Respiratory Alterations .pdf

Altered Respiratory Function COPD, Asthma, Emphysema, Tuberculosis, Pneumonia, Sinusitis, URI Upper Respiratory Problems Epistaxis ○ Etiology Digital manipulation Trauma Foreign bodies...

Altered Respiratory Function COPD, Asthma, Emphysema, Tuberculosis, Pneumonia, Sinusitis, URI Upper Respiratory Problems Epistaxis ○ Etiology Digital manipulation Trauma Foreign bodies HTN - BP is too strong, causes bleeding Topical steroid - nasal spray Blood dyscrasia - caused by low platelets, Hgb, anemia Septal perforation - caused by piercings, drugs Unknown ○ Management Etiology and location of bleeding will dictate management in most cases Simple measures can control most epistaxis Simple pressure (pinch soft part of nose) Topical vasoconstrictor - neosynephrine Packing Refer for repeated epistaxis Allergic rhinitis ○ Acute: < 6 weeks ○ Chronic: persistent ○ seasonal or perennial (most days) ○ Frequency Episodic Intermittent = < 4 days a week or < 4 weeks per year Persistent = > 4 days a week or > 4 weeks per year ○ Etiology Exposure to allergen, mast cells, basophils Release of histamine, cytokines, prostaglandins and leukotrienes. symptoms → sneezing, itching, rhinorrhea, congestion Usually after 4-8 hrs. Exposure, inflammatory cells enters nasal tissue causing and maintaining inflammation ○ Physical Exam Nasal congestion Turbinate hypertrophy, boggy, pale Clear, tenacious drainage Throat red with post nasal drip and can cause coughing and hoarseness Lung exam Ears should look normal ○ Diagnostic Tests  CBC: Eosinophils and basophils may be elevated Allergy testing: skin testing or antigen-specific immunoglobulin E testing ○ Treatment/Management Minimize symptoms Decreases inflammation of nose/sinuses Minimize medicine use Minimize side effects Increase tolerance of triggers Normal lifestyle ○ Medications Antihistamines: 2nd generation of antihistamine preferred Zyrtec, Clarinex, Allegra Generally safe Dry secretions, stop itching and sneezing NO help with congestion Decongestant: caution with cardiovascular disease, HTN, diabetes, BPH, liver and renal disease. may cause rebound rhinitis, CNS reaction Pseudoephedrine, topical nasal spray: phenylephedrine, dristane Nasal Steroids Nasacort, nasonex, beconase (2 sprays each nostril q 12 hrs), flonase (1 spray each nostril q 12 hrs Correct use: gently blow nose, tilt head forward, clos off one nostril, use left hand to spray right nostril, point away from septum, gently sniff Immunotherapy Allergy injections ○ Develop defensive reaction ○ Given monthly for at least three years ○ Useful in pts with: medication resistance, medication intolerance, perennial medication requirements Acute Viral Rhinitis - Common Cold (URI) ○ Physical exam/findings Cough Lungs: may have rhonchi that clear with cough Throat = red - lots of post nasal drip Ear (TM) should look normal Swollen lymph nodes common Nasal mucosa is red and inflamed Sinus drainage = thick, may be yellow Afebrile or low grade fever ○ Treatment Educate patient about viral vs. bacterial infection Decongestant Cough medication Throat lozenges  OTC med for sore throat, headache, body aches antiviral : Tamiflu NO ANTIBIOTICS Watch out for secondary infection which antibiotic may be needed Influenza- Flu ○ Highly contagious 5-20% population per year contracted 20,000 death per year/200,000 hospitalized yearly Season = sept to april (peak nov ○ Types Influenza A Can infect animals and humans Can mutate and spread quickly Influenza B and C - only infect humans Can change over time, and adapt to new hosts or environment Transmission Animal-human from direct contact Fecal contaminated water or contaminated surface Peak transmission risk starting at 1 day prior to onset of symptoms and continue for 5-7 days Incubation = 1 - 4 days GOAL is to prevent Pneumonia! Sinusitis ○ An inflammation of the sinus mucosa blocks the openings in the sinuses this prevent the mucus drain into the nose ○ 10% associated with dental abcess ○ Allergies are the main cause ○ Self limited in about 2 weeks ○ Can develop into secondary infection Bacterial - streptococcus pneumonia, H. influenza, Moraxella cataralis ○ Presentations Areas: frontal, ethmoid, maxillary Acute: begins within 1 week of URI and lasts less than 4 weeks Subacute: 4-12 weeks Chronic: longer than 12 weeks ○ Physical exam findings Red nasal mucosa Tender sinuses Clear lungs May have swollen lymph nodes Throat without redness Normal ears ○ Diagnostic Tests/Treatment  **usually none, but x-ray and ct can be done Allergies Loratadine (claritin) Fexofenadine (allegra) Nasal steroid spray (nasacort, fluticasone/flonase) Decongestant must be used for ALL sinusitis Afrin nasal spray ok short term Sudafed Other: warm moist cloth over face, OTC medication for headache ○ Chronic Sinusitis Longer than 12 weeks : polyps? Deviated septum? Allergic rhinitis? Treatment: surgery, allergy control pharyngitis - inflammation of pharynx ○ Etiology Acute bacterial Acute viral Chronic - more likely noninfectious ○ Findings Throat: mildly red to beefy red Possible exudate Strep: white patches along with redness Palpable lymph nodes Normal ears Nasal mucosa pink Clear lungs ○ Viral pharyngitis **antibiotics only if bacterial Strep Penicillin (Erythromycin if allergic to PNC) ○ Treatment Viral -> symptom management, fluids, mouth care Bacterial -> antibiotic Amoxicillin, Zithromax Strep -> antibiotic Penicillin Erythromycin if allergic to PCN Culture: only if uncertain about diagnosis Lower Respiratory Problems Acute bronchitis ○ Symptoms 90% are viral Inflammation of the bronchi in LRT Cough up to 3 weeks with clear mucoid sputum  Fever, malaise, hoarseness, myalgia, dyspnea, and chest pain ○ Physical Exam/Treatment Normal to rhonchi, crackles, wheezes Treatment with cough suppressants, bronchodilator, and other as needed Goal relieve symptoms and prevent pneumonia Pneumonia ○ An acute inflammation of lung tissue due to infection ○ May result from inhaled infectious agents or agents transported to the lungs via the bloodstream ○ Types Community Acquired (walking pneumonia) Hospital-Acquired or Ventilator associated Aspiration pneumonia Opportunistic pneumonia ○ Signs/Symptoms: Fever, cough with or w/o sputum, chills, chest discomfort, possible SOB, elders (altered mental status) ○ Diagnostic tests: chest x-ray, Pulse oximetry, ABG’s, CBC, sputum culture ○ Physical Assessment May hear crackles, wheezing, rhonchi May hear increased dullness f hyperresonance on percussion Increased tactile fremitus Difficulty breathing/use of accessory muscles Cough Assess sputum Fever ○ Nursing Management Administer medications as ordered Assess respiratory status Elevate HOB Monitor I&O Handwashing Rehab- gradual increase in activity as tolerated ○ Medical: may need antibiotics/combination, oxygen, and fluids (3,000 cc every 24 hours) ○ Nursing Diagnosis = impaired gas exchange, activity intolerance, ineffective airway clearance Tuberculosis ○ Chronic, recurrent infectious disease that usually affects the lungs (but may affect any organ) ○ Slow-growing ○ Report positive case to public health agency ○ Pathophysiology TB nuclei enter the lungs and implant in an alveolus or respiratory bronchiole, usually in the upper lobe  As bacteria multiply, they cause a local inflammatory response This brings neutrophils and macrophages to the site These cells surround and engulf bacilli, attempting to prevent their spread If the immune system is adequate, scar tissue develops around the tubercle, and granuloma develops. At this time, the client is infected by M.tuberculosis, but does NOT develop TB disease ○ Signs/Symptoms Fatigue, anorexia, weight loss, low-grade afternoon fever, night sweats Cough - initially dry, progresses to productive of purulent/blood tinged sputum Dyspnea = late in disease Chest pain = late in disease **initial infection causes few symptoms and usually goes unnoticed until the TB test is positive or the lesions are seen on x-ray ○ Screening Purified protein derivative (PPD) skin test IGRA Blood test - Quantiferon (used in people who had received the BCG) Positive test indicated An infection and cellular response have developed It does NOT mean the client has active disease ○ Diagnostic Tests Sputum culture - test for bacillus, series of 3 early morning sputum specimens Chest x-ray - dense lesions in upper lobs (white patches) ○ Additional tests Liver and renal, visual acuity, audiometry ○ Physical Exam Vital signs: afternoon temperature Diminished lung sounds Labored breathing, dyspnea Cough: dry, may have purulent or blood tinged sputum ○ Medications Used to prevent and treat tuberculosis infection GOALS: Make the disease non-communicable to others Reduce symptoms Effect a cure in the shortest possible time Prophylactic Used to treat clients with a positive PPD, but no symptoms = Latent TB Single drug therapy ○ INH (isoniazid) 300 mg daily ○ 9-12 months daily Active Infection Initially treated with four medications for 2 months: ○ Rifampin (RIF) - hepatotoxicity, thrombocytopenia  ○ Isoniazid (INH) - hepatotoxic and can cause neuropathy ○ Pyrazinamide (PZA) ○ Ethambutol - may cause optic neuritis ○ Streptomycin - may cause ototoxicity Followed by 2 drugs for 4 months ○ Rifampin, isoniazid ○ Nursing care Maintain isolation per protocol 2-4 weeks until non affected Airborne precautions: negative pressure room, visitor with N95 Administer medications as ordered Note lab values Assist with ADLs Client education ○ Nursing Diagnosis Ineffective airway clearance Teach effective cough Encourage fluid intake ○ Nursing Interventions Teach patient Importance of drug therapy Where to get new supplies of medications What the medication is and its side effects Rationale for the medications and dosing schedule Provide written materials Increase activity gradually Encourage patient to perform activities Provide appropriate isolation mask when patient leaves room OBstructive diseases ○ Asthma - chronic inflammatory reactive airway disorder that causes the bronchial tubes to spasm Reversible!!! Intrinsic = may not know cause, usually follows respiratory infections Extrinsic = occurs in people with allergies Contact with allergen causes: Bronchospasm Constriction Mucosal edema hypersecretions Precipitating factors Infection (URI), temperature change, odors, stress, exercise, allergens, air pollution, medications (aspirin and NSAIDs, Beta-Blockers, ACE Inhibitors) Signs/Symptoms Vary in severity  Wheezing - not a true indicator of severity. Some mild case wheezes loudly, some severe cases have no wheezing due to marked decrease in air flow Cough & Dyspnea - sometimes cough is only indication of asthma Cyanosis Diagnostic Tests = pulmonary function, allergy testing, ABGs ○ Chronic Obstructive Pulmonary Disease (COPD) Complex conditions that contribute to airflow limitation A Chronic, slow progressing disorder characterized by stable phases interrupted by worsening symptoms (acute exacerbation) MAIN CAUSE = cigarette smoking! Airflow limitation, alteration of oxygen-carbon dioxide exchange Decreased oxygen, retention of CO2 Chronic bronchitis Excessive bronchial mucus secretion Characterized by productive cough lasting 3 or more months S/S: dyspnea, increases RR, excessive productive cough, thick, tenacious sputum Structural changes include ○ Atrophy of airways ○ Ciliary abnormalities ○ Inflammation (causes mucus production) ○ Bronchial wall thickening Emphysema Abnormal permanent enlargement of the air spaces distal to terminal bronchioles Accompanied by destruction of the bronchial walls Defining element = destructive process Consequences of airway changes: ○ Increased lung compliance Loss of elastic recoil Lungs become permanently over distended (barrel chest) ○ Increased airway resistance Small airways narrow or collapse on expiration Air becomes trapped in distal air spaces Over distended lungs press down on diaphragm (use of accessory muscles) ○ altered-carbon dioxide exchange Mild hypoxia Increases RR CO2 is produced faster than being eliminated S/S: dyspnea, increased RR, pursed lip breathing, barrel chest, use of accessory muscles  Diagnostic Tests for COPD Bronchoscopy ○ A lung test whereby the lungs can be visualized through a camera that is attached to a device called a bronchoscope ○ Inserted into airway through nose or mouth ○ Images of larynx, trachea and bronchioles can be seen directly ○ Purposes: to examine tissues or collect fluid that is secretes in lungs, determine the location and extent of lung damage, obtain a sample of lung tissue for further study, discover whether a tumor can be resected, diagnose bleeding. ABG’s note:(PO2 and PCO2) Chest-x ray (flattened diaphragms) Pulmonary function and spirometry tests ○ Evaluates patients lung volumes ○ Measures inspiratory and expiratory volume PFT in COPD Forced expiratory volume (FEV) - measure how much air a person can exhale during a forced breath. The amount of air exhaled may be measured during the first (FEV1), second (FEV2) and/or third seconds (FEV3) of the forced breath. Forced vital capacity-FVC - the total amount of air exhaled during the FEV test In COPD the ratio FEV1/FVC is lower than normal rate (60-90% of breath during first second) TLC: the most air one can inspire into the lungs Results Obstructive: asthma and COPD ○ FEV1 decreased due to air flow restricted ○ FVC may be decreased due to air trapping ○ FEV1/FVC ratio is decreased Restrictive: Fibrosis and Interstitial Lung Disease ○ TLC decreased ○ FEV1 and FVC decreased proportionally ○ FEV1/FVC remains normal Physical Exam Lung sounds Percussion - what do you hear? AP diameter Respiratory rate Use of accessory muscles Pursed lip breathing Tripod position Cyanosis Decreased fremitus  Weight Medical Management Inhalers - spacers improves delivery of inhaler meds ○ Bronchodilator inhalers Alupent Proventil (albuterol) ○ Inhaled corticosteroids Flovent (fluticasone) Advair (fluticasone) ○ Oral ○ Bronchodilators Theo-dur (Theophylline) Prednisone Complications of COPD/Nursing Management Polycythemia Vera - increased hemoglobin due to chronic hypoxia Cor Pulmonale - right sided heart failure due to pulmonary hypertension (emergency!) Nursing Management ○ Impaired gas exchange ○ Patient will: Demonstrate improved ventilation and oxygenation Exhibit arterial blood PO2, PCO2 levels at patients baseline Explain how and when to use oxygen therapy ○ Interventions Monitor ABGs Monitor pulse oximetry Assess need for supplemental O2 Provide O2 per order No more than 2L/NC or 26% venturi mask ○ Ineffective airway clearance Patient will Demonstrate adequate airway clearance Use effective methods of coughing Use broncho active medications correctly Interventions Teach patient effective coughing Encourage adequate PO fluid intake Pulmonary physiotherapy