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Respiratory Disorders I

Atelectasis
Pneumonia, SARS, Swine Flu
Pulmonary Tuberculosis
Pleural Effusion
Pulmonary Fibrosis
What do they have in common?
A 19 year old with rib fractures

A 35 year old s/p open cholecystectomy

A 56 year old with severe ascites

A 21 year old in her 9th month of pregnancy


Potential for:

Atelectasis
Risk Factors
Post op patients – immobility – low TV

Mucous plugging- airway obstruction – Ca

Incorrect intubation

Pregnancy, obesity, ascites

Pleural effusion – hemo/pneumthorax


Clinical Manifestations
They all have:

Low grade fever, O2 Sat


HR & RR
SOB, cough
Pleuritis, pleural friction rub
Decreased breath sounds
Localized crackles

For massive atelectasis there will be significant


s/s of respiratory distress
Atelectasis
Closure or collapse of the alveoli

Can be caused by obstruction or


compression

Can be a small or large portion of one or


both lung fields
Obstructive Atelectasis
Due to an obstruction between the alveoli and
trachea = reabsorption of alveolar gas = alveolar
collapse

may be secondary to a foreign body, benign or


malignant tumor, secretions, mucus plug, blood
clot, granulomas, inflammation or a side effect of
radiation
Obstructive Atelectasis
d/t a
lung tumor
which is
obstructing
the right
main
bronchus
Obstructive: incorrect ETT
placement
Blue: correct
ETT
placement

Red: ETT in
right
Atelectasis
main-stem
bronchus Overinflation
Compressive Atelectasis
A space-occupying lesion of the thorax
compresses the lung and forces air out of
the alveoli.
Consequences
Atelectasis can lead to:

Pneumonia

Respiratory Failure

Death

Avoid at all costs in those with impaired pulmonary


history or lung surgery (**pneumonectomy**)
Diagnosis & Treatment
CXR & physical findings

Best treatment is PREVENTION!

Early ambulation TCDB q 2 hrs & prn


IS q 1-2 hr WA Postural drainage
Vibropercussion Bronchodilators
Inhalants Suction prn

Administer pain meds & teach splinting


If preventative measures fail:
PEEP or IPPB

Bronchoscopy

ETT & mechanical ventilation

Thoracentesis/paracentesis

Thorocotomy tube (chest tube)

Surgery or radiation
Pneumonia
Infection/inflamation of the lung

CAP* vs FAP or (HAP)

caused by bacteria, viruses, fungi & parasites

6th most common disease cause of death

most common fatal nosocomial infection


CAP
Most common bacterial: Strep pneumoniae
Mycoplasma
H. influenza

Viral common in infants & children

Immunocompromised: Cytomegaloviris
Herpes simplex
What do these people have in
common?
Client #1 takes 10 mg prednisone qd

Client #2 is receiving chemotherapy

Client #3 is severely malnourished

Client #4 has AIDS

Client #5 has been on life-support for 5 years


Pneumoccal Vaccine
Prevents pneumonia 65-85 %

Recommended for:
> 65 y/o/a
Chronic illnesses
Functional or anatomic asplenia
Immunocompromised
College students

***Avoid 1st trimester


FAP
Enterobacter - Kiebsiella -

E. Coli - Proteus -

H. Influenzae Serratia -

Pseudomonas - MRSA*

S. Pneumoniae

Gram – can cause consolidation & bacteremia


Risk Factors for FAP
Impaired host defenses NGT/ETT

Supine positioning & aspiration

Narcotics/ALOC/coma

Malnutrition Hypotension

Cross contamination Overuse of antibiotic


CM of Pneumonia

Maliase, fatigue
Fever, tachycardia*, tachypnea (25-45 bpm)
Cough & purulent sputum*
Leukocytosis

Rusty sputum is seen with streptococcal, staphlococcal &


klebsiella pneumonias
Diagnosis
CXR: infiltrates

Sputum culture*
*rinse mouth with H2O
*deep breathe several times
*cough
*expectorate into sterile container
*send immediately to lab

Blood cultures x 2-3


*drawn utilizing sterile technique
ss
CM
All CM depend upon causal agent, co-morbities & if client is immunosuppressed:

Pleuritic chest pain*


Orthopnea
Accessory muscles
Anorexia

Indications of consolidation:

Whispered pectoriloquy
+ Tactile fremitus (“99”)
Dullness to percussion
Egophony (“E” becomes “A”)
CDC Recommendations
1. Staff education

2. Infection & micro-surveillance

3. Prevention of transmission

4. Modify host risk


Nursing Diagnoses
Ineffective airway clearance r/t copious tracheobronchial
secretions

Activity intolerance r/t impaired respiratory function

Imbalanced nutrition: less than requirements

Deficient knowledge re: treatment regimen & prevention

Risk for deficient fluid volume r/t fever & increased RR


Collaborative Diagnoses
Potential for:

Shock
Respiratory failure
Atelectasis
Pleural effusion
Superinfection
Goals
Improved airway patency
Ability to perform ADL’s
Adequate fluid volume
Adequate nutrition
Understanding of treatment protocol &
prevention measures
Absence of complications

AEB:
Treatment: Obtain cultures PTA
CAP FAP

Azithromycin (Zithromax) IV Cefuroxime (Zinacef)

Clarithromycin (Biaxin) IV Ceftriaxone (Rocephin)

Doxycycline (Vibramycin) IV Ampicillin (Unasyn)

Levofloxacin (Levaquin) IV Levaquin

Aminoglycosides
Viral Infections

Antibiotics are ineffective against viral


pneumonia unless there is the presence of:

a secondary bacterial infection


bronchitis
sinusitis
What precautions should a nurse
take with ATB Rx?
Cultures?

Allergies?

During & after administration?

S/S anaphylaxsis? Side effects?

C & S results?
ATB
Prevent antibiotic resistant organisms:

*use narrow-spectrum ATB if possible

*Stop ATB for strep pneumonia 72 hrs


after pt is afebrile*

*Give on time*

*Give ALL of the ATB*


Other Interventions
IVF & FF * (2-3 L/d) Antihistamines

Fever management Nasal decongestants

Antitussives Bedrest

Respiratory tx & O2 with humidification

Titrate O2 to maintain O2 Sats > 92% (94% with anemia)

Pain medications
Interventions
ETOH & Smoking cessation*
Rescue position for high risk patients
Oral care
Clean respiratory equipment
Hand washing
TCDB & Chest PT
Suctioning prn
Early ambulation
IS
Interventions
Elevate the head of the bed

Pace activities

Relieve abdominal distention

Inspect skin for diffuse red rash


u
Monitor for Complications
If no improvement in 24-48 hrs after tx, consider other
disorders*

If BP drops, consider septic shock

Monitor CXR for atelectasis, plural effusion

If fever reoccurs, consider superinfection

If client becomes confused, restless consider hypoxemia or


sepsis*
Evaluate
CXR
VS
ABG & O2 Sats
BBS
No DOE
Adequate fluid balance & dietary intake
Exhibits no complications
SARS
Severe Acute Respiratory Syndrome

Coronavirus spread by cough/sneeze droplets


that deposit on nearby mucous membranes of
another person

OR

Touching a surface or object contaminated with


droplets
CM of SARS
High fever

Headache
Malaise

Diarrhea (10-20 %)

Dry cough (2-7 days later)


Progressive hypoxemia & pneumonia
Contagious
When s/s are present

During the second week of the illness

Contact with should be restricted until 10


days post fever and improvement of s/s
Screen for SARS if:
• Confirmed pneumonia by CXR or ARDS of unknown
etiology AND if, within 10 days of symptom onset, the
patient:

• Has traveled or has close contact to someone who is ill


and has traveled to mainland China, Hong Kong, or
Taiwan OR

• Is employed in a high risk occupation

• Is part of a cluster of cases of atypical pneumonia


SARS Precautions
Consult CDC

Negative pressure isolation room

PPE & Hand hygiene

Environmental cleaning techniques

Containment of secretions
Containment of Secretions
Cover the nose/mouth

Use tissues

Dispose of tissues in no-touch receptacles

Perform hand hygiene with soap & H2O or


alcohol-based hand rub after contact with
respiratory secretions and contaminated
objects/materials.
Containment of Secretions
Offer masks to persons who are coughing

Encourage coughing persons to sit at least 3 feet away from others

Healthcare workers should wear a surgical or procedure mask for close contact

A single patient room is preferred


When single rooms are limited:

Prioritize patients who have excessive cough and sputum production


for single-patient rooms

Place together in the same room (cohort) patients who are infected the
same pathogen

If it becomes necessary to place patients who require Droplet


Precautions in a room with a patient who does not have the same
infection:

Avoid patients who are immunocompromised or have prolonged


lengths of stay

Ensure that patients are >3 feet apart & curtain is drawn

Change protective attire and perform hand hygiene between contact


with patients in the same room
H1N1 (Swine) Flu
common respiratory disease in pigs

people who work with pigs have sometimes


caught swine flu

Suspect the pigs caught bird flu which


mutated so that the pigs could infect
people
Swine Flu

This strain appears to be a subtype not seen before

Contains genetic material from pigs, bird and humans

Unlike most cases of swine flu, this one can spread from
person to person

Do not catch from eating pork*


Spread of the Virus
Contagious for 1-7 days

Spread by coughing or sneezing

OR

touching something with flu viruses on it and


then touching their mouth or nose*
CM
Fever

Fatigue & anorexia

Coughing

some people also develop a runny nose, sore throat,


vomiting or diarrhea
If you suspect:
Stay home from work or school

Don't get on an airplane

Call your doctor to ask about the best treatment

Do not simply show up at a clinic or hospital that is


unprepared for their arrival
Treatment
Sensitive to the anti-viral drugs Relenza and
Tamiflu only

Take within the first 48 hours after symptoms


appear

Anti-virals can help people recover a day or two


sooner

Doctors sometimes prescribe anti-virals to


household members of people with the flu to
prevent them from getting sick.
Prevention
H1N1 vaccine may be available this fall

Wash hands, cover mouth

Stay home until you have been afebrile 24


hours

Clean surfaces with alcohol, chlorine, etc


Get help for children if there is:
Dyspnea or tachypnea

Bluish/gray skin color

Not drinking enough fluids, severe vomiting

Not waking up,not interacting or so irritable that the


child does not want to be held

Symptoms improve but then return with fever and


worse cough
Get help for adults if there is:
Dyspnea or SOB

Pain/pressure in the chest or abdomen

Sudden dizziness or confusion

Severe or persistent vomiting

Symptoms improve but then return with fever and


worse cough
Pulmonary TB
Infectious disease caused by Mycobacterium
tuberculosis

Affects lungs primarily*

AFB, grows slowly, sensitive to heat & UV light

Infects 1/3 of the world

Leading cause of infectious disease death in the


world
TB
Expected to be eradicated by 2000 in USA

*HIV
*Increased immigration
*Multidrug-resistant strains
*Increased homelessness
*Decreased detection
*Inadequate funding of the US public health
system
Transmission
Airborne droplet

Initial infection occurs 2-10 weeks after


exposure

10% of the people who are initially infected


develop active disease
Risk Factors
Close contact with infected persons or crowded conditions*

Immunocompromised & Substance abuse

Inadequate health care


*homeless
*minorities
*children & young adults
*immigrants

Preexisting medical conditions & Malnourishment

Certain health care professionals*


CM

Low grade fever, night sweats

Cough* > 3 wks, hemoptysis, chest pain

Fatigue, anorexia, weight loss


Diagnostic Tests
Tuberculin skin tests (Mantoux) ID
AKA TST

CXR: lesions

AFB: mycobacteria
Positive skin test
Reaction of 0-4 is not significant

5 + mm may be significant in pts at risk


(HIV)

10+ mm is considered significant

Significant reaction = past exposure to TB or


vaccine (in Latin America & Europe)
Skin Test
Read 48-72 hrs

Reaction indicated by BOTH erythma &


induration (hardness)*
Skin Test
Significant reaction does not indicate active
disease is present

nor do

Negative results exclude disease in the


immunosupressed
QuantiFERON-TB Gold Test
(QFT-G)

Approved in 2005

Results in less than 24 hr

Not affected by prior vaccination

Recommended by the CDC to replace the TST


CXR
Lesions
or
Infiltrates
are
usually in
the upper
lobes
Miliary TB
Nursing Diagnoses
Ineffective airway clearance related to
copious tracheobronchial secretions

Deficient knowledge about treatment


regimen & preventative health
management

Activity intolerance related to fatigue, altered


nutritional status and fever
Collaborative Diagnoses
Potential for:

Malnutriton

Adverse side effects of medication therapy

Multi-drug resistance

Spread of TB infection (miliary TB)


Goals
Adequate airway

Increased knowledge

Adherence to the medication regimen

Increased activity tolerance

Absence of complications…….AEB:
Orders
Admit all suspected/confirmed cases to AFB isolation
(Airborne Precautions < 5 microns)

Have a high degree of suspicion in pts with undiagnosed


pulmonary disease, especially if they are HIV +

Negative pressure rooms


at least 6 air exchanges/hr
exhausted directly outside

Ultraviolet light
Disposable particulate respirators
Monitor HCP for s/s TB
Airborne Isolation
HCP wears:

Standard Precautions*
Particulate Mask

Client Transport:

Limit only for essential purposes


Client wears mask
Notify personnel in receiving dept
Instruct client how to prevent spread in transport
Problem
When clients are identified as positive for TB
but precautions were not taken:

Follow up with all HCW, patients and visitors


that were exposed to TB
Treatment
Chemotherapy for 6 – 12 months:
Often meds are given in combination

Initial phase (0-8 wks)


Continuation phase (given for 4-7 months)

Isoniazid (INH) & Rifampin (Rifadin) 1st choice


Pyrazinamide
Ethambutol (Myambutol)

Streptomycin if resistance to other drugs


Side effects
Hepatitis, hepatotoxicity

Thrombocytopenia

Skin rash, purpura

Fever, arthralgias,
GI distress

These are caused by bleeding underneath the skin. Petechiae measure less than 0.5 cm,
purpura 0.5 – 1 cm, and ecchymoses are greater than 1 cm (Tongue)
Side Effects
Take on empty stomach or 1 hr before meals

INH: avoid foods that contain tyramine & histamine


(tuna, aged cheese, red wine, soy sauce &
yeast)

These foods & INH = headache, flushing,


hypoesnion, lightheadedness, palpatations,
diaphoresis
Side Effects
Rifampin increases the metabolism of:

Beta-blockers
Coumadin
Oral hypoglycemics
Digoxin
Oral contraceptives
Theophylline
Verapamil

Decreasing effectiveness which may require increasing


dosage

Avoid contact lenses, may discolor them


Side Effects
Ck for hepatitis, skin rash & neurological
changes (hearing loss, neuritis)

Monitor Liver enzymes, BUN & Cr, Sputum


AFB
Drug Resistance
Vital signs: fever, RR

Take meds as ordered for the duration*

Assess for Miliary TB:

Decreased leukocytes Fever

Increased spleen Renal/mental changes


Treatment
Educate client regarding:
Maintaining drug regimen
Hygiene measures
Proper disposal of tissues
Postural drainage
Progressive activity schedule
Nutritional consult, supplements
Nutrition
Get social services & family involved

Consider shelters, food kitchens, meals on wheels, etc

High-calorie supplements

Dietary help developing recipes that increase caloric


intake requiring minimal resources
Self-care
Proper tissue disposal

Covering mouth and nose

Handwashing

Keep follow up appointments


Pleural Effusion
An increased collection of fluid in the pleural
space (nl 5-15 mL)
Causes
Heart failure

Pulmonary infections/emboli & TB

Nephrotic syndrome (albumin)

Connective tissue disorders

Neoplastic tumors
CM
S/S underlying disease (occurs with >500 mL):

Determined by size & speed*

Decreased/absent BS
Decreased fremitus
Dull, flat to percussion
Tracheal deviation
CXR
Upright A & P (>300mL’s to detect)

Lateral Decubitus: (50 mL’s to detect)

pt lies on the affected side


the pleural effusion will “layer out”
fluid & airline is visible
CXR
PEI = width of A divided by B x
100
PEI = Pleural
Effusion index

A = pleural effusion

B = width of the
hemithorax
Treatment

Treat underlying cause


Treatment
Thorocentesis if > 10 mm and stable:

Send fluid immediately for:

Gram stain
C&S
AFB
RBC, WBC
Gl, amylase LDH, protein
Cytology
pH
Treatment
Note & record pt’s tolerance, condition
afterwards, color /characteristics of fluid

Important to know if:

transudate: systemic problem: LVHF, cirrhosis

exudate: local problem: infection, cancer, pulmonary


embolism
Treatment
Posterior Chest tube to drainage

Reoccurring P. effusions can occur with


malignancy

Treatment creates adherence of the pleural


to the chest wall
Pleurodesis
Done to prevent the rate of recurrence of pleural effusions
or pneumothorax

creates adhesion of the lung to the chest wall by


secretion of fibrin

Done mechanically by Marlex mesh/gauze

chemically by instillation of talc or silver nitrite

thermally by using electro cautery, laser or argon beam


Pleurodesis

Mechanical Chemical
Pleurodesis
Can be done with thoracentesis or CT

Clamp CT 60-90”

Assist pt in changing positions to distribute

Chest tube is unclamped & remains for


several days
Pleurodesis
Most common SE:
CP
Fever

Pain & fever management


Assess respiratory status
Pulmonary Fibrosis
Chronic lung inflammation =

Stiffens the lungs & scars the alveolar walls

Causes a restrictive disorder &


lung compliance
Causes

A growing body of evidence points to a genetic


predisposition

A mutation in the SP-C protein has been found to exist in


families with a history of Pulmonary Fibrosis.
Causes
Inflammatory conditions:
Sarcoidosis
Wegener’s granulomatosis
Infections
Asbestos, silica, cigarette smoking
Radiation
Hypersensitivity pneumonitis*
Lupus
Rheumatoid Arthritis

Chemotherapy meds:
Bleomycin
Mitomycin
BCNU
Busulfan.
CM
Progressive:

SOB & dry cough

Fatigue & weakness

Discomfort in the chest

Loss of appetite & rapid weight loss


Complications
Hypoxemia

Respiratory failure

Pulmonary HTN

Cor Pulmonale

DVT & PE
Cor Pulmonale
Diagnosis
The origin and development of the disease is not
completely understood so misdiagnosis is common.

CXR

PFT’s

Lung biopsy: fibrosis


Treatment
No effective tx or cure

Many experimental trials

Steroids (Prednisone)

Supplemental O2

Lung transplant
Question
Which infection control technique is
unnecessary when caring for a client
with tuberculosis (TB)?

1. Washing hands before and after contact


2. Always putting on gown, mask & gloves
3. Avoiding face-to-face contact
4. Careful disposal of soiled tissues
Question
The drug treatment for TB frequently
consists of which of the following?

1. Rifampin & ethambutol


2. Isoniazid & rifampin
3. Streptomycin & ethambutol
4. Isoniazid & streptomycin
Question
In what position should the nurse place a
client during a thorocentesis?

1. Supine, HOB elevated


2. Side-lying, affected lung up
3. Sitting up, leaning forward
4. Prone, affected lung down
Question
The nurse knows that the most positive
evidence of active TB is:

1. A positive skin test result


2. An elevation in the WBC count
3. Positive sputum AFB findings
4. Positive chest x-ray findings

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