Upper Airway Infections PDF

DISORDERS OF THE RESPITATORY SYSTEM: UPPER AIRWAY INFECTIONS Medical Management Correct administrations of nasal medications: RHINITIS...

DISORDERS OF THE RESPITATORY SYSTEM: UPPER AIRWAY INFECTIONS Medical Management Correct administrations of nasal medications: RHINITIS Instruct client to blow the nose before applying any A group of disorder characterized by inflammation of and medication into the nasal cavity irritation of the mucous membranes of the nose Keep the head upright May be acute or chronic, non allergic or allergic Spray quickly and firmly into each nostril away from the nasal septum and wait for 1 minute before administering Allergic Rhinitis: classified as seasonal rhinitis and is commonly the 2nd spray associated with exposure to airborne particles such as dust and The container should be clean after each use plant pollens VIRAL RHINITIS Seasonal Rhinitis: occurs during pollen season An acute inflammation of the mucous membranes of the nasal cavity characterized by nasal congestion, Personal Rhinitis: occurs throughout the year; allergen ps brought rhinorrhea, sneezing, sore throat, and general malaise by the household pets Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first Risk Factors part of the symptomatic phase Maternal smoking Cold cause by rhinoviruses are the most likely causative Living in areas of high pollution organisms tend to occur in the early fall and spring Higher socioeconomic status Exposure to indoor allergens as a child Clinical Manifestations Early introduction of food or formula as an infant Low grade fever A family history of allergies and/or asthma Nasal congestion Rhinorrhea and nasal discharges Clinical Manifestations Halitosis Rhinorrhea Tearing watery eyes Nasal congestion and pain Sore throat Pruritus of the nose, roof of the mouth, throat, eyes, and ears Headache Medical Management Nursing Management Antihistamines Provide adequate fluid intake, rest prevention of chilling The most common treatment and are administered for Warm water salt gargles soothe the sore throat sneezing, pruritus, and rhinorrhea. Non-steroidal, anti-inflammatory drugs (NSAIDs) such ss aspirin or ibuprofen Cromolyn (Nasal Crom) Antihistamines: used to relieve sneezing, rhinorrhea, and Inhibits the release of histamine and other chemicals nasal congestion Petroleum Jelly: can soothe irritated, chapped, and raw Oral Decongestants Agents skin around the nares Use for nasal obstructions Guaifenesin (Mucinex): an expectorant that promotes removal of secretions Saline Nasal Spray Antiviral Medications (Amantadine and Rimantadine): Acts as a mild decongestant and can liquefy the mucus reduce the severity of symptoms and may reduce duration of the common cold Nursing Management Antibiotics: should not be used; inappropriate use has been Intranasal Ipratroplum: administered in each nostril 2 to 3 implicated in the development of organisms resistant to times per day for symptomatic relief of rhinorrhea therapy Avoid or reduce exposure to allergens and irritants such as Topical Therapy: delivers medication directly to the nasal dusts, mold, animal fumes, powders, sprays, etc. mucosa and its overuse can produce rhinitis medicamentosa Maintain the cleanliness of the environment at home and work or rebound rhinitis Saline nasal spray or aerosols may be helpful in soothing mucus Provide hand hygiene to prevent transmission of the virus membranes and softens the crusted secretions and removing Use of tissue for coughing and sneezing the irritants RHINOSINUSITIS Amoxicillin-Cluvanic Acid (Augmentin) An inflammation of the paranasal sinuses and nasal cavity The antibiotic of choice Uncomplicated rhinosinusitis occurs without extension of inflammation outside of the paranasal sinuses Intranasal Saline Lavage An effective therapy to reduce inflammation and help clear Acute Rhinosinusitis the passages of stagnant mucus Less than 4 weeks duration Decongestant or Nasal Spray Subacute Increase the patency of the osteomeatal unit and improve 4 to 12 weeks duration drainage of the sinuses ACUTE RHINOSINUSITIS Topical Decongestant Classified as acute bacterial rhinosinusitis or acute viral Should not be used for longer than 3 to 4 days sinusitis Usually follows a viral URI or cold, an unresolved viral or Antihistamine bacterial infection or an exacerbation of allergic rhinitis Given if there is allergic component Also a nasal congestion caused by inflammation, edema, and leads to obstruction of the sinus cavity Nursing Management Exposure to environmental hazards such as raw dust and Instruct client about the methods to promote drainage of chemicals may result in chronic inflammation of the nasal the sinuses including humidification of the air in the home passages and the use of warm compresses to relieve pressure Avoid swimming, diving, and air traveling during acute Clinical Manifestations infection Purulent nasal discharge accompanied by nasal obstruction or a Instruct client to stop smoking or using any form of combination of facial pain tobacco Cloudy or colored nasal discharge congestion, blockage, or Provide effective teaching methods in using nasal sprays stuffiness as well as localized or diffused headache to prevent side effects such as nasal irritation, nasal Tenderness to palpation over the infected sinus area; percussed burning, bad taste, and epistaxis using the finger, tapping lightly to determine weather the Avoid people with URIs patient experiences pain Explain to the client that fever, severe headache, and nuchal rigidity are signs of potential complications Diagnostic Findings CT Scan CHRONIC RHINUSINUSITIS May be indicated because this can is sensitive inflammatory It is diagnosed when the patient has experienced 12 weeks changes and bone destruction and identify anatomic variations or longer or t wo or more symptoms like mucopurulent that can guide sinus surgery if indicated drainage, nasal obstructions, facial pain or pressure fullness, or hyposmia Sinus Aspirate Also diagnoses with four or more episodes of ABRS occur Confirms the diagnosis of maxillary and frontal rhinosinusitis per year with symptoms of acute rhinosinusitis bet ween the episodes Flexible Endoscopic Mechanical obstruction of the frontsl, maxillary, and A culture techniques and swabbing of the sinuses have been used anterior ethmoid sinuses is the common cause of CRS for this purpose The obstruction prevents the adequate drainage of the nasal passages resulting to accumulation of secretions and Medical Management a bacterial growth Antibiotic Therapy Caused by both aerobic bacteria like S. aureus and Usually 7 days; to shrink the nasal mucosa, relieve pain, and anaerobic bacteria like Pepto streptococcus and treat the infection Fusobacterium Oral antibiotics are prescribed when the patient has ABRS that persist for last 10 days Clinical Manifestation Impaired mucocillary clearance ventilation Hoarseness of voice  Headache common in periorbital area and periorbital edema and After the operation: facial pain Immediately after the operation, the patient may feel nose Nasal congestion leading to mouth breathing blocked, this may be because of the dressing inside the nose Snoring and sore throat or some special plastic sheets called splints Symptoms are generally more pronounced in the morning after The dressing are removed 24 hours after the surgery but awakening plastic sheet may stay for longer time Instruct the patient not to blow the nose for the first 48 Digital Finding hours following operation X-Ray Administer ointments, nasal drops, and salt water sprays An inexpensive and readily available tool to assess disorders of after the operation the paranasal sinuses Some mucus and blood-stained fluid may drain from the nose for the first week or t wo following the operation CT Scan It is important to stay away from dusty and smoky The paranasal sinuses can identify the mucosal abnormalities environments while recovering and sinus obstruction Possible complications after the operation: Nasal Endoscopy Bleeding: a risk for any operation; very common for small Allows for visualization of the posterior nasal cavity, amounts of bleeding to come from the nose in the days nasopharynx, and sinus drainage following the operation; transfusion may be required if bleeding is extreme Medical Management Eye Problems: the sinuses are very close to the wall of the Antibiotic Therapy eye socket; sometimes minor bleeding can occur into the Usually 2 to 4 weeks to eradicate the bacterial growth eye socket and this is usually noticed as some bruising Oral antibiotics are prescribed when the patient has ABRS that around the eye persist for last 10 days PHARYNGITIS Amoxicillin-Cluvanic Acid A sudden painful inflammation of the pharynx, back The antibiotic of choice portion of the throat includes the posterior part of the tongue, soft palate, and tonsils Intranasal Saline Lavage Incidence of pharyngitis peaks during winter and early An effective therapy ro reduce inflammation and help clear the spring in regions that have warm summers and cold passages of stagnant mucus winters Spreads easily in the droplets of cough and sneezes, as well Decongestant or Nsasal Spray as unclean hands that have been exposed to the Can increase the patency of the osteo-meatal unit and improve contaminated fluids drainage of the sinuses The responsible viruses are adenovirus, influenza virus, and herpes simplex Topical Decongestant Group A beta hemolytic streptococcus triggers Should not be used for longer than 3 or 4 days inflammatory responds in the pharynx that results in fever, pain vasodilation, and edema leading to tissue Antihistamine damage Given if there is allergic component Clinical Manifestations Surgical Management Pharyngeal tonsils accompanied by swollen with white Functional Endoscopic Sinus purple exudate A minimal invasive surgical procedure that is associated with Enlarged and tender cervical lymph nodes reduced postoperative discomfort and improvement of quality Fever higher than 38 degrees Celsius of breathing Painful sore throat for 1 to 5 days after being exposed to Application of local anesthesia and the operation is performed streptococcus bacteria usually reports of malaise and inside the nose and requires no cuts on the patient's nose fever and nausea Diagnostic Findings CHRONIC PHARYNGITIS Rapid Antigen Detection Testing (RADT) A persistent inflammation of the pharynx Uses swabs that collect specimens from the posterior pharynx Most common in adults who are working in a dusty and tonsils surroundings, who used their voice to excess, suffer from chronic cough or habitually use alcohol and tobacco Throat Culture To determine the presence of bacteria and the type of antibiotic Hypertrophic: characterized by general thickening and to be used congestion of the pharyngeal mucous membrane Medical Management Strophic: probably a late stage of the first type Penicillin Usually treatment of choice Chronic Granular: characterized by numerous swollen lymph Penicillin V potassium is given for 5 days as a single injection follicles on the pharyngeal wall Oral forms are used more often than IV and are less effective and less painful than injections Clinical Manifestations For patients who are allergic to penicillin may be given Constant source of sense of irritation or fullness in the cephalosporins throat, mucus that collects in the throat and can be expelled by coughing and difficulty swallowing Clarithromycin and Azithromycin A sore throat that us worse with swallowing in the Given once daily for 3 days due to its long half life absence pharyngitis suggests the possibility of thyroiditis Cefpodoxime and Cefuroxime Medical Management 5 days of administrations to procpduce bacteriologic cures Nasal Congestion (Phenylephrine) Given to congest the obstructive pharynx Analgesics Medications Can be taken with 4 or 6 hours interval Antihistamine Decongestant Pseudoephedrine Prescribed orally every 4 to 6 hours Nursing Management Provide liquid or soft diet during the acute stage of the disease Aspirin or Acetaminophen Cool beverages, warm liquids, and flavored frozen desert such as Recommended for analgesic property ice pop can be soothing Instruct the client to drink as much as fluids as possible, at least Nursing Management 2-3 liters per day Instruct the client to avoid intake of alcohol Bed rest during febrile stage Avoid smoking Used tissues should be disposed properly to prevent the spread Avoid exposure to cold or to occupational pollutants of infection Advice the client to wear disposable mask The visitors should examine the skin once or t wice daily for Instruct the client to drink plenty of fluids possible rash because acute pharyngitis may be precede such as Saline gargle to relieve throat discomfort rubella Instruct client to have a warm saline gargle TONSILITIS Irrigating the throat may reduce spasm in the pharyngeal Tonsils are composed of lymphatic tissues and are situated muscles and relieves soreness of the throat on each side of the pharynx Apply an ice collar to relieve severe sore throat Inflammation of the facial or palatine tonsils and lingual Oral care may promote patient comfort and prevent the tonsils development of fissures of the lips and oral inflammation when bacterial infection is present Viral: common to adults Activity should resume 24 hours after the antibiotic therapy Avoid sharing utensils, glasses, napkins, and towels Bacteria: common to children (group A streptococcus) Cleaning the telephones after use and using of tissue to cough or sneeze and dispose it properly Clinical Manifestations Educating patient about self-care: Sore throat, fever Instruct the client to take an alkaline mouthwashes and Difficulty of swallowing warm saline solutions in coping with halitosis and thick Enlarged adenoids may cause mouth breathing, earache, and mucus draining ears, frequent head colds and foul-smelling breath Soft diet, avoid spicy, hot, acidic, and rough food Nasal obstruction brought by enlargement of the adenoids Avoid milk and milk products because they make removal of Position client on prone with head turned to the side to allow mucus more difficult drainage from the mouth and the pharynx, resulting to otitis Maintain good hydration media Avoid vigorous tooth brushing this may cause bleeding Rupture of the tympanic membrane due to infection Encourage the use of a cool mist vaporizer or humidifier in Inflammation of the mastoid cells causing mastoiditis home post-operatively The unresolved infection in the middle ears and a chronic low Instruct the patient to avoid smoking and heavy lifting or grade smoldering process can lead to permanent deafness exertion for 10 days Diagnostic Procedure LARYNGITIS Culture Inflammation of the larynx, often occurs as a result of Culturing of the tonsillar site for the presence of bacterial voice abuse or exposure to dust, chemical, smoke, and other infection pollutants The common pathogen is the GABHS Audiometric Assessment The onset of infection may be associated with exposure to To identify the hearing acuity if recurrent episode of otitis sudden temperature changes, dietary deficiency or an media is present immunosuppressed state Medical Management Clinical Manifestations Penicillin Therapy Hoarseness or complete loss of voice The first line of treatment Throat pain that feels worse in the morning and improves when the patient is in the warm places Cephalosporins Dry cough and sore throat that worsen in the evening hours If surgery is indicated: "Tickle" in the throat that is made worse by cold liquids Tonsillectomy or Adenoidectomy Indicated if the patient had a repeated episodes of tonsillitis Medical Management despite antibiotic therapy and to remove the hypertrophy of Corticosteroids (Beclomethasone) the tonsils and adenoids that cause obstructions and Reduces the inflammatory reactions obstructive sleep disorder Proton Pump Inhibitors (Omeprazole) Nursing Management Given once daily Provide post-operative care: Position client on prone with head turned to the side to allow Antibiotic drainage fro the mouth and the pharynx To reduce the infection cause by bacteria Maintain oral air ways until the patients gag reflex and swallowing reflex have returned Expectorant Administered analgesic if post-operative pain occurs If there is a secretions Note and notify the physician if the client vomits large amount of bright red blood and if the pulse rate and temperature rises Analgesics (Acetaminophen) Have the following ready on bed side for the examination of the To relieve the discomfort suture site: light, mirror, gauze, curved hemostats, waste basin Instruct the client to refrain from too much talking and Nursing Management coughing to eliminate throat pain Instruct the client to rest the voice and communicate through writing instead Avoid irritants, smoking, and maintain a humid environment  Instruct the client to increase the fluid intake BIPAP Inhaling cool steam or an aerosol To make breathing easier and results in lower average In case of acute phase of illness, if the client develops dysphagia air way pressure or odynophagia, instruct the client to eat soft foods such as gelatin, soups, and yogurt Tonsillectomy Used to remove patients with larger tonsils that can cause Nursing Diagnosis obstruction of the air ways Ineffective air way clearance related to excessive mucus production secondary to retained secretions and inflammation Uvulopalatopharyngoplasty Acute pain related to upper air way irritation secondary to an The resection of pharyngeal soft tissue and removal of infection approximately 15 mm of the free edge of the soft palate Impaired verbal communication related to physiologic changes and uvula and upper air way irritation secondary to infections or swelling Deficient volume related to decrease fluid intake Tracheostomy Relieves upper air way obstruction but has numerous adverse effects like speech difficulties OBSTRUCTION AND TRAUMA OF THE UPPER RESPIRATORY AIRWAY Medical Management SLEEP APNEA Modafini (Provigil) A disorder characterized by recurrent episodes of upper air way To reduce daytime sleepiness obstruction and a reduction in ventilation It is defined as a cessation of breathing during sleep usually Protriptyline (Triptil) caused by repetitive upper air way obstruction Given at bedtime to increase respiratory drive and improve upper air way muscle tone Risk Factors Obesity: the larger the neck circumference and increased Medroxyprogesterone Acetate and Acetazolamide amounts of peri pharyngeal fat narrow and compress the upper For sleep apnea associated with chronic alveolar air way hypoventilation Structural Changes: tonsillar hypertrophy that can contribute to collapse of the air way Nursing Management Advance age and male gender Instruct the client and the family about the treatment including correct and safe use of CPAP, BIPAP, and oxygen Clinical Manifestations therapy Characterized by frequent and loud snoring with breathing cessation for 10 seconds or longer, for at least 5 episodes per EPISTAXIS hour A hemorrhage from the nose caused by the rupture of tiny, The classical sign and symptoms include the 3's: snoring, distended vessels in the mucus membrane of any area of sleepiness, and significant other report of sleep apnea episodes the nose Frequent complain of insomnia including difficulty of going to The most common site is the anterior septum sleep at night Early morning awakening with an inability to go back to sleep Risk Factors Day time sleepiness Local infection and systemic infections Drying of the nasal mucous membrane Diagnostic Findings Trauma of the nasal mucosa Polysomnographic Studies Use of aspirin The test is an overnight study that measures the multiple Thrombocytopenia physiologic signals to include those related to sleep respiration and oxygen level and cardiac dysrhythmia Medical Management Nasal Decongestants Surgical Management One or t wo sprays to act as vasoconstrictors CPAP Used to prevent air way collapse Silver Nitrate or Electrocautery Antihistamine For visible bleeding site and a supplemental patch of surgical or For management of allergies gel foam may be used Astringent Nursing Management To shrink the hypertrophied turbinate of the nasal mucosa A nasal speculum, penlight, or headlight may be used to identify the site of the bleeding in the nasal cavity Surgical Procedure The patient sits upright position with the head tilted for ward Functional Rhinoplasty to prevent swallowing and aspiration of blood Performed to reconstruct and reshape the hypertrophied Instruct the client to pinch the soft outer portion of the nose turbinate of the nose against the midline septum for 5 to 10 minutes continuously A cotton tampon may be used to try to stop the bleeding Post-operatively: Suction may be used to remove excess blood clots from the field Elevate the head of the bed to promote drainage and to of inspection alleviate discomfort from edema The nose can be packed with gauze with petroleum jelly or Frequent oral hygiene is encouraged to overcome dryness antibiotic ointment cause by breathing through the mouth A nasal sponge may be used, once the nasal sponge becomes Instruct the patient to avoid blowing of the nose with saturated with blood or is moistened with a small amount of force during post operative recovery period saline it may control bleeding that may remain for 3 to 4 days Instruct the patient about the signs and symptoms of The nurse monitors the vital signs, assist in the control of bleeding and infection bleeding, and provide tissues and an emesis basin to allow the patient to expectorate any excess blood FRACTURE OF THE NOSE Educate the client about self-care The most common facial fracture of the nose usually Instruct client to avoid vigorous exercise for several days and results from a direct assault avoid hot or spicy foods and tobacco use because this may cause May also affect the ascending process of the maxilla and vasodilation and increase the risk of bleeding septum and the thorned mucous membrane results in a Instruct the client to avoid forceful nose blowing, straining, nose bleeding high altitudes, and nasal trauma Adequate humidification may prevent drying of the nasal Clinical Manifestations passages Pain and bleeding on the nose externally and internally Teach the client apply direct pressure to the nose with the into the pharynx thumb and the index finger for 15 minutes in the case of a Swelling of the soft tissue of the nose recurrent bleeding Nasal obstruction and deformity The patient may have an asymmetric appearance that NASAL OBSTRUCTION may not be obvious until the edema subsides The passage of air through the nostril is obstructed by a deviation of the nasal septum, hypertrophy of the turbinate Diagnostic Findings bones, or the pressure of the nasal polyps X-Ray Chronic nasal congestion forces patient to breathe through the Reveals displacement of the fractured bones and may help mouth thus producing dryness of the oral mucosa and rule out extension of the fracture into the skull associated problems including persistent dry lips, sleep deprivation, and may lead to infection Medical Management Antibiotics Medical Management Analgesics Nasal Corticosteroids (Prednisose) Decongestant Spray 6-day course of corticosteroids may be beneficial in the treatment of nasal obstruction due to polyps Nursing Management The nurse applies ice pack to decrease swelling and keep the Antibiotics head elevated To treat for infection If there is bleeding from the nose, packing is inserted to stop the bleeding  Mouth rinses helps to moisturizes the mucous membranes If no passage of air is detected, begin cardiopulmonary Instruct the client to avoid activities for 6 weeks resuscitation (CPR) The used of analgesics agents such as acetaminophen is encouraged to relieve pain Bag and Mask Resuscitation Apply the mask to the patient face and create a seal by LARYNGEAL OBSTRUCTION pressing the thumb of the non-dominant hand on the Obstruction of the larynx because of edema is a serious, often bridge of the nose and the index finger of the chin fatal condition Using the rest of the fingers of the hand, pull on the chin Swelling of the laryngeal mucous membrane may close off the and the angle of the mandible to maintain the head in opening tightly, leading to life-threatening hypoxia or extension suffocation Use the dominant hand to inflate the lungs by squeezing the Foreign bodies frequently are aspirated into the pharynx, bag to its full volume larynx, or the trachea and cause t wofold problems Foreign bodies obstruct the air passages and causing DOB which Nursing Management may lead to asphyxia Monitor vital signs Foreign bodies may be drawn farther down, entering the Monitor oxygen saturation level bronchi or a bronchial branch causing symptoms of irritation Monitor for signs of oxygen desaturation and expectoration of blood or mucous and labored breathing Assess for the use of accessory muscles during inspiration Apply ice packs to the neck to reduce the edema Clinical Manifestations Patient may demonstrate lowered oxygen saturation MANAGEMENT OF CLIENT WITH LOWER RESPIRATORY The use of accessory muscles manifested by retracting in the TRACT DISORDERS neck and the abdomen during inspirations ATELECTASIS One of the most commonly abnormalities in chest Diagnostic Findings radiology X-Ray Divided physiologically into: obstructive and non- Reveals the location of the obstruction, the extent of the obstructive obstruction Refers to the closure or collapse of alveoli and often described in relation to x-ray findings Medical Management May be acute or chronic from micro atelectasis which is Respiratory Support nor detectable on chest x-ray and macro atelectasis which This is considered if the symptoms are at an immediate risk of loss of segmental, lobar or overall lung volume lung collapse The common causes are excess secretions and air way obstructions that impedes or blocks the flow of air to an Subcutaneous Epinephrine and Corticosteroids area of the lungs Used if the obstruction are caused by edema resulting from an allergic reactions ATELECTASIS ALVEOLI At the end of each alveolar duct, there are several sac-like Clearing an Air ways Obstruction structures called alveoli Attempt to open the air way: Within this structure, the surfactant is produced Perform the head tilt chin maneuver by placing one hand on the Gas exchange of oxygen and carbon dioxide takes place in forehead and placing fingers to the other hand underneath the the alveoli jaw lifting upward and for ward, this action pull the tongue away from the back of the pharynx Gas Exchange of Alveoli Oxygen from the inhaled air diffused through the walls of Attempt to clear the air way: alveoli and to capillaries and to the red blood cells Assess the patient by obser ving the chest and listening and feeling for the movement of the air Oxygen is then carried by the blood to the body tissues Use a cross finger technique to open the mouth and obser ve for obvious obstructions Carbon dioxide produced by the body's metabolism returns to the lung via the blood Carbon dioxide diffuses across the capillary and alveolar wall and NON-OBSTRUCTIVE ATELECTASIS removed with expiration Loss of contact bet ween the visceral and parietal pleura Adhesive atelectasis: due to lack of surfactant OBSTRUCTIVE ATELECTASIS Replacement atelectasis: due to filling by a tumor Most common causes: Scarring of the lung parenchyma Foreign body Post-operative atelectasis due to diminished surfactant Tumor activity Mucus plugging Types of Atelectasis Rate of development and extent and depend on: Resorption Atelectasis Extent of collateral ventilation Complete obstruction of an air way Composition of inspired gas Resorption of the oxygen trapped in the dependent alveoli, without impairment of blood flow through the affected Pathophysiology of Obstructive Atelectasis alveolar walls Obstruction of a bronchus Obstruction can be caused by: mucous plug, aspiration of foreign body, neoplasm and enlarged lymph node Tumor growth in an air way Retained secretions The involvement of lung depend on the level of air way obstruction Circulating blood absorbs gas in the peripheral alveoli Lung volume is diminished, and the mediastinum may shift toward the atelectatic lung Lesser volume of air is entering the alveoli Compression Atelectasis Retraction of the affected lung Results when the pleural cavity is partially or completely filled by fluids, exudates, tumor, blood, or air Displacing the surrounding structures and mediastinal shift Lungs cannot fully inflate owing to any space occupying towards the atelectatic area lesion Client may experience shallow breathing, diminished Diaphragm is elevated and chest wall flattens breath sounds, dullness to percussion, and DOB Reduced alveoli ventilation Signs includes cyanonis, Contraction Atelectasis leading to alveoli collapse decreased Sp02 and PaO2 Occurs when local or generalized fibrotic changes in the lung or pleural prevent full expansion Bronchial obstruction due to secretions Physical Assessment Impaired cough mechanism Inability to expel cough Dullness on the affected area Diminished or absent breath sounds Excessive pressure on the lung tissue Reduced chest excursion Trachea and heart are deviated on the affected side Restricts normal lung expansion on inspiration Clinical Manifestations Fluid accumulating within Symptom includes increase Increasing dyspnea the pleural space sputum production and Cough and sputum production crackles Cyanosis Difficulty of breathing in supine position Accumulation of air in the Symptom include pleural pain Marked respiratory distress: tachypnea, tachycardia, pleural space pleural pain Blood accumulation in the Symptom include hemoptysis Nursing Diagnosis pleural space Impaired gas exchange Impaired lung mechanics Alveoli collapse Increased pulmonary vascular resistance Diagnostic Procedure Pathophysiology Flexible Fiberoptic Bronchoscopy Streptococcus pneumoniae, haemophilus influenza, or Help evaluate the cause of the obstructions inhalation of physical and chemical irritants Helps clear mucus plugs Invasion of the causative agents to the tracheobronchial tree Chest X-Ray May reveal patchy infiltrates or consolidated area Causing inflammation of the bronchial mucosa Medical Management The inflamed mucosa of the bronchi tree produces mucopurulent Thoracentesis sputum Removal of the fluids by needle aspirations or insertion of a chest tube Clinical Manifestations Cough Bronchodilators Sputum production Encourage sputum expectoration Fever Nausea, vomiting, and diarrhea Mucolytics General malaise and chest pain May promote sputum removal of thick mucus plugs Dyspnea and cyanosis N-acetylcysteine: only recommended in an intubated client Sore throat Runny or stuffy nose Antibiotic Headache To treat underlying bronchitis or post obstructive infection and Muscle aches other causes of infection Extreme fatigue Antitussive Physical Examination Reduces the cough reflex Diffuse wheezes, high-pitched continuous sounds, and the Obstruction of a major bronchus may cause severe hacking or use of accessory muscles coughing Diffuse diminution of air intake or inspiratory stridor Sustained heave along the left sternal border Nursing Management Peripheral cyanosis Change patient position frequently, especially from supine to upright position to promote ventilation and prevent secretion Diagnostic Procedures from accumulating Complete blood count Encourage early mobilization from bed to chair followed by early ambulation Sputum Cytology Encourage appropriate deep breathing exercises and coughing to If the cough is persistent mobilize secretions and prevent from accumulating Perform postural drainage and chest percussion Blood Culture Institute suctioning to remove tracheobronchial secretions If the bacterial superinfection is suspected Surgical Management Chest Radiography Segmental Resection/Lobectomy If the patient is elderly or physical findings suggest Post-Operative: provide adequate oxygenation and supplemental pneumonia oxygenation; if severe hypoxemia, mechanical ventilation is considered; positive pressure and larger tidal volumes help to re- Bronchoscopy expand collapsed lung segments To exclude foreign body aspiration, tuberculosis, tumors, and other chronic diseases ACUTE TRACHEOBRONCHITIS Inflammation of the mucous membranes of the trachea and the bronchial tree, often follows infection of the upper respiratory tract Medical Management Predisposing Factors Central Cough Suppressants Defense mechanisms are incompetent or over whelmed Short-term symptomatic relief of coughing in acute and chronic Decreased cough and epiglottal reflexes bronchitis Mucociliary mechanism impaired: pollution, cigarette smoking, upper respiratory infections, tracheal Short-acting Beta-agonists intubation, aging Control of bronchospasm, dyspnea, and chronic cough in stable Alteration of leukocytes from malnutrition patients to control chronic cough Increased frequency of gram-negative bacilli Non-steroidal Anti-inflammatory Drugs Acquisition of Organisms Treatment of constitutional symptoms of acute bronchitis Aspiration including mild to moderate pain Inhalation Hematogenous Antitussives/Expectorants Treatment of cough, dyspnea, and wheezing Types of Pneumonia Organisms implicated: Mucolytics S. Pneumonia Management of moderate to severe COPE, especially in winter Legionella Mycoplasma Nursing Management Chlamydia Instruct the client to increase fluid intake to thin the viscous S. Aureus and tenacious secretions Respiratory viruses Instruct the client to cough out secretions Suction secretions regularly Classification Cool vapor therapy or steam inhalation may help to relieve Health Care Associated Pneumonia tracheal irritation Occurring in a non-hospitalized patient with extensive Advise the client to rest health care contact with 1 or more of the following: 1. Hospitalization for more than 2 days in an acute care PNEUMONIA facility within 90 days of infection An inflammatory process involving the respiratory bronchiole, 2. Residence in a nursing home or a long-term care facility alveolar space and walls, and lobes caused by chemical irritants 3. Antibiotic therapy, home infusion therapy, and family or by specific bacterial, viral, fungal, mycoplasma, or parasitic member with infection organisms The most common cause of death from infectious disease and Hospital Acquired Pneumonia the leading cause of death among elderly persons Occurs at 48 hours after admission Prolonged or inappropriate use of antibiotic use of COMMUNITY ACQUIRED PNEUMONIA antibiotic and the use of NGT Occurs either in community setting or within the first 48 hours Pseudomonas Aeruginosa: occurs in patient with prolonged after hospitalization intubation or with tracheostomy Streptococcus Pneumonia: the most common cause of CAP in Staphylococcal Pneumonia: occur through inhalation of the people younger than 60 years without comorbidity and in those organism or spread through inhalation and is often 60 years and older with comorbidity accompanied by bacteremia and positive blood culture S. Pneumonia: a gram negative organism that resides naturally in the upper respiratory tract but if invaded the lower Ventilator Associated Pneumonia respiratory tract it can cause invasive infection Develops 48 hours after endotracheal intubation and has Hemophilus Influenza: frequently affects adults and those with received mechanical ventilator comorbid diseases The most common infection seen in the ICU Mycoplasma Pneumonia: spread by infected respiratory droplet through person to person Aspiration Pneumonia Risk Factors Refers to pulmonary consequences resulting from entry of Condition that produce mucus or bronchial obstruction and endogenous or exogenous substances in the lower respiratory interfere with normal lung drainage: promote coughing and air ways expectoration of secretions The most common form of aspiration pneumonia is bacterial Immunosuppressed patients: initiate precaution against infection from aspiration of bacteria that normally reside in infection the upper air ways Smoking: encourage smoking cessation Common pathogens includes S. aureus, Streptococcus species, Prolonged immobility and shallow breathing pattern: and other gram negative frequent positioning and promote lung expansion, exercise Sequelae occurring from abnormal entry of secretions into coughing and chest physiotherapy lower air way Depressed cough reflex and aspiration of foreign material Usually history of loss of consciousness into the lungs: reposition frequently to prevent aspiration, Risk factor: tube feedings perform suctioning and chest physiotherapy Forms of aspiration pneumonia: mechanical obstruction, Placement of NGT, endotracheal tube: promote frequent chemical injury, bacterial infection oral hygiene, minimize risk for aspiration by checking placement of the tube and proper positioning of the Community Acquired Pneumonia patient Onset in community or during first 2 days of hospitalization Supine positioning in patient unable to protect the air way: Highest incidence in winter elevate head of the bed at least 30 degrees Smoking important risk factor Advanced age and possible depressed cough and nutritional depletion: promote frequent turning, early ambulation and Fungal Pneumonia mobilization, effective coughing and breathing exercises, and nutritious diet Pathophysiology: Pneumococcal Pneumonia Congestion from outpouring of fluid into alveoli Pathophysiology Red hepatization: massive dilation of capillaries; alveoli fill Offending organism/agent with organisms, neutrophils, RBCs, and fibrin Gray hepatization: blood flow decreases; leukocyte and fibrin Inflammatory pulmonary response consolidate in affected part of lung Resolution: resolution and healing if no complications; exudate Loose defense mechanism of the lungs lysed processed by macrophages; tissue restored Allow organism to penetrate the sterile LRT Develop inflammation Disruption of the mechanical defense Colonization of the lungs Inflamed and fluid filled alveoli Alveolar exudates tends to consolidate Difficulty to expectorate Clinical Manifestations Nursing Management Sudden onset of chills and rapidly rising fever Improving Air way Patency Pleuritic chest paun aggravated by DBE and coughing Encourage hydration: fluid intake (2-3 L/day) to loosen Tachypnea secretions Respiratory distress Provide humidified air using high-humidity face mask Relative bradycardia Encourage patient to cough effectively, and provide Mucopurulent sputum correct positioning, chest physiotherapy, and incentive The cheeks are flushed, the lips and the nails beds demonstrate spirometry central cyanosis Provide suctioning if necessary Orthopnea Provide appropriate method of oxygen therapy Poor appetite Monitor effectiveness of oxygen therapy Diaphoretic Rusty, blood-tinged sputum Promoting Fluid Intake and Maintaining Nutrition Encourage fluids (2 L/day minimum with electrolytes and Diagnostic Procedures calories) Chest X-Ray Administer intravenous fluids and nutrients, if necessary Blood Culture Promoting Activity Tolerance To determine if there is blood stream invasion occurs Counsel patient to rest and to avoid overexertion, which may exacerbate symptoms Sputum Examination Assist patient to comfortable position that maximizes To determine if there is bacteria and to determine the type of breathing bacteria Change position frequently Bronchoscopy Informing Patient If there is acute and severe infection Instruct on cause of pneumonia and management of symptoms The sputum sample is obtained by having the patient do the Explain treatments in simple manner and using appropriate following: language 1. Rinse the mouth with water to minimize the contaminzation by Repeat instructions and explanations as needed normal flora 2. Breathe deeply several times Monitoring and Preventing Complications 3. Cough deeply Assess for signs and symptoms of shock and respiratory 4. Expectorate the raised sputum into a sterile container failure Administer intravenous fluids and medications and Medical Management respiratory support as ordered Antibiotics Initiate preventive measures for atelectasis Prescribed based on gram stain results and antibiotic guidelines Assess for atelectasis and pleural effusion Prevent or treat infections caused by pathogenic microorganism Assist with thoracentesis and monitor patient for Before administering the first dose, assess the client for pneumothorax after procedure allergies and determine whether culture has been obtained Assess the insertion site for phlebitis if antibiotics are being Health Teachings administered IV Instruct patient to continue taking antibiotics until complete Nursing Diagnosis Advise patient to increase activities gradually after the Ineffective air way clearance related to copious fever subsides tracheobronchial secretions Advise patient that fatigue and weakness may linger Activity tolerance related to fever and dyspnea Encourage breathing exercises to promote lung expansion Imbalanced nutrition: less than body requirements and clearing Knowledge deficit about treatment regimen and preventive Review principles of adequate nutrition and rest health measures LUNG ABSCESS Risk Factors Necrosis of the pulmonary parenchyma caused by microbial Close contact with someone who has active TB infection Immunocompromised status (HIV, cancer, transplant In lung abscess, the chest x-ray demonstrates a cavity of at organs) least 2 cm Immigration from countries with a high prevalence of TB (Africa, Southeast Asia, Latin America) Clinical Manifestations Living in a crowded substandard housing Mild productive cough Being a health care worker performing high-risk activities Fever Any person without adequate health care Moderate to copious amounts of foul smelling sometimes bloody sputum INACTIVE PULMONARY TUBERCULOSIS Leukocytosis Happens after the organism has started to grow in the Pleuritic chest pain lungs but hasn't show any symptoms Dyspnea Body calcifies them - Gohn tubercle can remain for years Weakness When Gohn tubercle begin to grown, infection is activated Anorexia and weight loss Every time someone with TB coughs, they are releasing it Crackles into the air via droplet nuclei Diminished breath sounds ACTIVE PULMONARY TUBERCULOSIS Diagnostic Findings Infection begins when the mycobacteria reach the X-Ray pulmonary alveoli, where they invade and replicate Reveals an infiltrate with an air or fluid Primary site of infection: Gohn focus, generally located in either the upper part of the lower lobe, or the lower part CT Scan of the upper lobe Required to provide more detailed images of different cross Further spread through the bloodstream to other tissues sectional areas of the lung and organs where secondary TB lesions can develop in other parts of the lung, peripheral lymph nodes, kidneys, Fiberoptic Bronchoscope brain, and bone To visualize the location of the lungs and facilitate in the removal of the mucus plugged Pathophysiology Antibiotic Therapy Droplet nuclei containing tubercle bacilli are inhaled enter the Clindamycin is the standard treatment for an anaerobic lung lungs, and travel to the alveoli infection Oral administration of oral antibiotic therapy is continued for Tubercle bacilli multiply in the alveoli an additional 4-12 weeks and sometime longer Activation of the alveolar macrophages Nursing Management Perform chest physiotherapy to facilitate drainage of the Phagocytosis of the bacilli abscess Perform deep breathing exercises and coughing exercises to help Immune cells form a barrier shell called granuloma expand the lungs Encourage to have a high protein and high calorie diet Granuloma contained the TB bacilli Increase fluid intake to loosen secretions Immune system cannot keep the TB bacilli under control PULMONARY TUBERCULOSIS An infectious disease that primarily affects the lung TB bacilli begin to multiply rapidly parenchyma Primary infectious agent: Mycobacterium Tuberculosis Collagenous scar tissue begin to grow in the tubercle Complete isolation of the TB bacilli in the bronchi Secondary or Acquired Drug Resistance Resistance to one or more anti-TB drugs in patient TB bacilli spreads to the alveoli undergoing therapy Sudden multiplication of the TB bacilli causes activation of the Multi-Drug Resistance dormant bacilli Resistance to t wo agents like isoniazid and rifampicin A small number of tubercle bacilli enter the bloodstream and spread The initial phase consist of multiple medications: Isoniazid, throughout the body Rifampicin, Pyrazinamide, and Ethambutol plus Vitamin B6 are all taken taken once daily for 8 weeks Clinical Manifestations Cough The continuation regimen includesIsoniazid and Rifampin is Night sweats next that lasts for an additional 4-6 months Fatigue Weight loss Streptomycin: the first drug effective against TB Mucopurulent sputum Hemoptysis Chills Anorexia Pleuritic Pain Diagnostic Procedures PPD (Purified Protein Derivative) Nursing Management Take pieces of cell and inoculate under the skin Promoting Air way Clearance PPD is negative = you are happy Increasing the fluid intake promotes systemic hydration PPD is positive = take a chest x-ray in which they look for and serve as an effective expectorant infiltration Correct positioning to facilitate air way clearance Negative chest x-ray = 6 months of antibiotics Positive chest x-ray = 2 years of anti TB drugs Promoting Adherence to Treatment Instruct the client about the medication schedule and its Chest X-Ray side effects Reveals lesions in the upper lobes of the lungs Educate the client that TB is a communicable disease and that taking medication is the effective means of Tuberculin Skin Test preventing transmission To determine whether the person has been infected with TB Instruct the client to take medication either on empty bacillus stomach or at least 1 hour before meals because foods Tubercle bacillus extract, a purified derivative protein is injected interferes with medication absorption into intradermally on the inner aspect of the forearm Patient taking isoniazid should avoid foods that contain approximately 4 cm below the elbow tyramine because eating them while on therapy may result in headache, palpitations, and diaphoresis Sputum Culture Instruct the client to avoid drinking alcohol during the Done to confirm the diagnosis therapy because of the high potential for hepatotoxic Presence of AFB on a sputum smear may indicate disease but effects does not confirm the diagnosis of TB because some AFB are not Inform the client taking rifampin may discolor contact M. tuberculosis lenses and that patient may wear eyeglasses during the therapy Medical Management Primary Drug Resistance Promoting Activity and Adequate Nutrition Resistance to one of the first line of anti-TB drugs Plan a progressive activity schedule that focuses on increasing activity tolerance and muscle strength  A nutritional plan that allows small frequent meals and a liquid Assessment and Diagnostic Procedures nutritional supplements Radiographic Findings are subtle and often missed Preventing Transmission of Tuberculosis Infection Instruct the client about the important hygiene measures, Trans-Thoracic Echocardiography including mouth care, covering of the mouth and nose when coughing and sneezing, proper disposal of tissues and hand hygiene The case of TB must be reported to the health department for the necessary treatment PULMONARY HYPERTENSION A disorder characterized by elevated pulmonary arterial pressure and secondary right heart ventricular arterial Progressive increase in the blood pressure in the pulmonary vascular bed It may be suspected in a patient with dyspnea with exertion without other clinical manifestation Criteria for Pulmonary Hypertension Mean Pulmonary Artery Pressure (MPAP): >25 mmHg at rest with pulmonary capillary wedge pressure ≤ 15 mmHg Pathophysiology Toxic inhalation Scarring and damage to the alveoli Decrease surface to the lungs Decrease blood flow Increase pressure on the blood vessel Blood back up to the pulmonary artery Increase pulmonary pressure Blood backs up to the right ventricle, right atrium, inferior and superior vena cava Increase after load to the right ventricle Heart failure Clinical Manifestations Dyspnea Substernal chest pain Weakness, fatigue, and syncope Occasional hemoptysis Peripheral edema Ascites and abdominal pain Distended neck vein Liver enlargement Crackles and heart murmur Anorexia Clinical Classification of Pulmonary Hypertension Pulmonary Arterial Hypertension (PAH): idiopathic; secondary to systemic disorders Pulmonary Hypertension Associated with Respiratory Disease and/or Hypoxia: COPD, interstitial lung disease, OSA Chronic Thrombo: embolic/embolic pulmonary hypertensin Pulmonary Hypertension from Unclear Mechanisms ----- ---- ----- ---- ----- ---- ----- ---- ----- ---- ----- ----