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RESPIRATORY STRESSORS Pritam Pandit, RN, BSN, CCRN ASTHMA It is a chronic condition in which your airways narrow and swell and produce extra mucus. Pathophysiology Allergen → Mast Cells IgE (Immunoglobulin – antibody that identifies and neutralizes foreign objects). Mediators: a) Histamine – dilation of blood vessels, ↑ mucus production, and bronchoconstriction. Pathophysiology b) Leukotrienes – trigger contractions in smooth muscle lining in the bronchioles. Eosinophils – WBC; produces the mucus. Pathophysiology a) b) c) d) Bronchial lining is affected. Airway constriction: Thickening of wall Plasma leakage Mucus buildup Inflammation Signs/Symptoms Wheezing Cough Tightness in chest SOB Intensifies at night Sweating Orthopnea Signs/Symptoms Anxiety/ restlessness Inability to speak Cyanosis/ Hypoxemia No audible breath sounds Diminishing level of consciousness Breath sounds Dependent on degree of bronchospasm Audible Diminished Absent Vital Signs Tachypnea Tachycardia Hypoxia Asthma Attack Triggers Specific allergens Pollen Mold Dust Animal dander Asthma Attack Triggers Chemicals Forestry – Foliage Fishing Cigarette smoke Medications – beta blockers Pregnancy Exposure to cold Asthma Attack Triggers Smoke Food Sudden changes in the weather Environment Classes of Asthma 1. Mild Intermittent Symptoms < 2/week Brief exacerbations Night symptoms < 2/mo Asymptomatic with normal function between exacerbations Classes of Asthma 2. Mild Persistent Symptoms > 2/week, < 1/day Exacerbation affects ADLs Night symptoms > 2/mo Classes of Asthma 3. Moderate Persistent Daily symptoms Exacerbations >2 or more/week Exacerbations affects ADLs Night symptoms > 1/week Daily use of short term beta-agonists Classes of Asthma 4. Severe Persistent Continuous symptoms Frequent exacerbations Frequent night symptoms Activity limited Status Asthmaticus Severe episode of bronchospasm that does not respond to standard treatment Adult Onset – Risk Factors Obesity Allergies Exposure to latex Occupational hazards Exercise Induced Asthma Strenuous activity Decreased heat and moisture in lungs Inhaling large amounts cold, dry air Strenuous activities Playing in the cold Hyperventilating Laughing Crying Exercise requiring breathing through the mouth Signs/Symptoms Usually occurs 5-20 min into activity Tightness in chest Coughing Wheezing SOB or rapid shallow breaths Prevention Warm up exercise Meds prior to activity Cooling down post exertion Limit participation during high trigger days Occupational Asthma Triggers in the job Chemicals Vapors Allergens in the environment People Higher during “flu” season Bacteria & viruses Nocturnal Asthma Defined - as asthma from 12 midnight till 8am Wheezing SOB when lying down Usually awaken 2am-4am Miscellaneous Asthma Cough variant (chronic cough) Seasonal Aspirin induced (overproduction of leukotrienes) Diagnostics PFT – pulmonary function test CXR – chest x-ray Peak flow measurement Measures highest airflow during forced expiration Peak flow rate: The highest speed you can blow air out from your lungs Asthma Guidelines Asthma Guidelines Treatment – Quick-Relief Short-acting beta2adrenergics Proventil Xopenex Maxair Anticholinergics Atrovent Treatment – Long-Acting Corticosteroids Qvar Flovent Azmacort Mast Cell Stabilizers Intal Treatment – Long-Acting Long-acting beta2-adrenergics Serevent Foradil Xanthine derivatives Slo-bid Theodur Treatment – Long-Acting Leukotriene modifiers (inhibitors) Accolate Singulair Combination products Symbicort Advair Diskus Dulera Nursing Depends on severity of symptoms – use of quick relief meds Educate on use of inhalers (spacers, etc.) Breath sounds Pulse oximetry Vital signs Peak flow Nursing May need hospitalizations for severe exacerbations Educate on self-care and follow-up Importance of adhering to regime and preventative measures ATELECTASIS Complete or partial collapse of a lung or lobe. Causes Airway Obstruction Loss of surfactant Pressure on lung tissue Signs/Symptoms SOB/dyspnea/ tachypnea Tachycardia Anxiety Fever - not r/t infection but reaction to injury Signs/Symptoms Diminished/ absent breath sounds over collapsed area Affected chest wall moves little Signs/Symptoms Opposite chest wall excursion appears excessive Tracheal shift away from side of collapse Pathology Diagnostics ABG’s/ O2 therapy prn Pulse oximetry Elevate HOB Interventions Turn q2h or ambulate TCDB and use IS Treat cause Primary/Tertiary prevention ACUTE BRONCHITIS Inflammation of the bronchial tubes Aka – “Chest Cold” Causes: Virus Bacteria Irritating agents Bronchitis Signs/Symptoms Fever/Malaise Dry cough (most common) Rhonchi Interventions Maintain hydration Prevent pooling of secretions (TCDB) Rest ASA/Tylenol to ↓ fever/malaise Expectorants vs cough suppressants Interventions Inhaled bronchodilators In hospital: sputum C&S Treat with antibiotic CXR to r/o pneumonia Decongestant/ Antihistamine PNEUMONIA Infection that inflames the air sacs in one or both lungs. Fluid fills. Causes: Bacteria, Viruses, Fungi Food/Fluid aspiration, or Emesis Toxic/caustic chemical inhalation Signs/Symptoms Fever/ Chills/ Sweats/ Headache Pleuritic chest pain Cough/Sputum production Rales/ Crackles Signs/Symptoms Dsypnea/ Tachypnea Increase tactile fremitus Dull percussion Unequal Chest Expansion Signs/Symptoms Elderly weakness lethargy tachycardia confusion Diagnostics ABG’s CXR for consolidation Diagnostics Sputum gram stain, C&S WBC’s Interventions Raise HOB Maintain hydration Prevent pooling Chest PT/Postural draining Interventions Adequate rest Good Nutrition Mild analgesics (nonopiod) Inhaled bronchodilators TUBERCULOSIS Potentially serious infection of the lungs. Caused by acid-fast bacillus Mycobacterium tuberculosis Must be reported to Health Department Agencies Communicability Transmitted by aerosolization only Infectious, but brief exposure doesn’t cause infection Risk of transmitting TB reduced within 2-3 weeks after chemo Inflammatory disease may occur in any part of the body Pathophysiology Inhaled organism gets past defense mechanism and implants in lung tissue. Immune system triggers formation of “tubercles” around phagocytized bacilli and forms a protective wall. Forms into “hard” or “soft” tubercles. Pathophysiology Hard tubercles (primary infection) Tubercles calcify and keep bacilli in check. Client is infected, but does not have active disease Will have positive TB skin test, but can’t give to anyone Pathophysiology Soft tubercules Bacilli multiply Caseation: necrosis into cheese-like mass Inflammation subsides, lesions heal to calcified areas OR erode to bronchus Liquefied caseous material coughed up (full-blown disease) Factors That Lower Resistance Advanced age/very young Immunodeficiency Hormonal changes Malnutrition Alcoholism Factors That Lower Resistance Presence of other disease states Poverty (malnutrition and overcrowding) Certain ethnic groups – ex: Native Americans, Eskimos, immigrants from Southeast Asia, Mexico, Ethiopia, Latin America Assessment History Recent/Past exposure to TB Occupation Previous TB skin test Received BCG vaccine Assessment: Systemic Fatigue Anorexia Weight loss Persistent low-grade fever (afternoon temp up) Chills and sweats (often at NIGHT) Assessment: Respiratory Dyspnea (usually in advanced cases) Persistent cough, initially dry then productive Hemoptysis Chest pain: dull, aching, chest tightness Non-resolving bronchopneumonia Diagnostics Most definitive: AFB smear and culture CXR Tuberculin test aka PPD Diagnostics Interventions Chemotherapy First line drugs RIPES Side Effects Baseline studies prior to start of RIPE Liver - INH, pyrazinamide Kidney – Streptomycin Side Effects Hearing – Streptomycin Visual acuity (can’t differentiate between red/green) Ethambutol Side Effects Nausea - may need antinausea drugs Anorexia – qhs Peripheral neuropathies (INH) r/t vit. B6 deficiency may need concurrent use of PYRIDOXINE (vit. B6) Interventions Check hospital protocols: treatment usually continues for 6-9 months Social Service Referral or Public Health Department follow-up at home for regiment compliance Interventions Hospitalization = 1-2 weeks Respiratory isolation Fitted masks Negative pressure room ventilation UV - germicidal effect Interventions Pt. no longer considered a Health Hazard: after 2-3 weeks of chemo improvement in s/s 3 consecutive negative smears collected on different days maintenance of medication compliance at home Patient/Family Education Education assists with compliance Cover mouth No need to wash clothes/ dishes separately Handle used tissues carefully Prevention TB screening of at-risk populations Early ID and treatment of active cases Report to Public Health Department Increase public awareness EXTRA PULMONARY TB TB occurring anywhere outside the lungs Spreads from lung via blood or lymph Thrives in O2-rich areas Common Sites Renal cortex Bone growth plates Meninges Disseminated TB Larynx/Mouth Questions 1. Which of the following pathophysiological mechanisms that occurs in the lung parenchyma allows pneumonia to develop? a) Atelectasis b) Bronchiectasis c) Effusion d) Inflammation Questions 2. A 24-year-old client comes into the clinic complaining of right-sided chest pain and shortness of breath. He reports that it started suddenly. The assessment should include which of the following interventions? a) Auscultation of breath sounds b) Chest x-ray c) Echocardiogram d) Electrocardiogram (ECG) Questions 3. A client with pneumonia has a temperature ranging between 101* and 102*F and periods of diaphoresis. Based on this information, which of the following nursing interventions would be a priority? a) Maintain complete bedrest b) Administer oxygen therapy c) Provide frequent linen changes d) Provide fluid intake of 3 L/day Questions 4. A client with acute asthma is prescribed shortterm corticosteroid therapy. What is the rationale for the use of steroids in clients with asthma? a) Corticosteroids promote bronchodilation b) Corticosteroids act as an expectorant c) Corticosteroids have an anti-inflammatory effect d) Corticosteroids prevent development of respiratory infections Questions 5. Basilar crackles are present in a client’s lungs on auscultation. The nurse knows that these are discrete, non continuous sounds that are: a) Caused by the sudden opening of alveoli b) Usually more prominent during expiration c) Produced by airflow across passages narrowed by secretions d) Found primarily in the pleura