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Assessment & Management of Patients With Respiratory Tract Disorders Lower Respiratory Tract Trachea Bronchi Bronchioles Alveoli Cilia Respiratory anatomy Alveoli at the terminal end of the lower airway Clinical Manifestations 1. Local Manifestations Cough chronic, paroxysmal, dry , productive Excessive Nasal Secretion Expectoration of Sputum mucoid, purulent, mucopurulent, rusty, hemoptysis Pain pleuritic, intercostal, generalized chest pain Dyspnea- shortness of breath Function Gases are moved in and out of the lung through pressure changes. Intrapleural pressure is negative (less than atmospheric pressure – 760mmHg) Please refer to suggested reading notes Clinical Manifestations 2. Systemic Manifestations Hypoxemia insufficient oxygenation of the blood cyanosis- bluish, grayish discoloration of skin & mucous membranes Hypoxia inadequate tissue oxygenation Hypercapnia CO2 in arterial blood above normal limits Hypocapnia CO2 in arterial blood below normal limits Respiratory Failure Medical Terminology (Respiratory conditions) Respiratory Failure: The inability of the cardovascular and pulmonary systems to maintain an adequate exchange of oxygen and carbondioxide in the lungs. Maybe caused by a failure in oxygen or in ventilation. Can be hypoxemic or hypercapneic. Medical terminology cont. Ventilation: the process of moving gases into and out of the lungs Work of Breathing: The effort required for expanding and contracting of the lungs. The influencing factors: the rate and depth of breathing, the ease in which the lungs can be expanded and airway resistance Assessment of Respiratory System Health History Risk Factors Major Clinical Manifestations Cough Sputum production Chest pain Wheezing Clubbing of the fingers Cyanosis Assessment of Respiratory System Physical Examination Inspection posture, shape, movement, dimensions of chest, flared nostrils, use of accessory muscles, skin color, and rate, depth, & rhythm of respiration Palpation respiratory excursion, masses, tenderness Percussion flat, dull, resonant, hyperresonant sounds Auscultation breath sounds, voice sounds, crackles, wheezes Crackles Diagnostic Procedures Sputum Studies Methods- standard, saline inhalation, gastric washing Arterial Blood Gases measurements of blood pH , arterial O2 & CO2 tensions, acid-base balance Pulse Oximetry Chest X-ray Bronchoscopy Thoracentesis Laryngoscopy Lower Respiratory Disorders Pneumonia Inflammation & infection of lunginfecting organisms typically inhaledorganisms transmitted to lower airways and alveoli causing inflammation- impairs gas exchange Etiology: bacteria, virus, Mycoplasma, fungus, or from aspiration or inhalation of chemicals or other toxic substances Risk factors: cigarette smoking, chronic underlying disorders, severe acute illness, suppressed immune system, & immobility Pneumonia Assessment: Questions to ask Have you been experiencing difficulty breathing? Are you having pain? Where? Do you have a cough? Have you been running a fever? Have you been feeling tired? Clinical Manifestations: fever, pleuritic chest pain, tachypnea, SOB, tachycardia, cough, sputum productionrusty, blood-tingled or yellow-green, fatigue, poor appetite Pneumonia Diagnostic: Sputum and blood cultures, CBC, ABGs, CXR, & Bronchoscopy Nursing Diagnoses: Ineffective airway clearance sec. to thick, tenacious sputum Ineffective breathing pattern sec.to tachypnea, chest pain, & airway inflammation Impaired gas exchange sec. to exudate in alveoli Activity intolerance sec. to hypoxemia, fatigue Acute pain sec.to disease process Pneumonia Planning: Client Outcomes Maintain open & clear airway, normal RR, PO2 level without supplemental O2, complete physical care without frequent rest periods Interventions Improve airway patency- auscultate lung sounds, monitor ABGs or pulse oximetry, elevate HOB, C & DB q 2hrs, ambulate , O2 as needed Promote fluid intake & promote activity tolerance Monitor & prevent complications High fowler’s positioning to facilitate air exchange Pneumonia Pharmacology: Antibiotic therapy based on sputum culture & sensitivity Levaquin, Tequin, Rocephin, Primaxin, Zithromax, Ketek, Zinacef, Cipro, Tetracycline Instruct to finish all antibiotics at prescribed intervals Short acting beta 2 agonist such as Salbutamol Corticosteroids ,Prednisolone to decrease inflammation Influenza vaccine, pneumococcal vaccine Period of bed rest Promote adequate nutrition Provide support Evaluation: breathing easier without chest pain temperature normal, activity level increased without frequent rest periods ARDS Acute Respiratory Disease Syndrome A form of Acute Lung Injury Diffused alveolar injury An acute condition characterized by bilateral pulmonary infiltrates and severe hypoxemia Build up fluid in alveolar ARDS - Causes Breathing vomit into lungs (aspirations) Inhaling chemicals Lung transplannt Pneumonia Septic shock (infection thru body) Trauma ARDS -Characterstics Stiff heavy lungs(decreases the lungs ability to expand) The level of oxygen in the blood can stay dangerously low (even if oxygen is given via a ventilator) ARDS - Symptoms Symptoms usually develop 24 to 48 hrs of illness or injury Dyspnoea Low blood pressure (infection) and organ failure Rapid breathing ARDS - Diagnostics Arterial Blood Gas Blood Tests Blood and Urine cultures Bronchoscopy Chest x-ray Sputum culture and analysis ARDS - Treatment Intensive Care Admission Antibiotic therapy Steroid therapy Diuretics Ventilatory support PULMONARY EMBOLISM Is a complication of an underlying venous thrombosis Patient may not show classic signs and symptoms PE – SIGNS AND SYMPTOMS Classic presentation: Pleuretic chest pain Dyspnoea Hypoxia PE – Signs and symptoms Seizures Syncope Abdominal pain Fever Productive cough Wheezing Altered level of consciousness PE – Signs and Symptoms New onset of atrial fibrillation Hemoptysis Flank pain Delirium PE - Diagnosis ECG Chest xray, CT, MRI, Echo, VQ scan Blood tests –Dimer, coagulation profile, Arterial blood gas PE - Management Anticoagulation (warfarin, heparin, retaplse) Surgical intervention : Emoblectomy Vena Cava filters TUBERCULOSIS Infectious disease that primarily affects the lungs; may be transmitted to other parts of the body Pulmonary infiltrates accumulate, cavities develop, & masses of granulated tissue form within the lungs Primary infectious agentMycobacterium Bacilli Transmitted by inhalation of droplets (talking, coughing, sneezing, & singing) Risk factors: immune system disorder, preexisting medical conditions, institutionalized, health care workers Pulmonary Tuberculosis Mycobacterium tuberculosis Airborne transmission Tuberculin skin testing Pharmacologic therapy- multidrug regimens and prophylaxis Tuberculosis Assessment: Questions to ask - Are you suffering from night sweats? Have you lost weight? Have you been having low-grade fever? Have you been having SOB and coughing up anything from your lungs? Have you had chest pain? Where? Have you had weight loss? Clinical Manifestations- low-grade fever (late afternoon), night sweats, weight loss, anorexia, fatigue, chronic productive cough,pleuritic chest pain, hemoptysis Tuberculosis Diagnostic: Sputum culture- + acid-fast bacilli (AFB) Skin testing CBC- WBC elevated CXR Bronchoscopy Nursing Diagnosis: Ineffective airway clearance r/t thick, tenacious secretions Ineffective breathing pattern r/t airway inflammation Tuberculosis Altered nutrition less than body requirements sec. to anorexia and fatigue Fatigue sec. to disease process Anxiety sec. to social isolation secondary to isolation protocols Planning: Clients Outcomes Maintain clear airway,normal RR, achieve weight gain, anxiety decreased Interventions: Maintain respiratory isolation- infectious period - diversional activities Barrier protection should be used Evaluation: Client adheres to isolation precautions, takes medication as prescribed Complications Miliary TB The organism invade the blood stream and can spread to multiple body organ Meningitis Pericarditis Tuberculosis Promote airway clearance- bedrest, increase fluid intake, high humidity Pharmacology First-line meds- Isoniazid, Rifampin, Ehtambutol, & Pyrazinamide for 4 months Isoniazid and Rifampin continued for an additional 2 months or up to 12 months. Advocate adherence & prevention Monitor and manage potential complications Adequate nutrition Provide client and family education Provide emotional support Tuberculosis Questions to ask Do you have difficulty breathing- all the time or is it caused by exertion? Do you cough frequently and is it productive? Have you had a weight loss? Do you feel tired quite often and are your activities impaired by SOB or fatigue? Do you have many respiratory infections? Over what period of time? Tuberculosis Nursing Diagnosis Ineffective airway clearance r/t thick, tenacious secretion and fatigue Ineffective breathing pattern r/t fatigue and obstruction of the bronchial tree Impaired gas exchange r/t increased sputum production Activity intolerance r/t hypoxemia & fatigue Altered nutrition r/t increased metabolic demands, fatigue, & anorexia Anxiety r/t inability to breathe effectively Tuberculosis Diagnostics: ABGs, CBC, sputum culture, CXR, Pulmonary function tests Planning: Client Outcomes Effectively clear airway and breathing pattern, maintain normal ABGs, increase activity with decrease SOB or fatigue, maintain weight, and less anxious with episodes of SOB Bronchitis Inflammation of the bronchi caused by irritants or infection hypertrophy & hypersecretion of mucous- cause increase in sputum production increase mucous- decrease airway lumen sizelumen becomes colonized with bacteria. Bronchial wall becomes scarred - leads to stenosis & airway obstruction Defined as a productive cough that lasts 3 months a year for 2 consecutive years with other causes excluded. Cough in the morning with sputum production is indicative of Chronic Bronchitis Bronchitis Risk Factors: cigarette smoking, exposure to pollution, hazardous airborne substances Clinical Manifestations: productive cough, dyspnea esp. on exertion, wheezing, use of accessory muscles to breathe, cyanosis- “blue bloater”, clubbed fingers Interventions: Assess patency of airway- suction if cough ineffective, RR, accessory muscle use, lung sounds, skin color changes, ABGs Encourage high fluid intake & instruct in effective breathing & coughing Monitor oxygen administration & aerosol therapy Chronic Bronchitis Encourage to report sputum changes or worsening of symptoms Encourage exercise to improve resp. fitness Counsel to avoid respiratory irritants and stop smoking Immunize against common flu and pneumonia Pharmacology: Antibiotic therapy- Tequin, Levaquin Bronchodilators- Albuterol, Combivent, Theophylline Corticosteroids- Prednisone, Solumedrol Bronchiolitis:Bronchiolitis is a common illness of the respiratory tract usually caused by viral infection. It affects the tiny airways, called the bronchioles, that lead to the lungs. As these airways become inflamed, they swell and fill with mucus, making breathing difficult. The variable degrees of obstruction produced in air passage by these changes lead to hyperpnoea & progressive emphysema. Bronchiolitis: Nursing Assessment Sometimes more severe respiratory difficulties gradually develop: Rapid, shallow breathing. Drawing in of the neck and chest with each breath, known as retractions. Flaring of the nostrils. Irritability, with difficulty sleeping and signs of fatigue or lethargy. Bronchiolitis Nursing care: Follow strict precautions to prevent spread of infection. Administer high humidified oxygen. Clear nasal congestion, try a bulb syringe and saline (saltwater) nose drops. Provide adequate Ng. Care for vomiting, fever, & diarrhea. Small frequent diet, & increase fluid intake. Lung abscess A lung abscess is a localized area of lung destruction liquefaction necrosis usually related to pyogenic bacteria Cavity formation Clinical manifestation Dyspnoea Chest pain Tachycardia Diagnosis Method CT Chest X ray Encourage exercise to improve resp. fitness Counsel to avoid respiratory irritants and stop smoking Immunize against common flu and pneumonia Pharmacology: Antibiotic therapy- Tequin, Levaquin Bronchodilators- Albuterol, Combivent, Theophylline