Respiratory Disorders.pdf

Nursing care of conditions related to the respiratory system Learning Objectives: At the end of this chapter you will be able to: Recognize and evaluate the major symptoms of respiratory dysfunction by applying concepts from the patient’s health history and ph...

Nursing care of conditions related to the respiratory system Learning Objectives: At the end of this chapter you will be able to: Recognize and evaluate the major symptoms of respiratory dysfunction by applying concepts from the patient’s health history and physical assessment findings. Identify the diagnostic test used to evaluate respirator function and related nursing implications. Nursing assessment, planning and management for these related of respiratory conditions.  Anatomic and Physiologic Overview The respiratory system is composed of the upper and lower respiratory tracts. Together, the two tracts are responsible for ventilation (movement of air in and out of the airways). The upper respiratory tract, known as the upper airway, warms and filters inspired air so that the lower respiratory tract (the lungs) can accomplish gas exchange or diffusion. Gas exchange involves delivering oxygen to the tissues through the bloodstream and expelling waste gases, such as carbon dioxide, during expiration. The respiratory system depends on the cardiovascular system for perfusion, or blood flow through the pulmonary system (Porth, 2015). The respiratory system. A. Upper respiratory structures and the structures of the thorax. B. Alveoli. C. A horizontal cross-section of the lungs. Anterior view of the lungs. The lungs consist of five lobes. The right lung has three lobes (upper, middle, lower); the left has two (upper and lower). The lobes are further subdivided by fissures. The bronchial tree, another lung structure, inflates with air to fill the lobes. Management of Patients with Upper Respiratory Tract Disorders  Acute Sinusitis Acute Sinusitis an infection of the mucus membranes that line the paranasal sinuses. 5 subtypes: classification by duration Acute (< 4 weeks; generally, results from a common cold) Subacute (4 - 8 weeks) Chronic (> 3 months; follows when there is persistent bacterial infection) Allergic (accompanies allergic rhinitis) Hyperplastic sinusitis (a combination of purulent acute sinusitis and allergic sinusitis or rhinitis) 60 % of the cases are caused by bacterial organisms: Streptococcus pneumonia Haemophilus influenzae. Clinical manifestations Pain in the upper molar or pressure over the affected sinus area, nasal obstruction ,fatigue, green drainage in the oropharynx , fever, and headache Ear pain, sense of fullness Decreased sense of smell Sore throat Early morning periorbital edema Cough that worsens when patient is in supine position (if 2 symptoms, rules out bacterial sinusitis; 4 or more suggests it) Medical Management Antibiotic therapy Nasal decongestants or nasal saline spray Oral decongestants, antihistamines Saline irrigation (if s/s continues > 7 - 10 days the patient may need to be irrigated and hospitalization may be required) Nursing Management : Teach patient about early signs of a sinus infection and recommend preventive measures such as: Avoiding contact w/ people who have URI’s. Instruct patient about methods to promote drainage of the sinuses e.g., steam inhalation, warm compress, air humidification, and warm fluid intake. Avoid swimming, and air travel during the infection. Patient must be advised to stop smoking. Teach the patient about the side effects of overuse nasal spray that may cause rebound congestion. Explain to the patient that fever, severe headache and nuchal rigidity are signs of potential complications.  Chronic Sinusitis It is a result of prolonged inflammation or repeated or inadequately treated acute sinusitis infection. Organisms are the same as that of the acute sinusitis. In immunocompromised patients are at increased risks for developing fungal sinusitis. Clinical Manifestations: Impaired mucociliary clearance & ventilation Cough Chronic hoarseness Chronic headaches in the perioperbital area Snoring Sore throat Adenoidal hypertrophy Periorbital edema Facial pain Medical Management The same as acute sinusitis. Antimicrobial agents Decongestants Antihistamines Saline spray Heated mist Nursing Management Patient is instructed to blow her nose gently and use tissue to remove nasal drainage. Increase environmental humidity (hot shower, steam bath) Increase oral fluid intake Apply local heat Elevate head of bed  Acute Pharyngitis It is a sudden inflammation of the pharynx that is more common in patients younger than 25 years. Primary symptom: sore throat Causes: Adenovirus influenza, Herpes simplex virus A beta-hymolytic streptococci (more virulent bacteria) Clinical Manifestations: Fiery-red pharyngeal membrane and tonsils Lymphoid follicles that are swollen and flecked w/ white – purple exudate Enlarged and tender cervical lymph nodes No cough Fever Malaise and sore throat Medical Management: Bacterial pharyngitis – antibiotics Viral pharyngitis - no specific treatment. Instruct patient to gargle with warm salt water several times a day Take anti-inflammatory drugs or medications, such as acetaminophen, to control fever. Warn patient about excessive use of anti-inflammatory lozenges or sprays may make a sore throat worse. Pharmacologic management antibiotics (for bacterial pharyngitis only) Analgesics. Nutritional therapy: soft or liquid diet, cool beverages and patient is encouraged to drink as much fluid as possible  Tonsillitis Tonsillitis is an inflammation of the tonsils most commonly caused by viral or bacterial infection. Nursing goals Maintain open airway Restore function Prevent/manage complications Post operative Nursing management:  Continuous nursing observation is required in the immediate postoperative and recovery period because of significant risk of hemorrhage  The nurse should assess for the following to detect hemorrhage: - Bleeding from the mouth or nose - Frequent swallowing - Vomiting bright red or dark brown blood Put the patient on supine position with head turned. Nurse must not remove oral airway until the patient’s gag and swallowing reflexes has returned. Apply ice collar to the neck. Provide tissues and a basin for expectoration of blood and mucus.  Teaching patient self-care: Patient and family must understand the signs and symptoms of hemorrhage. Patient is instructed to refrain (stop) from too much talking and coughing. A liquid and semi liquid diet is given for several days. The patient should avoid spicy, hot, acidic, or rough foods. The nurse instructs the patient to avoid vigorous tooth brushing or gargling, since these actions could cause bleeding.  Laryngitis Laryngitis Inflammation of the larynx. Often occurs as a result of voice abuse or exposure to dust, chemicals, smoke, and other pollutants or as part of a URI. Cause: Virus (most common) and bacteria. Laryngitis is often associated with allergic rhinitis or pharyngitis. Onset of infection may be associated with sudden temperature changes, dietary deficiencies, malnutrition, or an immuno- suppressed state. Clinical Manifestations: Aphonia (complete loss of voice). Persistent hoarseness. Sudden onset of made worse by cold dry wind throat feels worse in the morning and improves when the patient is indoors or in a warmer climate. Dry cough and a dry sore throat that worsens in the evening hours. Medical management of acute laryngitis: Resting the voice. Avoiding irritants (e.g., smoking). Inhaling cool steam or an aerosol. Antibiotics if cause is bacterial in origin. Nursing Management: Instruct patient to rest the voice Maintain a well humidified environment Expectorants Daily fluid intake of 2-3 L to thin secretions Report signs of complications such as loss of voice, sore throat that makes swallowing difficult, hemoptysis and noisy respirations Caring for Clients with Lower Respiratory Disorders  I. Acute Bronchitis Inflammation of bronchial mucous membranes; tracheobronchitis. – Cause: Bacterial and fungal infection; chemical irritation. – Diagnostics: Sputum cultures; chest film – Signs/Symptoms: (Initial) Non-productive cough, fever, malaise; (Later) blood-streaked sputum, coughing attacks; inspiratory crackles. – Treatment: Antipyretics; expectorants; antitussives; humidifiers; broad-spectrum antibiotics.  Nursing Process Assessment Patient may manifest: ◾Wheezes/crackles on auscultation. ◾ Subcostal retraction. ◾ Nasal flaring. ◾ Presence of cough (can be severe enough at times to injure the chest wall, may be hang on more than 2 weeks and may be dry or rarely produce phlegm). ◾ Increase RR above normal range.  Nursing Interventions ◾Position head midline with flexion on appropriate for age/condition ◾Rationale: To gain or maintain open airway ◾Elevate HOB (semi- fowler) ◾Rationale: To decrease pressure on the diaphragm and enhancing drainage ◾Observe S/S of infections ◾Rationale: To identify infectious process ◾Auscultate breath sounds & assess air movement ◾Rationale: To ascertain status & note progress ◾Turn the patient q 2 hours ◾Rationale: To prevent possible aspirations ◾Instruct the patient to increase fluid intake ◾Rationale: To help to liquefy secretions and expectoration of thick sputum. ◾ Demonstrate effective coughing and deep - breathing techniques by Using diaphragmatic breathing. ◾Rationale: To maintain patent airway. ◾ Keep back dry ◾ Rationale: To prevent further complications ◾ Demonstrate chest physiotherapy, such as bronchial tapping when in cough, proper postural drainage. ◾Rationale: These techniques will prevent possible aspirations and prevent any untoward complications ◾ Administer bronchodilators if prescribed. ◾Rationale: More aggressive measures to maintain airway patency.  II. Pneumonia Etiology: – Acute infection – Radiation therapy – Chemical ingestion, inhalation – Bacteria Steptococcus pneumoniae – Virus – Fungus – Aspiration (stroke victims) – Artificial Ventilation (VAP) Ventilator-associated pneumonia – Hypostasis  Pneumonia Risk factors: – Very Young – Elderly – Hospitalized – Intubated – Immunocompromised Prevention – Pneumococcal vaccine – Flu vaccine – Coughing and deep breathing – Hand washing – Frequent mouth care, continuous suction for VAP (Ventilator-associated pneumonia)  Pneumonia – Diagnostic tests: Chest film Blood count Sputum C & S (culture and sensitivity) – Signs/Symptoms Chest pain Fever, chills Cough, dyspnea Yellow, rusty, or blood-tinged sputum Crackles, wheezes Malaise  Pneumonia Complications – Pleurisy inflammation of the pleurae – CHF – Empyema collection of pus in pleural cavity – Pleural effusion – Atelectasis partial or complete collapse of the lung – Septicemia blood poisoning, caused by bacteria or their toxins Signs and Symptoms in Elderly – New-Onset Confusion Lethargy Fever Dyspnea  Collaborative Problems Continuing symptoms after initiation of therapy Shock Respiratory failure Atelectasis Pleural effusion Confusion Superinfection  Pneumonia Treatment: – Antibiotic (bacterial) PO or IV – Hydration – Chest physical therapy – Analgesics/antipyretics – Antiviral medication (Zovirax) – Bronchodilators – Expectorants or cough suppressants – Oxygen therapy  Nursing Management Nursing Process: Care of the Patient with Pneumonia - Assessment Changes in temperature, pulse Secretions Cough Tachypnea, shortness of breath Changes in physical assessment, especially inspection, auscultation of chest Changes in CXR Changes in mental status Fatigue, dehydration,  Nursing Process: Care of the Patient with Pneumonia - Diagnoses Ineffective airway clearance Activity intolerance Risk for fluid volume deficient Imbalanced nutrition Deficient knowledge Nursing Process: Care of the Patient with Pneumonia - Planning Improved airway clearance Maintenance of proper fluid volume Maintenance of adequate nutrition Patient understanding of treatment, prevention Absence of complications  Improving Airway Clearance Encourage hydration; 2 to 3 L a day, unless contraindicated Humidification may be used to loosen secretions – By face mask or with oxygen Coughing techniques Chest physiotherapy Position changes Oxygen therapy administered if O2 saturation decreased to increase O2 Sa to normal range.  Other Interventions Promoting rest and maintain activity as tolerated Encourage rest, avoidance of overexertion Positioning to promote rest, breathing (Semi- Fowler’s) Avoid being overweight to decrease O2 demand Promoting fluid intake Encourage fluid intake to at least 2 L / day Maintaining nutrition Provide nutrition: enriched foods, fluids Patient teaching  III. Pleural Effusion Abnormal fluid collection between visceral, parietal pleurae. Pleural fluid not reabsorbed, may collapse lung Etiology Heart failure Liver or kidney disease Pneumonia TB CA = carcinoma cancer that forms in epithelial tissue Diagnostic tests Chest radiograph; CT scan  Pleural Effusion cont. Signs/Symptoms: – Fever; pain; dyspnea; – Dullness upon chest percussion; dim breath sounds; – Tachypnea; cough Treatment: – Antibiotics; analgesics; – Thoracentesis (long needle inserted to the thorax to remove fluid); chest tube. Pleural Effusion  Nursing Process for pleural effusion  Nursing diagnosis Risk for infection related to introduction of foreign object (thoracentesis needle, chest tube) into chest cavity. Impaired gas exchange related to ineffective breathing pattern. Anxiety related to diagnosis and therapeutic procedure (thoracentesis, chest drainage).  Nursing Process for pleural effusion  Nursing Interventions Administer oxygen as ordered. Record the client response to these treatments. Encourage to perform pulmonary exercise such as deep breathing, effective coughing and use of spirometry etc. Prepare the client for thoracentesis procedure and assist to physician during procedure and monitor complications associated with thoracentesis (bleeding, pain, dyspena and cyanosis).  Monitor client respiratory status frequently. Obtain ABGs if necessary. Ensure chest tube patency by close observation  IV. Tuberculosis Pathophysiology: Tuberculosis (TB) is an infectious disease caused by the Mycobacterium tuberculosis bacteria. TB primarily affects the lungs, although other areas, such as the kidneys, liver, brain, and bone, may be affected as well. Etiology: Crowded or poorly ventilated living conditions place people at risk for becoming infected with tuberculosis Prevention: Clean, well-ventilated living areas. Respiratory isolation to prevent spread to staff or other patients. Special isolation rooms are ventilated to the outside. Staff should wear special high-efficiency filtration masks when in the patient’s room. A regular surgical mask is not effective against TB.  If the patient must travel through the hallway for tests or other activities, the patient must wear a mask. Additional protective barriers, such as gowns, gloves, or goggles, are used when contact with sputum is likely. A vaccine against tuberculosis and is used in areas where TB is prevalent.  Signs and Symptoms: Active tuberculosis is characterized by: Chronic productive cough. Blood-tinged sputum. Drenching night sweats. A low-grade fever may be present. If effective treatment is not initiated, a downhill (decline) course occurs, with pulmonary fibrosis, hemoptysis, and progressive weight loss.  Complications: Spread of the tuberculosis bacilli throughout the body can result in: pleurisy, pericarditis, peritonitis, meningitis, bone and joint infection, genitourinary or gastrointestinal infection, infection of many other organs. Diagnostic test: Mantoux test : Used to determine the extent of TB lesion Acid- fast staining is the most common laboratory techniques used to identify tubercle bacilli in sputum Medical Management Pulmonary TB is treated primarily with antituberculosis agents for 6 to 12 months  Nursing Care: Promoting airway clearance Assess lung sounds, respiratory rate and effort, use of accessory muscles. Observe skin and mucous membranes for cyanosis. Monitor for confusion or changes in mental status. Monitor arterial blood gas values and pulse oximetry as ordered. Elevate head of bed or help patient to lean on over bed table. Position with good lung dependent (“good lung down”). Administer supplemental oxygen at 2 L/min unless ordered otherwise.  Teach patient relaxation exercises. Teach patient diaphragmatic and pursed-lip breathing. Encourage patient to stop smoking if patient is a current smoker. Turn patient q2h or encourage to ambulate if able. Encourage patient to cough and deep breathe every hour. Administer expectorants as ordered. Chest physiotherapy if needed. Place patient in Fowler’s or semi-Fowler’s position.  General Instructions Breathe slowly and rhythmically to exhale completely and empty the lungs completely. Inhale through the nose to filter, humidify, and warm the air before it enters the lungs. If you feel out of breath, breathe more slowly by prolonging the exhalation time. Keep the air moist with a humidifier.  Encourage patient to stop smoking if patient is a current smoker. Turn patient q2h or encourage to ambulate if able. Encourage patient to cough and deep breathe every hour. Administer expectorants as ordered. Chest physiotherapy if needed. Place patient in Fowler’s or semi-Fowler’s position. Chronic Obstructive Pulmonary Disease  Chronic Obstructive Pulmonary Disease COPD may include diseases that cause airflow obstruction (e.g., emphysema, chronic bronchitis) or any combination of these disorders. Other diseases such as cystic fibrosis, bronchiectasis, and asthma that were previously classified as types of COPD are now classified as chronic pulmonary disorders.  Chronic Bronchitis Chronic bronchitis, a disease of the airways, is defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years. In many cases, smoke or other environmental pollutants irritate the airways, resulting in inflammation and hypersecretion of mucus. Constant irritation causes the mucus-secreting glands to increase in number, leading to increased mucus production. Mucus plugging (closing) of the airway reduces ciliary function. Bronchial walls also become thickened, further narrowing the bronchial lumen  Figure Pathophysiology of chronic bronchitis as compared to a normal bronchus. The bronchus in chronic bronchitis is narrowed and has impaired air flow due to multiple mechanisms: inflammation, excess mucus production, and potential smooth muscle constriction (bronchospasm).  Emphysema In emphysema, impaired oxygen and carbon dioxide exchange results from destruction of the walls of over distended alveoli. There are two main types of emphysema: The panlobular (panacinar) Centrilobular (centroacinar)  Risk Factors for Chronic Obstructive Pulmonary Disease (COPD) Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases Passive smoking Occupational exposure — dust, chemicals Surrounding air pollution Genetic abnormalities, including a deficiency of alpha1- antitrypsin, an enzyme inhibitor that normally counteracts the destruction of lung tissue by certain other enzymes  Clinical Manifestations Although the natural history of COPD is variable, it is generally a progressive disease characterized by three primary symptoms: chronic cough, sputum production, and dyspnea on exertion. As COPD progresses, dyspnea may occur at rest. Weight loss is common As the work of breathing increases over time, the accessory muscles are recruited to breathe. Patients with COPD are at risk for respiratory insufficiency and respiratory infections, which in turn increase the risk of acute and chronic respiratory failure. In patients with COPD that has a primary emphysematous component, chronic hyperinflation leads to the “barrel chest”.  Assessment and Diagnostic Findings Obtain a thorough health history Pulmonary function studies Spirometry is used to evaluate airflow obstruction Arterial blood gas measurements High-resolution CT scan may help in the differential diagnosis Screening for alpha1-antitrypsin deficiency  Medical Management Risk Reduction Smoking cessation is the single most cost-effective intervention to reduce the risk of developing COPD and to stop its progression. Pharmacologic Therapy Bronchodilators relieve bronchospasm. Corticosteroids Although inhaled and systemic corticosteroids may improve the symptoms of COPD. A short trial course of oral corticosteroids may be prescribed. Other pharmacologic treatments that may be used in COPD include alpha1-antitrypsin augmentation therapy, antibiotic agents, mucolytic agents, antitussive agents, vasodilators. Vaccines may also be effective. Influenza vaccines and Pneumococcal vaccination Oxygen Therapy  Surgical Management Bullectomy: surgical removal of a bulla, which is a dilated air space in the lung parenchyma measuring more than 1 cm Lung Volume Reduction Surgery: Treatment options for patients with end-stage COPD. Lung Transplantation  Nursing Management Nursing diagnosis: Impaired gas exchange and airway clearance due to chronic inhalation of toxins and ventilation–perfusion inequality. Goal: Improvement in gas exchange Nursing Interventions 1. Evaluate current smoking status, educate regarding smoking cessation, and facilitate efforts to quit. 2. Evaluate current exposure to occupational toxins or pollutants and indoor/outdoor pollution. 3. Emphasize primary prevention to occupational exposures. This is best achieved by elimination or reduction of exposures in the workplace. 4. Administer bronchodilators as prescribed. 5. Instruct and encourage patient in diaphragmatic breathing and effective coughing. 6. Administer oxygen by the method prescribed. Expected Outcomes: Reports a decrease in dyspnea Shows an improved expiratory flow rate Nursing diagnosis: ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough, bronchopulmonary infection, and other complications GOAL: Achievement of airway clearance Nursing Interventions: 1. Adequately hydrate the patient. 2. Teach and encourage the use of diaphragmatic breathing and coughing techniques. 3. Assist in administering nebulizer. 4. If indicated, perform postural drainage with percussion and vibration in the morning and at night as prescribed. 5. Instruct patient to avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperature, and fumes. 6. Teach early signs of infection that are to be reported to the clinician immediately: increased sputum production, change in color of sputum, increased thickness of sputum, increased shortness of breath, tightness in chest, or fatigue, increased coughing and fever or chills 7. Administer antibiotics as prescribed. 8. Encourage patient to be immunized against influenza and Streptococcus pneumoniae. Expected Outcomes Verbalizes need to drink fluids Demonstrates diaphragmatic breathing and coughing  Nursing diagnosis: Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction, and airway irritants GOAL: Improvement in breathing pattern Nursing Interventions: 1. Teach patient diaphragmatic and pursed-lip breathing. 2. Encourage alternating activity with rest periods. Allow patient to make some decisions (bath, shaving) about care based on tolerance level. 3. Encourage use of an inspiratory muscle trainer if prescribed. Expected Outcomes Shows signs of decreased respiratory effort and paces activities  Nursing diagnosis: Activity intolerance due to fatigue, hypoxemia, and ineffective breathing patterns GOAL: Improvement in activity tolerances 1. Support patient in establishing a regular regimen of exercise using treadmill and exercise bicycle, walking, or other appropriate exercises a. Assess the patient’s current level of functioning and develop exercise plan based on baseline functional status. b. Suggest consultation with a physical therapist or pulmonary rehabilitation program to determine an exercise program specific to the patient’s capability. Have portable oxygen unit available if oxygen is prescribed for exercise. Expected Outcomes Performs activities with less shortness of breath Collaborative problem Monitoring and Managing Potential Complications The nurse must assess for various complications of COPD, such as life-threatening respiratory insufficiency and failure, as well as respiratory infection and chronic atelectasis, which may increase the risk of respiratory failure. The nurse monitors for cognitive changes (personality and behavioral changes, memory impairment), increasing dyspnea, tachypnea, and tachycardia, which may indicate increasing hypoxemia and impending respiratory failure. Assess for signs and symptoms of right-sided heart failure, including peripheral edema, ascites, distended neck veins, crackles, and heart murmur. 23/01/1438 74