Medical Surgical Nursing - Respiratory Disorders and their Interventions

Nursing Intervention of Patients withRespiratory Tract Disorders

By: Andreas A. Teferra

11/4/2015 1Nursing Interventions for Patients with Respiratory

Disorders

Learning Objectives• At the end of the topic the learners will be able to:

Assess and diagnose a patient with respiratory disorders

Differentiate URTI and LRTI diseases.

State pathophysiology of patients with respiratory diseases

Mention the clinical manifestation of each respiratory problems.

Provide nursing care for a patient with respiratory disorders using nursing process


Disorders

Review of the Anatomy & Physiology of the Respiratory System

Upper and lower respiratory tracts.

Responsible for Ventilation

Upper airway, warms and filters inspired air

LRT (lungs) can accomplish gas exchange.

Gas exchange involves delivering oxygen to the tissues through the bloodstream and expelling waste gases.


Disorders

Respiration includes four distinct processes

Pulmonary ventilation (Breathing )

Gas exchange

External respiration Gas exchange between the respiratory membrane and the lungs

Internal respirationRefers to gas exchange across the respiratory membrane in the metabolizing tissues, like your skeletal muscles.

Oxygen utilization by tissues

Cellular respirationTakes place inside cells

Transport of respiratory gases11/4/2015 4

Nursing Interventions for Patients with Respiratory Disorders

Anatomy of the respiratory systemUpper respiratory division

Mouth /Nose → Pharynx → Larynx →Trachea→ bronchus → bronchioles.

Lower respiratory division

Respiratory bronchioles → Alveolar ducts → alveolar sacs → alveoli


Disorders

Lung Right Lung has three lobes

Left lung has two lobes

The structures of the chest wall (ribs, pleura, muscles of respiration)


Disorders

Lung….

Pleura

Parietal pleura

Visceral pleura

What is located between the two membranes?


Disorders

Movement of the Chest


Disorders

Lung volume and Lung capacities


Disorders

Assessment of the Respiratory SystemHealth history

Obtained by interviewing

Provides data why the patient needs Nursing care, what kind of care is required to maintain a sufficient intake of air

Helps to prioritize the problem and to plan interventions


Disorders

Assessment….

The assessment includes;

Any respiratory problems

Onset of the problems

Aggravating factors

Relieving factors

Any measures that was taken

Effects on daily living activity

• Reason the pt is seeking health care could be

Dyspnea (SOB)

Pain

Accumulation of mucus

Wheezing

Hemoptysis

Edema of the ankles & feet

Cough

Fatigue and weakness.


Disorders

Assessment….

Major Clinical Manifestations

Cough

Sputum production

Chest pain

Wheezing

Clubbing of the fingers

Cyanosis

Risk factorsSmoking

Pack years = (number of packs of cigarette per day) X (the number of years the person has smoked)Exposure to smokeHistory of attempts to quit, methods, results

Sedentary lifestyleAgeEnvironmental exposure

Dust, chemicals, etc.Obesity Family history

TB, Lung CA, Asthma


Disorders

Assessment….Cough

TypeDry, Moist, Productive

OnsetDurationPattern

Activities, time of daySeverity

Effect on ADLsWheezing Associated symptoms Rx and effectiveness

Sputum

Amount

Color

Presence of blood (hemoptysis)

odor

consistency

pattern of production


Disorders

Assessment….

Past Health History

– URI

– Trauma

– Surgery

– Chronic conditions of other systems

Family Health History

– Tuberculosis

– Emphysema

– Lung Cancer

–Allergies

–Asthma


Disorders

Physical Examination

• The nurse should proceed in well organized manner with a sequence of

– Inspection

– Palpation

– Percussion

– Auscultation


Disorders

InspectionThe nurse should inspect

– Any abnormality in the chest

– Movement of the chest

– Skin color of the thoracic area

– Respiratory rate and rhythm

– Uses of accessory muscles


Disorders

Inspection… Tracheal deviation

Barrel Chest

Pectus Excavatum

Cyanosis

Pigeon Chest


Disorders

Pectus Excavatum

Barrel

Chest

Inspection…

11/4/2015Nursing Interventions for Patients with Respiratory

Disorders18

Tracheal

Deviation Pigeon Chest

Palpation

The nurse should palpate

– Skin temperature

–Any mass, edema,

– Tenderness

–Vocal Fremitus

–Chest expansion


Disorders

Palpation…


Disorders20

Tactile

Fremitus Exam

Percussion• Identify the consistency of the tissue under the

thoracic cavity (air, fluid or solid).

• The sounds that are heard on percussion are;

– Resonance

– Dullness

– Hyper resonance

– Tympanic


Disorders

Percussion …


Disorders22

Percussion

notes on the

posterior chest

Percussion…


Disorders

Percussion ….


Disorders

Auscultation

• The nurse should move from the apex to the base with the stethoscope by comparing and contrasting one side with the other.

• It helps to hear normal breath sounds and added breath sounds.

• There are three classified sounds


Disorders

Auscultation…

• Vesicular Breath Sounds

– low pitch and soft intensity

– long inspiration phase than expiration phase

– heard over most lung area

– no clear gap between inspiration and expiration


Disorders

Auscultation…

Bronchial Breath Sounds

– high pitch and loud intensity

– long expiration phase than inspiration phase

– have clear gap between expiration and inspiration

– heard over the trachea


Disorders

Auscultation…

Bronchovesicular Breath Sounds

– Medium pitch

– equal expiration and inspiration phase

– heard posteriorly between the scapula & anteriorly in the first and second intercostals space


Disorders

Auscultation…

11/4/2015 29

Normal Auscultatory

Sounds


Auscultation….

Abnormal

• Decreased air entry - Pneumothorax, Atelectasis, Effusion.

• BBS in areas of VBS - Pneumonia, TB

Added sounds

• Wheezing - Asthma, Emphysema

• Cryptation Crackles - Pneumonia, TB , CHF

• Ronchii – secretion in large airway, fluid in bronchial tubes.


Disorders

Auscultation….


Disorders


• 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, hyper resonant sounds

• Auscultation– breath sounds, voice sounds, crackles, wheezes


Disorders

Diagnostic Procedures

• Sputum Studies

• Arterial Blood Gases

– measurements of blood pH , arterial O2 & CO2 tensions, acid-base balance

• Pulse Oximetry

• Chest X-ray

• Bronchoscopy

• Thoracentesis

• Laryngoscopy


Disorders

Diagnostic Procedure …


Disorders34

Diagnostic Procedures


Disorders35

Thoracentesis

Upper Airway Infections (URTI)

Viral Rhinitis (Common Cold)

The term “common cold” often is used whenreferring to an URTI.

The term “cold” refers to an afebrile, infectious, acute inflammation of the mucous membranes of the nasal cavity.

Caused by a virus (viral rhinitis).


Disorders

Viral Rhinitis…

Clinical Manifestations

Nasal congestion

Runny nose

Sneezing

Nasal discharge, Nasal itchiness

Tearing watery eyes, “scratchy” or sore throat

General malaise, low-grade fever, chills, and oftenheadache and muscle aches.

The symptoms last from 1 to 2 weeks.


Disorders

Viral Rhinitis - Management

No specific treatment

Symptomatic therapy

Adequate fluid intake

Encouraging rest

Increasing intake of vitamin C

Using expectorants as needed.

Warm salt-water gargles soothe the throat

NSAIDs

Antihistamines are used to relieve sneezing, rhinorrhea, and nasal congestion.


Disorders

Viral Rhinitis - Management

Nursing Management• Patient teaching of self care & prevention of infection & break chain of

infection

• Hand washing remains the most effective measure to preventtransmission of organisms.


Disorders

Acute Sinusitis– The sinuses, mucus-lined

cavities filled with air that drain normally into the nose.

– Acute sinusitis frequently develops as a result of an URTI particularly a viral infection or an exacerbation of allergic rhinitis.


Disorders

Acute Sinusitis …Pathophysiology

Acute sinusitis is an infection of the paranasal sinuses.

Develops as a result of an URI, and an exacerbation of allergic rhinitis.

Nasal congestion, caused by inflammation, edema, and transudation of fluid, leads to obstruction of the sinus cavities and result for bacterial growth.

Bacterial organisms account for more than 60% of the cases of AS, namely Streptococcus Pneumoniae and Haemophilus Influenzae.


Disorders

Acute Sinusitis…Clinical Manifestations

Facial pain or pressure

Nasal obstruction

Fatigue

Purulent nasal discharge

Fever

Headache

Ear pain and fullness

Dental pain

Cough

↓ed sense of smell

Sore throat

Eyelid edema

Facial congestion or fullness.


Disorders

Acute Sinusitis…

Medical management

Antibiotics (Amoxicillin & Ampicillin).

Decongestants may be administered.

Saline irrigation for opening blocked passages, there by allowing drainage of purulent discharge.

Topical decongestants should be administered with the patients head back to promote maximal drainage.


Disorders

Acute Sinusitis…

Nursing intervention

The nurse can instruct the patient on methods to promote drainage such as

Inhaling steam (steam bath, hot shower)

Increasing fluid intake

Applying local heat (hot wet packs)


Disorders

Acute Sinusitis…

Complications

Meningitis

Brain abscess

Ischemic Infarction

Osteomyelitis


Disorders

Chronic Sinusitis

Chronic Sinusitis is an inflammation of the sinuses that persists for more than 3 weeks in an adult and 2 weeks in a child.


Disorders

Chronic Sinusitis…Pathophysiology

Narrowing or obstruction in the Ostia (openings)of the sinuses.

Could be because of infection, allergy, or structural abnormalities

Results in stagnant (non flowing) secretions, an ideal medium for infection.

The organisms are the same as those implicated in acute sinusitis.


Disorders

Chronic Sinusitis…Clinical Manifestations

Impaired mucociliary clearance and ventilation

Cough

Chronic hoarseness

Chronic headaches in the periorbital area

Facial pain.

Fatigue and nasal stuffiness.

Decrease in smell and taste and a fullness in theears.


Disorders

Chronic Sinusitis…Diagnostic Findings

CT scan of the sinuses

MRI

Nasal Endoscopy

Management

Almost the same as forAcute Sinusitis.

The course of treatmentmay be 3 to 4 weeks

Complications

Severe orbital cellulites

Subperiosteal abscess

Sinus thrombosis

Meningitis

Encephalitis

Ischemic Infarction.


Disorders

Chronic Sinusitis…


Disorders50

Orbital CellulitesSubperiosteal Abscess

Tonsillitis and Adenoiditis

Is the inflammation of tonsils and adenoids.

Infection of the adenoids frequently accompanies acute tonsillitis.

Group A beta-streptococcus is the most common organism associated with tonsillitis and adenoiditis.


Disorders

Tonsillitis and Adenoiditis…Clinical manifestation

Sore throat

Fever

Snoring

Difficulty in swallowing

Ear ache

Draining ears

Bronchitis

Foul smelling

Voice impairment

Noisy respiration


Disorders

Tonsillitis and Adenoiditis …

Peritonsillar abscess

Is a collection of purulent exudate between the tonsillar capsule and the surrounding tissues, including the soft palate.

Develop after an acute tonsillar infection, progresses to a local cellulitis & abscess


Disorders


C/M of Peritonsillar abscess

Odynophagia

Otalgia

Dysphagia

Thickening of the Voice

Drooling & local pain

Swelling of the soft palate


Disorders


Medical management

Antibiotics (usually penicillin)

Abscess must be drained

Abscess may also be incised and drained


Disorders

Tonsillitis and Adenoiditis …Surgical Management

Tonsillectomy or Adenoidectomy

Tonsillectomy or Adenoidectomy is indicated only if

Repeated period of illness of tonsillitis

Hypertrophy of the tonsils and adenoids thatcould cause obstruction and obstructive sleepapnea

Repeated attacks of purulent Otitis media


Disorders


Nursing intervention

– Patient Education

– Advise adequate fluid intake

– Frequent use of mouth washes and gargles using saline solution


Disorders

Acute Pharyngitis

Is an inflammation in the throat.

Usually causing symptoms of a sore throat.

Most cases caused by viral infection.

When group A beta-hemolytic streptococcus, the most common bacterial organism, causes Acute Pharyngitis (Strep Throat).


Disorders

Acute Pharyngitis …


Disorders59

Acute Pharyngitis…Pathophysiology

Infection

Inflammatory response in the pharynx

Pain, fever, vasodilation, edema, and tissue damage

Manifested by redness and swelling in the tonsillarpillars, uvula, and soft palate

A creamy exudate may be present in the tonsillarpillars

If left untreated, leads to bacteremia, pneumonia,meningitis, rheumatic fever, or nephritis


Disorders

Acute Pharyngitis…

Clinical Manifestation

Affected pharyngeal membrane and tonsils

Lymphoid follicles that are swollen with exudates.

Enlarged and tender cervical lymph nodes

Fever and malaise

Sore throat

Hoarseness cough and rhinitis


Disorders

Acute Pharyngitis… Complication

Sinusitis

Otitis media

Pneumonia

Peritonsilar abscess

Mastoiditis

Cervical Adenitis

Rheumatic fever

Nephritis

Diagnostic Findings

– Rapid screening tests for streptococcal antigens Streptolysin titers

– Throat cultures

– Nasal swabs and blood cultures


Disorders

Acute Pharyngitis… Medical management

– Viral pharyngitis is treated with supportive measures.

– Bacterial pharyngitis is treated with Antibiotics.

– Antibiotics are administered for at least 10 days

– Liquid or soft diet is provided during the acute stage of the disease.

– In sever situations; fluids are administered by intravenously.


Disorders

Acute pharyngitis… Nursing intervention

– Patient education

– Patient should stay in bed during the febrile stage

– Alcohol, tobacco, second-hand smoke, and exposure to cold are avoided

– Encourage the patient to drink plenty of fluids.

– Gargling with warm saline solutions may relieve throat discomfort.

– Lozenges will keep the throat moistened


Disorders

Chronic Pharyngitis

persistent inflammation of the pharynx.

common in adults who work or live in dusty surroundings

use their voice to excess

suffer from chronic cough, and

habitually use alcohol and tobacco.


Disorders

Chronic Pharyngitis ….


–Constant sense of irritation or fullness in the throat

–Mucus that collects in the throat and can be expelled bycoughing, and

–Difficulty swallowing


Disorders

Chronic Pharyngitis ….Management

Is based on relieving symptoms,

Avoiding exposure to irritants, and

Correcting any upper respiratory, pulmonary, orcardiac condition that might cause chronic cough.

Nasal congestion may be relieved by short-term use of nasal sprays or medications containing ephedrine sulfate or phenylephrine hydrochloride.


Disorders

Chronic Pharyngitis ...Antihistamine decongestant medications, such asDrixoral or Dimetapp, is taken orally every 4 to 6hours.

Aspirin or Acetaminophen is recommended forits anti inflammatory and analgesic properties.

Encourage the patient to drink plenty of fluids.

Gargling with warm saline solutions may relievethroat discomfort.

Lozenges will keep the throat moistened.


Disorders

Chronic Pharyngitis…


Disorders69

LaryngitisIs an inflammation of the larynx

Often occurs as a result of voice abuse or exposure to dust, chemicals, smoke & other pollutants, or as part of an URTI.

It also may be caused by isolated infection involving only the vocal cords.

The cause of infection is almost always a virus.


Disorders

Laryngitis…

Usually associated with allergic rhinitis or pharyngitis.

The onset of infection may be associated with exposure to sudden temperature changes, dietary deficiencies, malnutrition, and an immune suppressed state.


Disorders

Laryngitis…Clinical Manifestations

– Hoarseness

– Aphonia (complete loss of voice)

– Severe cough

– Chronic laryngitis is marked by persistent hoarseness

– May be a complication of URTI


Disorders

Laryngitis…Medical Management

Resting the voice

Avoiding smoking

Avoiding second-hand smoke

Inhaling cool steam or an aerosol

Appropriate antibacterial therapy

Topical corticosteroids, such as Vanceril inhalation


Disorders

Laryngitis…Nursing Management

The nurse instructs the patient

To rest the voice

To maintain a well-humidified environment.

Expectorant agents are suggested

Along with a daily fluid intake of 3 L to thin secretions.


Disorders

Laryngitis…COMPLICATIONS

Sepsis

Meningitis

Peritonsillar abscess

Otitis media

Sinusitis


Disorders

Management of Patients With Chest and Lower Respiratory Tract

Disorders


Disorders

Acute Bronchitis– Is a common acute inflammation of the mucous

membrane lining the inside of the bronchi

– Often follows URTI and often occurs in people with chronic lung disease.

Causes

– Bacteria (Streptococcus Pneumonia and Hemophilus Influenza)

– Virus and chemical and smoke irritants also can cause inflammation


Disorders

Acute Bronchitis …Pathophysiology

–Colonization of bacteria to the bronchi

– Inflammation of the bronchi

–As inflammation progresses there is increased blood flow to the bronchi

–Causing an increase in pulmonary secretions (so goblet cell produces mucus)


Disorders

Acute Bronchitis …


– Dry, irritating cough

– Scanty amount of mucoidsputum

– Sternal soreness

– Fever (low grade)

– Chills

– Night sweats

– Headache

– General malaise

– Shortness of breath


– Rhonchi and Wheezes

Diagnosis

– Hx

– P/E

– CXR to R/o Pneumonia


Disorders

Acute Bronchitis…Medical Management

– Antibiotic treatment

– Usually don’t prescribe Antihistamines

– Expectorants may be prescribed

– Increase fluid intake

– Suctioning

– Moist heat to the chest may relieve the soreness and pain.

– Mild analgesics or antipyretics may be indicated.


Disorders

Pneumonia– An inflammation of the lower respiratory tract

that involves the lung parenchyma.

Causes:

bacteria

virus

fungus

chemical or radiations


Disorders

Pneumonia….Mode of transmission

• Pathogens can be introduced into the lungs by 3primary routs

Aspiration:- transmitted micro-organisms from the oropharynx and GIT to the lungs by direct-contact

Causes

• Glottis disorder

• Pts with NGT

• Unconscious patients


Disorders

Pneumonia…Inhalation:

It is an important MOT for organisms suspended in water droplets and spread into the air with coughing, sneezing and talking.

Circulatory spread:

Spread of infection occurs when pathogens are transmitted through the circulatory system to lung from pre-existing infection in other parts of the body.


Disorders

Pneumonia…Pathophysiology

Invasion of microorganisms

Inflammatory reaction occurs in the alveoli

Exudates production that interferes with the diffusion of oxygen and carbon dioxide.

Migration of WBC, mostly neutrophils and filling of the normal air containing space.

Reduced ventilation of the lung b/c of secretions & mucosal edema that cause partial occlusion of the bronchi or alveoli

Decreased alveolar oxygen tension

Hypoxia


Disorders

Classification of PneumoniaBased on the place where it’s acquired

Community acquired pneumonia

Pneumonia that occurs in the community

CAP occurs either in the community setting or within the first 48 hours of hospitalization.

Usually begins as common respiratory infections

Streptococcus Pneumonia is the most common cause


Disorders

Classification of Pneumonia…Common agents are S. Pneumoniae, H. Influenzae, Legionella, Pseudomonas Aeruginosa, and other gram negative rods

Influenzae is another cause of CAP

Mycoplasma Pneumonia, occurs most often in older children and young adults

Viruses are the most common cause of pneumonia in infants and children but are relatively uncommon causes of CAP in adults.


Disorders

Classification…Hospital acquired pneumonia

HAP, also known as nosocomial pneumonia, is defined as the onset of pneumonia symptoms more than 48 hours after admission to the hospital

Results from exposure to potentially infectious agents, such as P. Aeruginosa, S.Aurous in the hospital setting


Disorders

Classification ...

These bacilli colonize in the Oropharyngeal region and are aspirated to the lungs

Common organisms: Enterobacter species, Escherichia coli, Klebsiella species, Proteus, Serratia marcescens, P. aeruginosa, and methicillin-sensitive or methicillin-resistant Staphylococcus aureus.


Disorders

Classification…Anatomical Classification

Lobar pneumonia A substantial portion of one or more lobes is involved.

Bronchopneumonia

Describes pneumonia that is distributed in a patchy fashion


Disorders

Classification...According to causative agents

Bacterial Pneumonia

–Can be caused by both from –ve and from +ve bacteria.

– Streptococcus Pneumonia is the most common bacteria & causative agent

–Most prevalent during the winter and spring when URTIs are more frequent


Disorders

Classification…Viral pneumonia

– Influenza virus type A is the most type of causative agent in a healthy person

–CMV is the most common cause of viral pneumonia in Immunosuppressed patient with high mortality rate


Disorders

Classification ….Fungal pneumonia

– Most common in immune compressed and neurogenic patients

– Histoplasmosis is caused by Histoplasma Capsulatum

Other pneumonia

– Protozoa and Helminths

– PCP which caused by Pneumocystic Carini has high incidence with AIDS


Disorders

Classification …Pneumonia classified as based of C/M

Typical

– (The most causative agents; Streptococcus pneumonia, staphylococcus pneumonia, klebsella pneumonia, pseudomonas pneumonia, H. influenza)

Atypical• (Pneumonia associated with mycoplasma

pneumonia, influenza virus, legionella pneumonia, Pneumocystis carinii , fungal pneumonia )


Disorders

Clinical ManifestationsFor Typical Pneumonia

– Chills

– Abrupt onset of fever

– Cough with purulent sputum

– Chest pain

– Tachypnea

– Granting

– Nasal flare

– accessory muscles use

Physical Examinations

– Dullness to percussion on the affected area of lung

– Increased fremitus on palpation

– Bronchophony, Egophony, Crackles on auscultation

– WBC generally elevated


Disorders

C/M…For Atypical Pneumonia

– Gradually many patients have had symptoms of URTI (nasal congestion, sore throat)

– Symptom are headache, low-grade fever, pleuritic pain, myalgia, rash and pharyngitis

– Dry cough and sub-mucoid sputum

– Physical examination reveal scattered wheeze and crackles WBC commonly < 10,000


Disorders

Pneumonia…

Diagnoses

– History

– Physical Examination

– Chest X-Ray

– Blood culture

– Sputum examination


Disorders

Pneumonia… Treatment

– Administration of appropriate antibiotic as determined by the result of Gram Stain.

– Supportive therapy

– Bed rest, maintenance of adequate fluid and nutritional intake

– Warm, moist inhalation to relieve bronchial irritation, mild analgesic to relieve pain, and administration of O2 if hypoxia develops.


Disorders

Pneumonia… Potential complications

– Hypotension and shock

– Respiratory failure

– Atelectasis

– Pleural Effusion

– Delirium

– Superinfection


Disorders

Pneumonia… Nursing care

– Improving airway potency

– Removing secretion

– High level of fluid intake (2-3 L/d) is encouraged that thins and loosens pulmonary secretion and also replace fluid losses resulting from fever, diaphoresis .

– Chest Physiotherapy :- important in loosening and mobilization secretions

– Promote rest and conserving energy

– Promoting fluid intake

– Monitoring and managing potential complications


Disorders

Chronic Obstructive Pulmonary Disease (COPD)

A disease state characterized by airflow limitation that is not fully reversible

COPD may include diseases that cause airflow obstruction (e.g., Emphysema, Chronic Bronchitis) or a combination of these disorders

Common during the middle adult years, and the incidence of COPD increases with age.


Disorders

COPD…Pathophysiology

Exposure to noxious particles or gases

Progressive abnormal inflammatory response of the lungs throughout the airways, parenchyma and pulmonary vasculature

Narrowing occurs in the small peripheral airways

Over time, this injury-and-repair process causes scar tissue formation and narrowing of the airway lumen

And also Parenchymal destruction

Airflow limitation/obstruction


Disorders

Chronic Bronchitis

A disease of the airways, defined as the presence ofcough and sputum production for at least 3 monthsin each of 2 consecutive years.

Causes

– Cigarette smoking

– Exposure to pollution

– A wide range of viral, bacterial and mycoplasma infection can produce acute episodes.


Disorders

Chronic Bronchitis…

Pathophysiology

– Smoke irritates the airways ,resulting in hyper secretion of on mucus and inflammation

– Because of this constant irritation, the mucus secretion glands and goblet cells increase in number, cilia function is reduced and more mucus is produced.

– Bronchial walls become thickened, the bronchial lumen is narrowed, and mucus may plug the airway


Disorders


– Alveoli adjacent to the bronchioles may become damaged and fibrosed, resulting in altered function of the alveolar macrophages.

– The patient becomes more susceptible to respiratory infection.

– Further bronchial narrowing occurs, possibly resulting in emphysema and bronchiectasis


Disorders



Disorders105

Pathophysiology of Chronic Bronchitis



– A chronic productive cough in the winter month is the earliest sign of chronic bronchitis

– The cough may be exacerbated by cold weather dampness and pulmonary irritants

– The patient usually has a history of cigarette smoking and frequent respiratory infections


Disorders

Chronic Bronchitis…Diagnostic Evaluation

– A complete history of exposure to irradiating substances and occupational history is taken including smoking habits (number of packs per day)

– The pulmonary function studies - decrease in vital capacity and forced expiratory volume

– Hematocrit and Hemoglobin may be slight increased

– The blood gas analysis may reveal hypoxia with hypercapnia

– The CXR may reveal an enlarged heart with normal or flattened diaphragm


Disorders

Chronic Bronchitis…Medical management

Recurrent bacterial infections are treated with antibiotic therapy

To help removing bronchial secretion

Bronchodilators are prescribed to relieve bronchospasm

Postural drainage and Chest Percussion

Fluid administration


Disorders

Chronic Bronchitis… Prevention

– Preventing its occurrence

– Avoids respiratory irritants (tobacco smoke)

– Treat infection

– Immunize against Influenza and Pneumonia etc.


Disorders

Pulmonary Emphysema

– Is abnormal distention of air spaces beyond the terminal bronchioles with destruction of the walls of the alveoli.

– In emphysema, impaired gas exchange results from destruction of the walls of over distended alveoli.

– Is the end stage a process that has progressed slowly for many years

– By the time the patient develops symptoms, pulmonary function is irreversibly impaired


Disorders

Pulmonary Emphysema...The walls of the alveoli are destroyed

The alveolar surface area continually decreases

Increase in dead space and impaired oxygen diffusion, leads to hypoxemia.

As the alveolar walls continue to break down, the pulmonary capillary bed is reduced

Pulmonary blood flow is increased forcing the right ventricle to maintain a higher blood pressure in the pulmonary artery


Disorders

Pulmonary Emphysema….CO2 elimination is impaired

Hypercapnia

Hypoxemia

Increased Pulmonary Artery Pressure.

RHF (Cor-Pulmonale)

Congestion, Dependent edema, Distended neck veins.


Disorders

Types of Emphysema Panlobular Emphysema

Destruction of respiratory bronchiole, alveolar duct, and alveoli.

All the air spaces within the lobule are enlarged.

Patient has a barrel chest, marked dyspnea on exertion and weight loss

Centrilobular EmphysemaThe pathologic changes take place mainly in the center of secondary lobule, while the peripheral portions of the acinus are preserved.

Derangement of ventilation-perfusion ratios, producing chronic hypoxemia, hypercapnia, polycythemia & episodes of RHF.

Leads to central cyanosis, peripheral edema and respiratory failure.


Disorders

Types of Emphysema…


Disorders114

Pulmonary Emphysema…Risk Factors

– Environmental exposures

–Cigarette smoking - major

–Antitrypsin deficiency (enzyme inhibitor)


Disorders

Pulmonary Emphysema… C/M’s

– Dyspnea and insidious onset.

– History of cigarette smoking

– Long history of chronic cough

– Wheezing

– Rapid breathing

– Anorexia

– Weight loss

– Weakness

– Neck veins may be distended during expiration11/4/2015 116


Pulmonary Emphysema…P/E

– Hyper-resonance

– Barrel chest

– Dyspnea

– Prolonged wheezing on expiration

Dx

– Hx.

– P/E

– CXR

– Pulmonary Function Test

– CBC


Disorders

Pulmonary Emphysema…Management

Goal of treatment – To improve the quality of life – To slow the progression of the disease process– To treat the obstructed air ways to relive hypoxia

Rx– Bronchodilators – Aerosol therapy– Corticosteroids– Oxygen supplement – Antibiotics


Disorders

Bronchiectasis

Chronic, irreversible dilatation of the bronchial tree.

Associated with chronic infection and inflammation of these passageways.

Causes

Airway obstruction

Diffuse airway injury

Pulmonary infection

Obstruction of the bronchus

Genetic disorder such as Cystic Fibrosis

Abnormal host defense11/4/2015 119


Bronchiectasis…Pathophysiology

– Infection damages the bronchial wall

– Causing a loss of its supporting structures

– Producing thick sputum

– It may obstruct the bronchi

– The walls permanently distended by severe coughing

– The lower lobes are most frequently involved


Disorders

Bronchiectasis…– Retention of secretion and subsequent obstruction

ultimately causes the distal alveoli to obstruct and collapse (Atelectasis)

– Inflammatory scarring or fibrosis replaces functioning lungs tissue

– Patient develops respiratory insufficiency with reduced vital capacity, decreased ventilation and an increase ratio of residual volume to total lungs capacity.


Disorders

Bronchiectasis…– There is impaired milking of inspired gas,

Ventilation perfusion imbalance and hypoxemia.


Disorders

Bronchiectasis…Clinical manifestation

– Chronic productive cough, with sputum

– Hemoptysis

– Clubbing of the fingers

– Repeated episodes of respiratory infection

– Dx is established on the basis of Bronchography.


Disorders

Bronchiectasis…

• Bronchography is a radiological technique, which involves x-raying the respiratory tree after coating the airways with contrast.


Disorders124

Bronchiectasis… Medical management

The objectives of RX are to prevent and control infection and to promote bronchial drainage

– Infection is controlled with anti-microbial therapy

– Postural drainage of the bronchial tube

– Patient should be vaccinated against Influenza & Pneumococcus

– The affected chest area may be percussed

– Brochodilator (Ventolin, Xopenex …)

– Increase oral fluid intake


Disorders

Bronchiectasis… Surgical management

It may be necessary to remove

– A segment of a lobe (segmental resection)

– A lobe (lobectomy)

– An entire lungs (pneumonectomy)

– Bronchography aids in delineating the segment.


Disorders

Bronchial Asthma– Asthma is an intermittent, reversible, obstructive

airway disease in which the trachea and bronchi responds in a hyperactive way of certain stimuli.

– It is characterized by bronchial hyperactivity to various stimuli causing;

• Narrowing of airways or reversible bronchospasm

• Edema of the muscular surface of bronchioles

• Increased mucous production


Disorders

Bronchial Asthma…Etiology and Classification

1. Allergic /Extrinsic/ Atopic asthma

– It is caused by known allergens e.g. dust, pollen, food, animals, perfumes, etc...

– The patient usually has a family history of allergies & a past medical history of eczema or allergic rhinitis.

– It is more common than other types and is responsible for most of the childhood asthma but often out grow the diseases by adolescent.


Disorders

Bronchial Asthma…2. Non-Allergic /Intrinsic/ Non-Atopic Asthma

– It is not related to specific allergen.

– It occurs, in adults and becomes more severe and frequent with time

– Can progress to Chronic Bronchitis and Emphysema

– Factors such as respiratory infections, exercise, emotional stress, cold, environment pollutants, some pharmacologic agents such aspirin and other NSAIDs, hair dye etc … may also trigger an attack


Disorders

Bronchial Asthma…Pathophysiology

– Exposure to allergens

– IG-E attach with mast cells

– release several chemical mediators

– Inflammation

– mucosal edema, bronchospasm and increased mucus production

– alveoli hyperinflate


Disorders

Bronchial Asthma…


Disorders

Bronchial Asthma…Clinical Manifestation

– Dyspnea

– Cough and wheezing

– Sensations of chest tightness

– Slow, laborious or forceful, wheezing breathing

– Expiration is always, much more strenuous and prolonged than inspiration, which forces the patient to sit upright and use every accessory muscle of respiration

– Obstructed airway causes Dyspnea


Disorders

Bronchial Asthma…– Initially coughing is tight and dry but soon

becomes productive

– The attack may last from 30 minutes to several hours and may subside spontaneously, occasionally a more severe continues reaction called status Asthmaticus occurs

• An acute, severe asthma attack that doesn't respond to usual use of inhaled bronchodilators and is associated with symptoms of potential respiratory failure is called Status Asthmaticus.

• This condition is life threatening


Disorders

http://www.webmd.com/asthma/guide/status-asthmaticus

http://www.webmd.com/asthma/guide/asthma_inhalers_bronchodilators

Bronchial Asthma…Later signs

– Cyanosis secondary to severe hypoxia

– Symptoms of CO2 retention including sweating, tachycardia, and widened pulse pressure

– Related reactions like eczema, rash


Disorders

Bronchial Asthma…Diagnosis

– No single test confirm the diagnosis of asthma

– A complete history, including family, environmental and occupational history

– Sputum - clear and foamy (allergic asthma) and thick and white(non allergic asthma)

– CXR during the attacks

– Increased serum IgE in Allergic asthma

– Arterial blood gas analysis (PCO2)


Disorders

Bronchial Asthma…Management

1. Prevention of the attack– Avoidance of the causative agent and the

situation that precipitate an attack

– Cromolyn Sodium prevents release of inflammatory mediators but has no benefit if taken during the attack.

2. Treating or managing the attack– There are 5 categories of medication used in the

treatment of asthma.


Disorders

Bronchial Asthma…1. B-Agonist/Adrenergic agents

– It includes adrenaline, metaproterenol, terbutalineetc...

– They are initial medication used because they dilate bronchial smooth muscles and increase cilliarymovement, decrease the chemical mediators.


Disorders

Bronchial Asthma…2. Methylxanthin

– Aminophyllin (IV injection) and Theopyilline (PO), are used because of their bronchodilating effects.

– They relax bronchial smooth muscle, increase movement of mucus in the airways, and increase the contraction of the diaphragm

– Methaylxanthins are not used in acute attacks b/c they have slower effect than beta agonists

– Caution should be given when administering, if given too rapid tachycardia or cardiac arrhythmia may result.


Disorders

Bronchial Asthma…


Disorders139

Bronchial Asthma…3. Anticholinergics

– Includes Atropine Methyl-Nitrate, IpratopiumBromide.

– They have excellent bronchodilatory effect with minimal side effects

– Act by reducing inflammation

and bronchoconstriction.


Disorders

Bronchial Asthma…4. Corticosteroids

– It includes Hydrocortisone (IV), Prednisolone (orally), Dexamethasone (inhalation).

– They may be used for acute attacks that do not respond to bronchodilators.

– They are particularly beneficial for those who are not candidates for B-Agonists and Methaylxanthinbecause of their underling cardiac disease


Disorders

Bronchial Asthma…5. Mast cell inhibitors

– Cromolyn Sodium (inhalational), a mast cell inhibitor prevents the release of chemical mediators of anaphylaxis there by resulting bronchodilation and decrease airway inflammation .

– most beneficial between attacks or while the asthma is in remission.

– Oxygen administration

– Monitoring arterial blood gases

– Fluid administration


Disorders

Bronchial Asthma…Status Asthmatics

– It is severe and persistence asthma that does not respond to conventional therapy.

– The attack lasts longer than 24 hours.

C/M

– The same as asthma but severe

– Laboured breathing

– Prolonged expiration

– Engorged neck vein, wheezing


Disorders

Bronchial Asthma…

Rx

– Beta-Agonists and Corticosteroids

– Oxygen administration

– IV fluid administration

– Frequent monitoring


Disorders

Lung AbscessIt is localized necrotic lesion of the lung parenchyma containing purulent material, the lesion collapse and forms a cavity.

It is generally caused by aspiration of anaerobic bacteria.

CXR will demonstrate a cavity of at least 2cm.


Disorders

Lung Abscess…Risky clients for aspiration

Patients with impaired cough reflexes

Patients with swallowing difficulty

Patients with altered state of consciousness

Drug addiction, Alcoholism or Esophageal disease, as well as patients fed by NGT

Immunocompromised patients

Patients with Pneumonia


Disorders

Lung Abscess… Etiology

Staphylococcus Aurous

Klebsiella

Anaerobic bacteria (more prevalent)


Disorders

Lung Abscess… Pathophysiology

– It is a complication of bacterial pneumonia or aspiration of oral anaerobes into the lung.

–May occur secondary to mechanical or functional obstruction of the bronchi by a tumor, foreign body, bronchial stenosis, necrotizing pneumonias, TB, pulmonary embolism etc.


Disorders

Lung Abscess… The site of the lung abscess is related to gravity and is determined by the pt’s position.

For pts who are confined to bed, theposterior segment of an upper lobe and the superior segment of the lower lobe are the most common areas in which lung abscess occurs.


Disorders

Lung Abscess…Initially, the cavity in the lung may or may not extend directly into a bronchus.

Eventually the abscess becomes encapsulated.

The necrotic process may extend until it reaches the lumen of a bronchus or the pleural space and establishes communication with the respiratory tract, the pleural cavity.


Disorders

Lung Abscess…– If the bronchus is involved, the purulent contents

are expectorated continuously in the form of sputum.

– If the pleura is involved, an Empyema results.

– A communication between the bronchus and pleura is known as a bronchopleural fistula.


Disorders

Lung Abscess…

Clinical manifestations

Productive cough which is foul smelling sputum that often bloody sputum

Pleurisy, or dull chest pain

Dyspnea, weakness, anorexia and weight loss

Fever & cough may develop insidiously & may have been present for several weeks before diagnosis.


Disorders

Lung Abscess…Diagnosis

– History

– Physical examination

• Dullness

• Decreased or absent breath sound

• Pleural friction rub

• Crackles

• CXR and culture of sputum are confirmatory of the diagnosis


Disorders

Lung Abscess…

Medical management

Antibiotic parentrally

• Cloxacillin for Ataph. Aureus

• Clindamycin or Penicillin + Metronidazole

• Large dose is needed to pass the necrosis & followed by long-term therapy with an oral agents (6-16 weeks)

Adequate drainage by postural drainage and chest physiotherapy


Disorders

Lung Abscess… • Diet: high protein and calories should be given

• Surgical intervention

Prevention

– Before tooth extraction if there is infection give antibiotics.

– Adequate dental and oral hygiene

– Appropriate Rx for patients with Pneumonia


Disorders

Lung Abscess… Nursing intervention

Prescribed antibiotic

Chest physiotherapy

Nutrition

Emotional support pt. education on homecare

Wound care if surgery is performed

Deep breath and coughing every 2 hrs.

Postural drainage


Disorders

Lung Cancer

– Lung cancer (broncho-carcinoma) is a malignant tumor arising from the bronchus.

– Evidences indicate that carcinoma tends to rise at site of previous scaring (TB, Fibrosis) in lung.

– Most causes are preventable if smoking is controlled.


Disorders

Lung Cancer…Risk factors include:

– Tobacco smoking (active and passive smoking)

– Air pollutions (Sulfur, Pollutants)

– exposure - Industrial carcinogens such as Arsenics and Radiation

– Genetics predispositions


Disorders

Lung Cancer…


– Chronic cough

– Wheezing

– Chest pain and tightness

– Hoarseness

– Dysphagia

– Head and neck edema

– Pleural or pericardial effusions

– Anorexia

– Weight loss

– Anemia

– Fatigue

– Clubbing of fingers

– Hemoptysis

– Shortness of breath

– Frequent lung infections


Disorders

Lung Cancer…Diagnosis

–History

–P/E

–CXR

– Sputum for malignant cell detection

– Lung Scans (liver, bone scans to detect metastases)


Disorders

Lung Cancer…Management

– Surgery

– Radiation therapy

– Chemotherapy

– Immunotherapy


Disorders

Empyema

– Empyema is a collection of purulent liquid pus in the pleural cavity.

– It may occur if a long abscess extends through to the pleural cavity.

– It is an unusual complication of a pulmonary infection, may occur if Rx is delayed


Disorders

Empyema…


Disorders163

Empyema…


– Fever

– Night sweats

– Pleural pain

– Dyspnea

– Anorexia

– Weight loss


– Decreased or absence of breath sounds

– Decreased Fremitus

– Flatness on Percussion

Diagnostic evaluation

– Thoracentesis

– CXR


Disorders

Empyema… Medical management

– Drainage of the pleural fluid depends on the stage of the disease

– Needle aspiration, if the fluid is not too thick

– Chest drainage using large diameter intercostals tube attached to water seal drainage

– Large dose of antibiotic depending on the causative agent is given


Disorders

Pleurisy– Inflammation of both layers of the pleura

Pathophysiology

– Pleurisy may develop in conjunction with pneumonia or an URTI, TB, after trauma to the chest, pulmonary infarction, or pulmonary embolism; in patients with primary and metastatic cancer; and after thoracotomy.


Disorders

Pleurisy…

– The parietal pleura have nerve endings; the visceral pleura does not.

– When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain.


Disorders

Pleurisy…


Disorders168

Pleurisy…Clinical manifestations

– Pleuritic pain is related to respiratory movement.

– Taking a deep breath, coughing, or sneezing worsens the pain.

– The pain may become minimal or absent when the breath is held, or it may be localized or radiate to the shoulder or abdomen.


Disorders

Pleurisy…Dx

– CXR

– Sputum

– Thoracentesis

– Pleural biopsy

Medical Management

– Treat the underlying cause, i.e Pneumonia

– Indomethacin

– Follow for signs of Pleural Effusion, i.e SOB, Pain


Disorders

PneumothoraxAir in the chest

Partial or complete collapse of the lung.


Disorders

Pneumothorax….Closed Pneumothorax

Is when air or gas gets in the pleural space without any outside wound

Occurs spontaneously

Occurs mostly in tall, thin individuals and in smokers

Patients who have had one spontaneous pneumothorax are at greater risk for a recurrence.

If untreated can become a tension pneumothorax


Disorders

Pneumothorax….Causes of Closed Pneumothorax

Blunt chest trauma

Air leakage from ruptured Emphysematous Bleb

Tubercular or Cancerous lesions

Severe bouts of coughing


Disorders

Pneumothorax…Open pneumothorax

Air enters the pleural space through an opening in the chest wall

Air sucking wound

It is a life treating condition

Can cause Tension Pneumothorax

There is a possibility of developing Hemothorax


Disorders

Pneumothorax…Causes of Open Pneumothorax

Penetrating chest injury

Insertion of a Central Venous Catheter

Chest surgery

Transbronchial Biopsy

bronchoscope is inserted through the nose or mouth to collect several pieces of lung tissue

Thoracentesis or Closed Pleural Biopsy.


Disorders

Pneumothorax…Tension pneumothorax

– is the progressive build-up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space but not to return. Positive pressure ventilation may exacerbate this 'one-way-valve' effect.

– When air in the pleural space is under higher pressure than air in the adjacent lung.

– When air enters the pleural space on inspiration but cannot leave it on expiration it produces a positive pressure in the chest cavity => lung collapse


Disorders

Pneumothorax…

Causes of Tension Pneumothorax

Penetrating chest wound treated with an air-tight dressing

Fractured ribs

Mechanical ventilation

Chest tube occlusion or malfunction.


Disorders

Pneumothorax…

Pneumothorax Clinical Manifestations Medical Management

Closed Smaller & slow developing Rapid sharp pain on inspiration Increased dyspnea DiaphoresisHypotension Tachycardia Absence of chest movement on the affected sideAbsence of breath sounds on affected side.

observation & treat on outpatient settingNeedle aspiration of air from pleural space Inspiration of chest catheter closed drainage system


Disorders

Pneumothorax… Pneumothorax Clinical manifestation Medical management

Open • Sucking sound at

wound site with

respiration

• Tracheal deviation

occlusion of open

wound

Same as for closed


Disorders

Pneumothorax… Pneumothorax Clinical manifestation Medical management

Tension Sever Dyspnea

Agitation

Tracheal deviation

Jugular venous

Distension

Breath sound absent

Subcutaneous

Emphysema

Ineffective ventilation

True emergency

Sterile dressing on

the defect

Insertion of chest

tube and closed

system


Disorders

Nursing Interventions For closed

Place in semi-fowler’s position

Administer oxygen

For outpatient or after chest tube removal, instruct to

– Report any increased dyspnea

– Avoid strenuous exercise

– Avoid holding breath


Disorders

Nursing Interventions…• For Tension

– Life-threatening event– Closed monitoring of vital signs – Observe for Cardiac Dysrhythmias – Check for Subcutaneous Emphysema in upper chest

and neck.

• For open – Occlude wound with Non-porous Covering – Same interventions as for closed pneumothorax.


Disorders

Pulmonary Embolism PE is the blockage of pulmonary arteries by a thrombus, fat, air emboli or tumor tissue.

Most PE arise from thrombi in the deep veins of the legs.

Common risk factors for PE are Immobilization, Surgery, Stroke, History of DVT and Malignancy.


Disorders

Risk Factors for Pulmonary Embolus

• Venous Stasis

Prolonged immobilization

Prolonged sitting/traveling

Varicose veins

Spinal cord injury

• Hypercoagulability

Injury

Tumor

Increased platelet count

• Venous Endothelial Disease

Thrombophlebitis

Vascular disease

Foreign bodies (IV)


Disorders

Risk Factors….• Certain Disease States

Heart disease

Trauma

Postoperative state

Diabetes Mellitus

COPD

• Other Predisposing

Advanced age

Obesity

Pregnancy

Oral contraceptive Use

Constrictive clothing


Disorders

PE….Pathophysiology

– When a thrombus obstructs a pulmonary artery

– The alveolar dead space is increased.

– Area to be ventilated receives little blood flow.

– Gas exchange is impaired in this area.

– Various substances are released from the clot and surrounding area

– Causing regional blood vessels and bronchioles to constrict.


Disorders

PE….– Causes an increase in pulmonary vascular

resistance.

– Ventilation-Perfusion imbalance.

– Results an increase in pulmonary arterial pressure

– Increase in right ventricular work to maintain pulmonary blood flow.

– Right ventricular failure occurs

– Decrease in Cardiac Output followed by a decrease in systemic BP

– Development of shock.11/4/2015 187


PE….Clinical Manifestations

Symptoms are nonspecific

Dyspnea

Tachypnea

Chest pain is usually sudden and pleuritic

It may be Substernal and mimic Angina Pectoris or MI

Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope.


Disorders

PE….Assessment and Diagnostic Findings

Ventilation-Perfusion scanA lung ventilation/perfusion scan, or VQ scan, is a test that measures air and blood flow in your lungs. A VQ scan most often is used to help diagnose or rule out a pulmonary embolism.

Pulmonary AngiographyPulmonary angiography is a test to see how blood flows through the lung. Angiography is an imaging test that uses x-rays and a special dye to see inside the arteries.

CXR

ECG

Impedance Plethysmography

Arterial blood gas analysis.11/4/2015 189Nursing Interventions for Patients with Respiratory

Disorders

PE….Medical Management

– Emergency management is of primary concern.

– The treatment of PE may include a variety of modalities:

• Measures to improve respiratory and vascular status

• Anticoagulation therapy

• Thrombolytic therapy

• Surgical intervention


Disorders

Cor PulmonaleCor Pulmonale (also called right ventricular failure)

Hypertrophy and dilation of the right ventricle developing secondary to disease affecting the structure or function of the lungs or their vasculature.

It can occur at the end stage of various chronic disorders of the lungs, pulmonary vessels, chest wall, and respiratory control center.


Disorders

Cor Pulmonale…

Causes

COPD

Bronchial Asthma

Pulmonary Hypertension

Vasculitis

Pulmonary Emboli

Kyphoscoliosis

Pectus Excavatum

Muscular dystrophy

Poliomyelitis

Obesity

High altitude


Disorders

Cor Pulmonale…Pathophysiology

In Cor Pulmonale, pulmonary hypertension increases the heart's workload.

To compensate, the right ventricle hypertrophies to force blood through the lungs.

Severity of right ventricular enlargement in CorPulmonale is due to increased afterload.

An occluded vessel impairs the heart's ability to generate enough pressure.


Disorders

Cor Pulmonale….Pulmonary hypertension results from the increased blood flow needed to oxygenate the tissues.

In response to hypoxia, the bone marrow produces more red blood cells, causing polycythemia.

The blood's viscosity increases, which further aggravates pulmonary hypertension.

This increases the right ventricle's workload, causing heart failure.


Disorders

Cor Pulmonale….In chronic obstructive disease, increased airway obstruction makes airflow worse.

The resulting hypoxia and hypercarbia can have vasodilatory effects on systemic arterioles.

Hypoxia increases pulmonary vasoconstriction.

The liver becomes palpable and tender because it is engorged and displaced downward by the low diaphragm.

Hepatojugular reflux may occur.


Disorders

Cor Pulmonale….Compensatory mechanisms begin to fail and larger amounts of blood remain in the RV at the end of diastole, causing ventricular dilation.

Increasing intrathoracic pressures impede venous return and raise jugular venous pressure.

Peripheral edema can occur and right ventricular hypertrophy increases progressively.

The main pulmonary arteries enlarge, pulmonary hypertension increases, and heart failure occurs.


Disorders

Cor Pulmonale….Clinical Manifestations

Symptoms of Cor Pulmonale are usually related to the underlying

lung disease, such as COPD.

With right ventricular failure, the patient may develop increasing edema of the feet and legs


Disorders

Cor Pulmonale….

Neck veins, an enlarged palpable liver, pleural effusion, ascites, and a heart murmur

Headache

Confusion, and Somnolence*

Hypercapnia

SOB

Wheezing, cough, and fatigue.


Disorders

Cor Pulmonale….Medical Management

• Therapy of Cor Pulmonale has three aims:

Reducing hypoxemia and pulmonary vasoconstriction

Increasing exercise tolerance

Correcting the underlying condition when possible.


Disorders

Cor Pulmonale….Bed rest to reduce myocardial oxygen demands

Digoxin to increase the strength of contraction of the myocardium

Antibiotics to treat an underlying respiratory tract infection

A potent pulmonary artery vasodilator, such as Nitroprussideor Hydralazine*


Disorders

Cor Pulmonale….Administration of low concentrations of oxygen

Mechanical ventilation to reduce the workload of breathing in the acute disease

A low-sodium diet with restricted fluid to reduce edema

Small doses of Heparin

Tracheotomy, if the patient has an upper airway obstruction


Disorders

Pulmonary Edema– Pulmonary edema is the abnormal accumulation

of fluid in the lungs.

– Pulmonary edema represents the ultimate stage of pulmonary congestion, in which fluid has leaked through the capillary walls and is permeating the airways, giving rise to dyspnea of dramatic severity.


Disorders

Pulmonary Edema…– Pulmonary congestion occurs when the

pulmonary vascular bed has received more blood from the right ventricle than the left can accommodate and remove.

– Non cardiac pulmonary edema has a wide variety of cause like near drowning, trauma, renal failure, drugs and inhaled toxins.


Disorders

Pulmonary Edema…– Medication overdose

– Neurogenic etiologies

– Cardiac cause (the most common)

– Atherosclerosis

– Hypertensive state

– Valvular defects


Disorders

Pulmonary Edema…C/F

– Sudden onset of breathlessness

– Sense of suffocation

– Hand becomes cold and moist

– Nail beds cold and cyanotic

– Skin color turns gray

– Weak rapid pulse


Disorders

Pulmonary Edema…

– Distended neck vein

– Productive cough

– Anxiety

– Confused, Stupor

– Noisy breathing

– Suffocation by the blood tinged, frothy fluid pouring into the bronchi and trachea

– Immediate action is needed.


Disorders

Pulmonary Edema…

• Diagnostic evaluation: Hx , P/E, Chest x- ray

Management

• Goal of medical management

– To reduce total circulating volume

– To improve respiratory exchange

– Oxygenation concentration adequate to relive hypoxia

– Morphin to reduce anxiety and dyspnea to decrease peripheral resistance

– Diuretics : Lasix (IV)

– Digitalis


Disorders

Pulmonary Edema…Prevention

– Placing the patient in an upright position with the feet and legs dependent

– Eliminating overexertion and emotional stress to reduce the left ventricular load

– Administering morphine to reduce anxiety, dyspnea, and preload

– Preventing circulatory overload IV fluids are administered slowly

– Surgical treatment: Minimize valvular detect.


Disorders

Pulmonary Edema…Nursing Management

Administration of oxygen, intubation and mechanical ventilation if respiratory failure occurs.

Adminstering medications (ie, morphine, vasodilators, inotropic medications, preload and afterload agents) as prescribed and monitors the patient’s response.


Disorders

TuberculosisIs a granulomatous inflammation.

Caused by M. Tuberculosis & M. Bovis.

M. tuberculosis is transmitted by inhalation of infective droplets coughed or sneezed.

M. Bovis is transmitted by milk from infected cows.


Disorders

Tuberculosis…

TB can affect almost all parts of the body, except the enamel of the teeth.

TB is closely associated with poverty, malnutrition, overcrowding, substandard housing, and inadequate health care.

The leading cause of death from infectious disease in the world.


Disorders


Disorders

Tuberculosis…

Pathophysiology

A susceptible person inhales mycobacterium bacilli and becomes infected

The bacteria are transmitted through the airways to the alveoli, where they are deposited and begin to multiply.

The bacilli also are transported via the lymph system and bloodstream to other parts of the body (kidneys, bones, cerebral cortex) and other areas of the lungs (upper lobes).

11/4/2015

213


Tuberculosis

The body’s immune system responds by initiating an inflammatory reaction

Phagocytes (neutrophils and macrophages) engulf many of the bacteria, and TB-specific lymphocytes lyse (destroy) the bacilli and normal tissue.

This tissue reaction results in the accumulation of exudate in the alveoli, causing bronchopneumonia, 2 to 10 weeks later.

11/4/2015

214


Tuberculosis…Clinical Manifestations

Low-grade fever

Cough

Night sweats

Fatigue

Weight loss

The cough may be non-productive, or mucopurulent sputum may be expectorated

Hemoptysis also may occur


Disorders

Tuberculosis…

Assessment and Diagnostic Findings

– A complete history

– Physical Examination

– CXR

– Acid-fast bacillus smear

– Sputum culture


Disorders

Medical TreatmentFirst-line Drugs

• Isoniazid

• Rifampin

• Streptomycin

• Ethambutol

• Pyrazinamide

Second-line Drugs

• Ethionamide

• Kanamycin

• Para-aminosalicylic acid

• Cycloserine


Disorders

Tuberculosis…

Assignments

Nursing Management for a patient with Tuberculosis using the Nursing Process. (to be presented)

Read about Pulmonary TB on Brunner and Suddarth textbook of MSN.


Disorders

Additional Reading Assignments

Postural Drainage

Chest Physiotherapy/Percussion

Tracheotomy

Thoracentesis

Water-Sealed Drainage


Disorders219

The End


Disorders

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Medical Surgical Nursing - Respiratory Disorders and their Interventions

Health & Medicine