. The other types of A sudden and life-threatening deterioration of gas exchange diuretics cause to lose potassium, which can lead to health problems function of the lungs such as arrhythmia. Potassium-sparing diuretics may be prescribed Causes of Acute Respiratory Failure for people at risk of low potassium levels, such as those who take 1. Alveolar hypoventilation other medications that deplete potassium. Examples include amiloride, triamterene (Dyrenium), spironolactone (Aldactone), and 2. Diffusion abnormalities eplerenone (Inspra). 3. Ventilation-perfusion mismatching 4. Thiazide Diuretics 4. Shunting Thiazides are the most commonly prescribed diuretics. They’re most Categories of ARF Causes often used to treat high blood pressure. These drugs not only 1.  respiratory drive decrease fluids, they also cause the blood vessels to relax. 2. Dysfunction of the chest wall Thiazides are sometimes taken with other medications used to lower 3. Dysfunction of the lung parenchyma blood pressure. Examples of thiazides include chlorthalidone, 4. Other causes (post-surgical procedure) hydrochlorothiazide (Microzide), metolazone, and indapamide. Signs and Symptoms of ARF 5. Osmotic Diuretics ✓ Restlessness ✓ Diaphoresis Osmotic diuretics increase urinary flow by osmotic retention of water ✓ Fatigability ✓ Respiratory arrest throughout the nephron. Mannitol is used to decrease intracranial ✓ Headache pressure and cerebral edema. It is given by IV injection (intermittent ✓ DOB bolus preferred), and preferably via a large central vein, as it is a ✓ Tachycardia vesicant. ✓ Increased BP ✓ Confusion ✓ Lethargy ✓ Central cyanosis Medical Management of ARF Signs and Symptoms of ARDS 1. Intubation and mechanical ventilation ✓ Tachypnea To maintain adequate ventilation and oxygenation while ✓ Difficulty of Breathing (DOB) correcting the underlying cause ✓ Retractions ✓ Central cyanosis ✓ Dry cough ✓ Crackles ✓ Fever ✓ Altered level of consciousness (LOC) ✓ ABGs:  PaO2, PaCO2 Medical Management of ARDS 1. Intubation and mechanical ventilation Nursing Management of ARF 2. Pharmacologic treatment 1. Assisting in intubation and mechanical ventilation a. Human recombinant interleukin – 1 receptor antagonist 2. Monitor level of responsiveness, ABGs, pulse oximetry and VS b. Neutrophil inhibitor 3. Frequent turning, mouth care, skin care and ROM exercises c. Vasodilators d. Corticosteroids I. Acute Respiratory Distress Syndrome (Adult RDS) 3. Surfactant replacement therapy It occurs as a result of an inflammatory trigger that initiates the release of cellular and chemical mediators, causing injury to the Nursing Management of ARDS alveolar capillary membrane which leads to impaired gas 1. Maintain patency of airway (Oxygen therapy, Chest physiotherapy, exchange. Endotracheal intubation or tracheostomy care, Suctioning) 2. Proper positioning technique – Fowler’s position Causes of ARDS 3. Frequent turning to improve ventilation and perfusion in the lungs 1. Aspiration 2. Drug overdose J. Pulmonary Heart Disease 3. Hematologic disorder A condition in which the right ventricle of the heart enlarges as 4.  oxygen inhalation result of diseases that affects lung functions and vasculature 5. Infection Also called “Cor Pulmonale”, 6. Shock “Right Heart Failure” 7. Trauma Common with COPD such as 8. Fat or air embolism chronic bronchitis & 9. Systemic Sepsis emphysema Share common characteristics with Pulmonary Edema.  Causes of Pulmonary Heart Disease Medical Management of Pulmonary Heart Disease 1. Chronic Obstructive Pulmonary Disease (COPD) 1. Pharmacologic treatment 2. Chest wall deformities a. Digitalis glycosides 3. Obesity To relieve pulmonary hypertension if caused by ventricular Put so much pressure in the blood vessels and heart failure and arrhythmias because of too many fatty acids in the body. Digitalis are positive inotropic drugs (strengthen heart 4. Hypertension (HPN or HTN) pumping) and negative chronotropic drugs (slows down 5. Pulmonary Embolism heart rate) Presence of blood clot dislodged to one of the many arteries Example: Digoxin of the pulmonary artery. b. Diuretics Signs and symptoms of Pulmonary Heart Disease To reduce peripheral edema ✓ Edema of the lower extremities 2. Oxygen therapy ✓ Distended neck veins 3. Chest Physiotherapy (CPT) ✓ Abdominal enlargement (caused by hepatomegaly or ascites) 4. ET intubation and mechanical ventilation ✓ Hepatomegaly (enlargement of the liver) If respiratory failure occurs ✓ Ascites (abnormal accumulation of fluids in the peritoneum) 5. Continuous pulse oximetry and ECG monitoring ✓ Heart murmurs To watch out for further progression and complications of the Pathophysiology of Pulmonary Heart Disease disease such as dysrhythmia. Edema happens from the reflux of the blood Nursing Management for Pulmonary Heart Disease due to right ventricle 1. Maintain airway patency hypertrophy wherein 2. Sodium and fluid restriction they cannot accommodate Sodium may cause fluid overload as it attracts water in the enough blood; this body. blood will go to the 3. Provide skin care for edematous extremities. right atrium back to the superior and 4. Encourage compliance on the therapeutic regimen. inferior vena cava. But more blood goes K. Pulmonary Embolism to inferior vena cava Obstruction of the pulmonary artery or one of its branches by a due to gravity and causes lower thrombus if attached to endothelium (or emboli if freely moves extremity edema. to pulmonary arteries) that originates somewhere in the venous system The Key Difference! Why embolism is common in venous system? We all know that pulmonary edema and pulmonary heart Pressure in veins is lower than the arteries because the disease share manifestations. But the key difference is that ventricles pump only for arteries to move blood away from the heart. pulmonary edema shows central manifestations while pulmonary Because of this, blood in veins is moving slowly or worst, in stasis heart diseases display peripheral manifestations. conditions which is prone to clotting. Causes of Pulmonary Embolism 3. Do not massage the legs (it may move embolus to blood vessels 1. Fat embolism Both from fracture wherein fats from bone marrow specifically to medullary and cause obstruction to the heart). 2. Multiple trauma cavity escapes and go to the blood stream and may form emboli. 4. Patient teaching when on anticoagulant: 3. Peripheral Vascular Diseases (PVD) i. Observe for bleeding (sign of anticoagulant toxicity) Such as varicose veins, deep vein thrombosis (DVT) ii. Use soft toothbrush, electric razor (since blood is thin) 4. Abdominal surgery iii. Do not take aspirin with Coumadin (has antiplatelet effect 5. Immobility and doubles anticoagulation effect) Signs and Symptoms of Pulmonary Embolism iv. Avoid prolonged sitting or standing (promote blood stasis) ✓ Restlessness – cardinal / initial sign v. Stop smoking ✓ Dyspnea Independent Learning! ✓ Stabbing chest pain You may use the following link for reference: L. Chronic Obstructive Pulmonary Disease ✓ Cyanosis Pulmonary Embolism: A disease state characterized by airflow limitation that is not ✓ Tachycardia https://youtu.be/5FFQa1fiJ2k fully reversible associated with abnormal inflammatory ✓ Anxiety Thrombectomy: response of the lungs to noxious stimuli ✓ Diaphoresis https://youtu.be/lWfpDbRfcvM Classification of COPD ✓ Dysrhythmia 1. Chronic Bronchitis Medical Management of Pulmonary Embolism Disease of the airway defined as the presence of cough and 1. Oxygen therapy sputum for at least a combined total of 3 months in each of 2 2. Pharmacologic treatment consecutive years a. Anticoagulant – Heparin IV (2 wks) then Coumadin (3-6mos) 2. Emphysema A disease of the airways characterized by destruction of the Antidotes for Heparin and Coumadin walls of over-distended alveoli. Protamine sulfate helps in neutralization of heparin. It should Can be inherited by alpha1 – antitrypsin deficiency. be administered IV in 0.25 to 0.375 mg per 100 units of Heparin. A 1 to 2 mg IV dose of Vitamin K is used to reverse the action of warfarin (Coumadin). b. Thrombolytics – Urokinase & streptokinase for breakdown of blood clots. 3. Surgical treatment a. Surgical embolectomy – surgical removal of embolus b. Transvenous catheter embolectomy – manual removal of embolus in the venous system using a catheter. Causes of COPD Nursing Management for Pulmonary Embolism 1. Smoking – common and leading cause 1. Instruct early ambulation post-operatively if surgical procedure is 2. Passive smoking done (promote circulation preventing embolism). 3. Occupational exposure 2. Oxygen therapy 4. Respiratory Tract Infections (RTI) 5. Genetic abnormalities such as chest wall deformities. Signs and Symptoms of COPD Pathophysiology of Chronic Bronchitis Hypercapnia is the increase partial pressure of CO2 (PaCO2) which is similar to Cor Pulmonale or Pulmonary Heart Failure because it both due to Chronic Bronchitis vs. Emphysema pulmonary arterial Since patients with Chronic Bronchitis experience DOB hypertension because of mucosal edema and hypersecretion of the airways, cyanosis is observed due to overall tissue hypoxia; hence we call them the BLUE BLOATERS. On the other hand, emphysema patients are termed the PINK PUFFERS because they distinctly suffer from ‘air-trapping’ Pathophysiology of Emphysema leading to hyperventilation. With hyperventilation, sufferers are able to maintain adequate O2 levels in the blood hence cyanosis which would suggest hypoxia is not imminent. Bronchitis Notes: Bronchitis is formed because of the inflamed mucus and smooth muscle together with the formation of excess mucus. To manage, bronchodilators may help to relax and smoothen the bronchi and bronchioles as it dilates to open more airway efficiently. Emphysema Notes: Inspiration is normal but expiration is the only problem as the air recoils due to constricted alveolar walls and entrapment of mucus plug. Elastase is an enzyme that breaks down elastin while Antielastase counteracts Oscillating Positive Expiratory elastase by helping the production of elastin. Both enzymes must be equal to ensure equilibrium or homeostasis but because of imbalance wherein elastase Pressure (OPEP) therapy increases than antielastase, it leads to destruction of Elastin which is important may help as it allows alveoli protein that allows alveoli to fully inflate and fully recoil. If that happens, air walls expand while adding entrapment occurs and retention of CO2 which may inhibit to blow off because positive pressure to mobilize there is also bronchospasm filled with mucus. mucus out. Diagnostic Test for COPD Surgical Management for COPD 1. Pulmonary Function Test 1. Bullectomy 2. Arterial Blood Gases (ABGs) Surgical excision of bullae (enlarged airspaces that do not 3. X-ray and CT scan may be performed but rarely done contribute to ventilation but occupy space in the lungs) in a 4. Screening for alpha1 – antitrypsin deficiency patient with bullous emphysema. 2. Lung Transplantation Medical Management for COPD 1. Risk reduction Nursing Management for COPD STOP smoking 1. Instruct pursed-lip breathing for emphysema 2. Pharmacologic treatment Allow full expansion of bronchioles). a. Bronchodilators 2. Oxygen therapy To relieve bronchospasm and reduce airway obstruction 3. Plan and implement adequate rest periods. E.g., Salbutamol (Ventolin), Aminophylline (Theophylline), COPD patients frequently experiencing body malaise. Bricanyl (Terbutaline) 4. Increase fluid intake b. Expectorants To compensate dehydration tendencies and allow mucus to If productive cough to expel mucus like Guaifenesin be thin for easy expectoration. c. Antitussives 5. Chest Physiotherapy (CPT) as necessary Cough suppressants since too much coughing is 6. Avoid SMOKING exhausting. 7. Proper positioning – semi or high Fowler’s position E.g., Codeine To improve ventilation of lungs. d. Antihistamine – if respiratory allergic reaction e. Corticosteroids – to reduce inflammation M. Asthma f. Antibacterial – if causation is bacterial infection A chronic inflammatory disease of the airways that causes airway 3. Oxygen therapy hyper-responsiveness, mucosal edema and mucus production. For clients with emphysema, do not give high O2 It is largely reversible, either spontaneously or with treatment concentration. The drive for breathing will be depressed. compare to obstructive lung diseases 4. Diet  Calorie,  CHON (protein),  CHO (carbohydrate) in order Causes of Asthma to provide strength and prepare client for tissue repair. 1. Allergens 5. Chest Physiotherapy (CPT) 2. Respiratory Tract Infections (RTI) Percussion, vibration and postural drainage to loosen airway 3. Air pollution secretion to easily expectorated. 4. Active / passive smoking Signs and Symptoms of Asthma N. Bronchogenic Carcinoma (Lung Cancer) ✓ Wheezing It arises from a single-transformed lung epithelial cells where in ✓ Cough which carcinogens binds to and damages it resulting to cellular ✓ Difficulty of Breathing (DOB) changes, abnormal cell growth and eventually malignant cells. ✓ Chest tightness ✓ Tachypnea Causes of Lung Cancer ✓ Nasal flaring 1. Smoking ✓ Restlessness 2. Asbestosis ✓ Diaphoresis (excessive sweating) 3. Chronic Pulmonary Obstructive Diseases (COPD) ✓ Cold, clammy skin 4. Pulmonary Tuberculosis (PTB) ✓ Pallor, cyanosis 5. Heredity ✓ Exhaustion Signs and Symptoms of Lung Cancer Diagnostic Test for Asthma Cough: hacking, non-productive, thick, purulent, blood-tinged 1. ABGs and pulse oximetry Wheezing 2. Physical examination Dyspnea Recurring fever Medical Management for Asthma Chest and shoulder pain 1. Pharmacologic treatment Regional lymph nodes a. Long-acting medications Hoarseness o Corticosteroids (Prednisone) Dysphagia o Bronchodilator (Theophylline) Neck edema o Antileukotriene (Montelukast) Hemoptysis b. Short-acting medications o Bronchodilatoor (Salbutamol) Classifications of Lung Cancer 2. Nebulization 1. Squamous cell carcinoma – with good prognosis 3. Oxygen therapy 2. Adenocarcinoma – with good prognosis 3. Oat cell carcinoma – with poor prognosis Nursing Management for Asthma 4. Undifferentiated – with poor prognosis 1. Remove, avoid, and prevent known allergens that causes acute attacks Diagnostic Test for Lung Cancer 2. Oxygen therapy 1. Chest X-ray 3. Nebulize, as ordered 2. CT scan 4. Increase fluid intake once stable 3. Bronchoscopy 5. Proper positioning 4. Fine needle aspiration biopsy 6. Advise adequate rest periods  Warning Signs to Majority of Cancers Medical Management for Lung Cancer 1. Surgery Change in bowel / bladder habits (common in colon cancer) a. Pneumonectomy (removal of an entire lung) A sore that does not heal (common in skin cancer) b. Lobectomy (removal of the lung lobe) Unusual bleeding or discharges (common in cervical cancer) c. Segmentectomy (removal of a respiratory organ) Thickening or lump in the breast or elsewhere (common in breast cancer) d. Wedge resection (removal of small lung triangular tissue) Indigestion or difficulty in swallowing (common in gastric cancer) Obvious change in warts or moles (common in skin cancer) Nagging cough or hoarseness (common in lung and laryngeal cancer) Unexplained anemia (common in blood cancer or leukemia) Sudden unexplained weight loss (common in liver cancer) O. COVID-19 COVID-19 is the infectious disease caused by the most recently discovered coronavirus. This new virus and disease were unknown before the outbreak began in Wuhan, China, in December 2019. COVID19 is now a pandemic affecting many countries globally. (WHO, 2020) A person-to-person kind of disease spreading through acquisition of infected small droplets via coughs, sneezes and speeches. It was 2. Radiation therapy claimed that the droplets are relatively heavy hence settling of 3. Chemotherapy viruses on air is not expected or more likely come to the ground upon 4. Palliative therapy release from an infected person. The time between exposure to COVID-19 and the moment when Nursing Management for Lung Cancer symptoms start is commonly around five to six days but can range 1. Maintain airway patency from 1 – 14 days. (WHO, 2020) 2. Oxygen therapy 3. Deep Breathing Exercises (DBE) Signs and Symptoms of COVID-19 4. Protection from infection ✓ Flu-like initial symptoms, chiefly fever, cough and tiredness 5. Adequate nutrition ✓ Body pain 6. Quit SMOKING ✓ Nasal congestion 7. Early detection and screening ✓ Headache 8. Psychological Support ✓ Conjunctivitis ✓ Sore throat - Diarrhea ✓ Loss of taste or smell ✓ Skin rashes or discoloration Special Consideration to COVID-19 Together Let’s Beat COVID-19! People of all ages who experience fever and/or cough The world nowadays appreciates the role of nurses as health associated with difficulty breathing/shortness of breath, chest educators; with the advancing technology let us help spread information that pain/pressure, or loss of speech or movement should seek medical will save more lives. Below are health-focused video links in regards to attention immediately. If possible, it is recommended to call the health COVID-19 particularly Overview of the COVID19, Ways to Prevent care provider or facility first, so the patient can be directed to the right COVID19 and Importance of Compliance to Minimum Health Standards: clinic. https://www.facebook.com/gmapublicaffairs/videos/904300976757648 https://www.facebook.com/watch/?v=524728894850866 Diagnostic Test for COVID-19 https://www.facebook.com/watch/?v=1456308737912198 1. Nasal swabbing 2. Chest radiologic examination Medical Management for COVID-19 1. No specific pharmacologic treatment yet. Researchers, currently run tests for variety of possible treatments. a. Remdesivir – an FDA-granted antiviral for emergency use as to treat or palliate severe symptoms of COVID-19. b. Dexamethasone – aids in supplemental oxygen support or mechanical ventilation. 2. Palliative-Supportive Care a. Pain relievers (ibuprofen or acetaminophen) b. Cough syrup (mucolytic and/or antitussives) c. Rest d. Increase fluid intake Note: no evidence yet that ibuprofen or other nonsteroidal anti- inflammatory drugs (NSAIDs) need to be avoided. Nursing Management for COVID-19 1. Early detection and screening (including travel history-taking) 2. Wash hands regularly and maintain social distancing. 3. Monitor vital signs particularly body temperature and respiratory rate. 4. Ensure adequate oxygen saturation as to avoid risks of hypoxia. 5. Institute respiratory isolation such as proper disposal of patient’s Prepared by: airway secretions and use of protective masks. DHAVE KIEZER L. ESGUERRA, SN 6. Maintain adequate nutrition and exercise. Future RN, MD 7. Supportive psychological support and health education.