RESPIRATORY
I.
General Respiratory Anatomy and Physiology ( illustration ) A. The respi respirat ratory ory syst system em is compr comprise ised d of the upper upper airwa airway y and lower lower airw airway ay struc structur tures. es. B. The upper upper respi respirat ratory ory syste system m filter filters, s, moiste moistens ns and warms warms air air during during inspi inspirat ration ion..
C. II.
V.
The lower respiratory system enables the exchange of gases to regulate serum PaO 2, PaCO2 and Ph.
Physiology (illustration ) A. Basic Basic gasgas-exc exchan hange ge unit unit of of the respir respirato atory ry syst system em is is the the alveo alveoli li.. B. Alveolar Alveolar stret stretch ch recepto receptors rs respond respond to inspira inspiration tion by sending sending signals signals to to inhibit inhibit inspiratory inspiratory neurons neurons in the brain stem to prevent lung over distention. C. During During expira expiratio tion n stretch stretch recep receptor torss stop sendin sending g signals signals to inspir inspirato atory ry neurons neurons and and inspirat inspiration ion is ready to start again. D. Oxygen Oxygen and and carbon carbon dioxid dioxidee are excha exchange nged d across across the alve alveola olarr capilla capillary ry membr membrane ane by proce process ss of diffusion. E. Neural Neural cont control rol of respi respirat ration ionss is located located in the the medul medulla. la. The The respir respirato atory ry cente centerr in the medul medulla la is stimulated by the concentration of carbon dioxide in the blood. F. Chem Chemor orec ecep epto tors rs,, a seco second ndar ary y feed feedba back ck system system,, loca locate ted d in the the caro caroti tid d arte arteri ries es and and aort aortic ic arch respond to hypoxemia. These chemoreceptors also stimulate the medulla. G. Ph regulation I. Bloo Blood d Ph (par (parti tial al pres pressu sure re of hydro hydroge gen n in blood) blood):: a decr decrea ease se in bloo blood d Ph stim stimul ulat ates es respiratio respiration n hyperventi hyperventilati lation, on, both through through the neurons neurons of the brain's brain's respiratory respiratory center and through the chemoreceptors in carotid arteries and aortic arch.
II.
Blood PaCO2 (partial pressure of carbon dioxide in arterial blood): an increase in the PaCO2 results in decreased blood Ph, and stimulates respiration as described above.
III.
Blood PaO2 (partial pressure of oxygen in arterial blood): a decrease in the PaO 2 results in a decreased blood Ph, stimulating respiration as described above.
IV.
When arterial Ph rises or the arterial PaCO 2 falls, hypoventilation occurs.
Diso Disord rder erss of of the the Uppe Upperr Resp Respir irat ator ory y Syst System em A. Allergic Allergic rhinitis rhinitis (hay (hay fever) fever) - sensiti sensitivity vity to allerg allergens ens with with whitish whitish or clear clear nasal nasal discha discharge rge
B.
C.
Sinusitis (illustration ) 1. Medical condition a. infl inflam amma mati tion on of of muc mucus us mem membr bran anes es in in the the sinu sinuse sess b. may be foll followe owed d by infec infectio tion n with with a yellow yellowish ish-gre -green en dis discha charge rge 2. Management a. treatm treatment ent with with anti antibio biotic tics, s, decong decongest estant ants, s, antihi antihista stamin mines es b. b. surg surger ery y to to drai drain n and and open open sinu sinuse sess c. antr antral al irr irrig igat atio ion n (sin (sinus us irr irrig igat atio ion) n) d. Caldwell-Luc pr procedure Uppe Upperr air airwa way y obs obstr truc ucti tion on (cho (choki king ng)) 1. Findings a. stri strido dorr (ha (hars rsh, h, vibr vibrat atin ing g bre breat ath) h) b. no sound of air c. both both hand handss of of cli clien entt aro aroun und d the the thro throat at
d.
D.
E.
management: emergency treatment ( illustration i. Heimlich maneuver ii. ii. cric cricot othy hyrot rotom omy y (cut (cut cric cricoi oid d car carti tila lage ge)) iii. ii. trac racheot heotom omy y/tra /traccheos heosttomy omy
Pharyngitis 1. Infla Inflamm mmat atio ion n of of muc mucou ouss mem membr bran anes es of phar pharyn ynx x 2. Bact Bacter eria ial, l, vira viral, l, envi enviro ronm nmen enta tall caus causes es 3. Treat Treat findin findings; gs; if cult culture ure shows shows bacter bacteria, ia, use antibi antibioti otics cs Tonsillitis 1. Infla Inflamm mmat atio ion n and/ and/or or infe infect ctio ion n of tons tonsil ilss 2. Acut Acutee form form is usua usuall lly y bact bacter eria iall 3. Treat Treat findin findings; gs; if cult culture ure shows shows bacter bacteria, ia, use antibi antibioti otics cs
)
F.
G.
Peritons onsillar abscess 1. Comp Compli lica cati tion on of acut acutee ton tonsi sill llit itis is 2. Infe Infect ctio ion n spre spread adss to sur surro roun undi ding ng tis tissu suee 3. If swel swelli ling ng is mass massiv ive, e, can can enda endang nger er airw airway ay 4. Treat Treat findin findings; gs; if cult culture ure shows shows bacter bacteria, ia, use antibi antibioti otics cs Vocal cord disorders 1. Laryngitis a. inflam inflammat mation ion of vocal vocal cords cords and and surr surround ounding ing mucous mucous membra membranes nes b. b. caus cause: e: some someth thin ing g irri irrita tate tess the the lary larynx nx c. occu occurs rs in vira virall and and bac bacte teri rial al infe infect ctio ions ns
d.
H.
VI.
in children, called croup (larynx blocked by edema, spasm or both) e. treat treat findi findings ngs,, rest rest voice voice,, remove remove irri irritan tants, ts, garg gargle le with with warm warm salt salt wat water er 2. Vocal co cord pa paralysis a. injury injury,, traum traumaa or dise disease ase of lary larynx, nx, laryng laryngeal eal nerves nerves or vagus vagus nerve nerve b. may result result as a compli complica catio tion n afte afterr thyro thyroide idecto ctomy my surger surgery y c. asse assess ss how how wel welll cli clien entt can can prot protec ectt air airwa way y d. can someti sometime mess be surgica surgically lly treat treated ed wit with h Tefl Teflon on inje injecti ction on Cancer of the larynx 1. Etiology a. most most tum tumor orss of the the lar laryn ynx x are are squa squamo mous us cel celll carc carcin inom omaa b. b. more more comm common on amon among g men men,, age age 50 to 65 c. ciga cigare rett ttee smok smokin ing g and alc alcoh ohol ol cons consum umpt ptio ion n are rel relat ated ed 2. Findings a. persistent sore throat b. dyspnea c. dysphagia d. incr increa easi sing ng pers persis iste tent nt hoar hoarse sene ness ss e. weight loss f. enla nlarged rged cervic rvical al lym lymph node nodess 3. Management a. radiation therapy b. chemotherapy c. surg surger ery: y: rem remov oval al of of all all or par partt of lar laryn ynx x to tre treat at can cance cer r i. tota totall laryn larynge gect ctom omy: y: no voic voice, e, perm perman anen entt stoma stoma in neck neck with with no risk risk of aspiration from oral cavity ii. ii. radica radicall neck neck disse dissecti ction: on: when when canc cancer er has has metast metastasi asized zed to to surroun surroundin ding g tissues 4. Nursing inte nterventions a. arra arrang ngee for clien clients ts with with larny larnyge gect ctom omie iess to meet meet with with membe members rs of suppo support rt groups b. b. esta establ blis ish h a meth method od for for comm commun unic icat atio ion n befor beforee surg surger ery y c. main mainta tain in air airwa way; y; hav havee suct suctio ion n equip equipme ment nt at at beds bedsid idee d. obse observ rvee for for sign signss of of hem hemorr orrha hage ge or infe infect ctio ion n e. teac teach h abo about ut trac trach h and and stom stomaa care care f. assi ssist wit with pe period riod of gri grieving ving
Disord Disorders ers of Lower Lower Respir Respirat atory ory System System (LRS): (LRS): Obstru Obstructi ctive ve A. Genera Generall facts facts:: proces processs in chro chronic nic obstru obstructi ctive ve pulm pulmona onary ry dise disease asess 1. Block ai airflow ou out of of lu lungs 2. Trap Trap air, air, with with impa impair irme ment nt of gas gas exch exchan ange ge 3. Inc Increa rease the the wor work k of of bre breaathi thing B. Emphysema 1. Destroys alveoli 2. Narr Narrow owss and and coll collap apse sess sma small ll airw airway ayss 3. Over Overaall lung lung lose losess el elasti astici city ty 4. Traps air 5. As alve alveola olarr walls walls die, die, there there is less less surfac surfacee for vital vital gas gas exch exchang angee C. Chronic bronchitis 1. Definition
2.
D.
a. b. b. Findings a. b. b.
infl inflam amma mato tory ry resp respon onse se in the the lun lung g affe affect ctss few few alve alveol oli, i, mos mostl tly y air airwa ways ys lung lungss chro chroni nica call lly y prod produc ucee flui fluids ds infl inflam amma mati tion on and and muc mucus us narr narrow ow the the airw airway ayss
Asthma 1. Definition/etiology ogy a. reve revers rsib ible le obst obstru ruct ctio ion n of of air airwa ways ys b. b. infla nflamm mmat atio ion n of airw airway ayss c. airw airway ayss hype hypers rsen ensi siti tive ve to vari variet ety y of of sti stimu muli li d. bron bronch chos ospa pasm sm is a min minor or comp compon onen entt e. dise diseas asee waxe waxess and wan wanes es,, remis remissi sion onss and exa exace cerb rbat atio ions ns 2. Findings
a. b. c. d.
e. f.
3.
4.
orthopnea, orthopnea, expiratory wheezing barrel chest, chest , cyanosis, cyanosis, clubbing of fingers distention of of ne neck ve veins edema of of ex extremities increased PCO2 and decreased PO2
polycythemia Diagnostics a. phys physic ical al exam examin inat atio ion n with with hist histor ory y of of find findin ings gs b. arterial blo blood gases c. chest x-ray Complications
a. b. c.
hypoxemia hypercapnia vari variet ety y of of res respi pira rato tory ry infe infect ctio ions ns
d.
E.
cor pulmonale e. dysrhythmias Mana Manage geme ment nt for for obs obstr truc ucti tive ve dise diseas asee 1. Antibi Antibioti otics cs and and cortic corticost ostero eroids ids for for infec infectio tion n or chron chronic ic infl inflamm ammati ation on 2. Bronchodilators 3. Mucolytics 4. Expectorants
5.
Respiratory program: postural drainage, exercise, nebulizer, high protein diet ( illustration
) F. Nurs Nursin ing g inter interve vent ntio ions ns comm common on to obs obstr truc ucti tive ve dise diseas ases es 1. Asse Assess ss clie client nt's 's risk risk of resp respir irat ator ory y fai failu lure re 2. Assess Assess for for degre degreee of respi respirat ratory ory effor effortt for an an increa increased sed work work of brea breathi thing ng or dyspn dyspnea ea 3. Assess Assess oxyge oxygenat nation ion with with pulse pulse oxime oximeter ter if if hemoglo hemoglobin bin leve levell is within within norma normall limits limits 4. Measur Measuree arte arteria riall blood blood gases gases (ABG (ABG)) to to evalu evaluat atee gas gas exch exchang angee 5. Admi Admini nist ster er oxyg oxygen en as indi indica cate ted d 6. If risk risk of respir respirato atory ry failur failure, e, antici anticipat patee ventil ventilati ation on 7. Assi Assist st with with secr secret etio ion n rem remova ovall as as indi indica cate ted d 8. Pace Pace clie client nt acti activi viti ties es to redu reduce ce oxyge oxygen n dem deman and d 9. Teach Teach diaphr diaphragm agmati aticc breath breathing ing and pursed pursed-li -lip p brea breathi thing ng 10. 10. Posi Positi tion on in in a high high Fow Fowle ler' r'ss to eas easee brea breath thin ing g effo effort rt 11. 11. Provi Provide de for for nutri nutriti tiona onall con consu sult ltss as as ind indic icat ated ed 12. Reinfor Reinforce ce the the plan plan for small small,, frequ frequent ent high high carbo carbohyd hydrat ratee meals meals 13. Provid vide re referrals fo for: a. depr depres essi sion on asso associ ciat ated ed with with dise diseas asee b. b. pul pulmona monary ry reha rehabi billitat itatio ion n c. stop top smok smokiing supp suppor ortt grou groups ps 14. For asthm asthma, a, teach teach clie clients nts that that aspi aspirin rin or peanu peanuts ts may may stuimu stuimulat latee an asthma asthma atta attack ck LRS Dis Disor orde ders rs:: Res Restr triictiv ctivee A. In gener general al:: these these disor disorder derss preven preventt full full lung lung expans expansion ion via via three three mechan mechanism ismss 1. Lung st stiffening 2. External comp ompression 3. Muscle weakness 1
VII VII.
illustration 2
B.
Pulm Pulmon onar ary y fib fibro rosi siss- lung lung sti stiff ffen enin ing g 1. Occ Occupat upatio iona nall lung lung dis disease easess
a.
C.
coal worker's pneumoconiosis worker's pneumoconiosis - risk increases with length of exposure to coal dust (>15 years), intensity of exposure, and silica content of dust b. b. sili silico cosi sis: s: wor worke kers rs who who will will hav havee inha inhale led d sili silica ca dus dustt 2. Asbestosis a. inhal nhalat atio ion n of of asb asbeestos stos fibe fibers rs b. b. dise diseas asee may may dev devel elop op 15 15 to 20 yea years rs aft after er expo exposu sure re Pulm Pulmon onar ary y sarc sarcoi oido dosi siss - lung lung stif stiffe feni ning ng 1. Etiology a. unknown or origin
b.
characterized by formation of tubercles of tubercles,, most often in the lungs may pr progress to to fi fibrosis
c. Findings a. dyspnea b. anxiety 3. Diagnostics a. chest x-ray b. b. biop biopssy of affe ffected ted tissu issuee 4. Management a. antitussives b. oxygen th therapy c. remo remova vall of toxi toxicc subs substtance nces Nursin Nursing g inter interven ventio tions ns comm common on to to all all type typess of pulmon pulmonary ary fibros fibrosis is 1. Prev Preven entt infe infect ctio ion n or or exp expos osur uree to to inf infec ecti tion on 2. Pace Pace clien clients' ts' activi activitie tiess to reduce reduce oxygen oxygen demand demandss and and dyspne dyspneaa 3. Rein Reinfo forc rcee the the need need for for sma small ll,, fre freque quent nt meal mealss 4. Encoura Encourage ge daily daily activi activitie tiess within within pulmon pulmonary ary tolera tolerance nce a. provide referrals for for: I. depr depres essi sion on ass assoc ocia iate ted d wit with h dis disea ease se II. II. stop stop smok smokin ing g supp suppor ortt grou groups ps III. III. occu occupa pati tion onal al reha rehabi bili lita tati tion on 2.
D.
E.
Diso Disorde rders rs of of flui fluid d in pleu pleura raee 1. Pleural Pleural fluid fluid disorders disorders - all all treated treated with with water water seal seal chest drainage drainage systems systems
2.
Pneumo Pneumotho thorax rax:: air air betwee between n the the pleu pleurae rae a. open pneumot pneumothorax: horax: hole in in the chest chest wall wall,, communica communicates tes with with the the lung b. closed closed pneumot pneumothorax: horax: hole in lung, lung, chest wall intact intact c. tensio tension n pneumot pneumothora horax x - a nursing nursing and medic medical al emerg emergenc ency y i. closed pn pneumothorax ii. ii. air is forc forced ed into into the pleura pleurall space space with with a cont continu inued ed pres pressur suree build build up up
iii iii. iv. iv. v.
shif shifts ts media mediast stin inum um away away from from affec affecte ted d side side with with resu result ltss of a compressed heart trea treate ted d wit with h che chest st tube tube inse insert rtio ion n card cardia iacc and and res respi pira rato tory ry arre arrest st if not not tre treat ated ed
d. examples of the above (illustration ) Ple Pleural ural effu effusi sion on a. fluid fluid (tran (transud sudate ate or exuda exudate) te) in in the pleura pleurall space space b. b. if smal small, l, no tre treat atme ment nt c. if larg larger, er, treate treated d with with ches chestt tube tube inse inserti rtion on 4. Hemothorax a. bloo blood d in in the the ple pleur ural al spac spacee b. treate treated d with with thor thorace acente ntesis sis or ches chestt tube tube 5. Empyema a. purule purulent nt drai drainag nagee in in the the pleura pleurall spac spacee b. often often from from a chroni chronicc condit condition ion such such as as lung lung cance cancer r c. trea treate ted d with with che chest st tub tubee inse insert rton on 6. Chylothorax a. lymp lympha hati ticc flui fluid d in ple pleur ural al spa space ce b. treate treated d with with thor thorace acente ntesis sis or ches chestt tube tube Musculoske Musculoskeleta letall diseases diseases associate associated d with with difficul difficulty ty breath breathing ing 2. Guilla Guillainin-Bar Barre re syndro syndrome me - follow followss a viral viral infecti infection on 3.
6.
a.
ascending paralysis that may affect muscles of respiration as paralysis ascends muscle muscless so weak that that client client cannot cannot breath breathee deeply, deeply, a nursing nursing and medica medicall emergency c. may progre progress ss to respir respirat atory ory failur failuree i. may require intubat bation ii. ii. mec mechani haniccal vent ventil ilat atio ion n iii. iii. cour course se of of illn illnes esss vari varies es fro from m a few few mont months hs to to year yearss Myas Myasth then enia ia grav gravis is a. sporad sporadic, ic, progr progress essive ive weak weaknes nesss of skelet skeletal al muscl musclee b. cause: cause: lack lack of acetylc acetylcholine holine with results results of a myoneura myoneurall junction junction malfunc malfunction tion c. may not be able able to to chew chew and swallo swallow w well well i. may aspirate ii. ii. may may lose lose prot protec ecti tive ve air airwa way y refl reflex exes es d. repeated repeated muscle muscle movemen movements, ts, especi especially ally towards towards days days end, end, can exacer exacerbate bate acute acute respiratory failure
b.
3.
All of these musculoskeletal disorders EXCEPT Guillain-Barre feature the letter M: -Myasthenia gravis -Poliomyelitis -Amyotrophic Lateral Sclerosis -Muscular dystrophies
3.
4.
Poliomyelitis a. vira virall infe infect ctio ion n b. if disease disease strikes strikes the the respirator respiratory y muscles muscles the result result may may be respirator respiratory y failure failure c. may not not sw swallo allow w we well i. may aspirate ii. ii. may may lose lose prot protec ecti tive ve air airwa way y refl reflex exes es Amyotrophic Amyotrophic lateral lateral sclerosis sclerosis (ALS; Lou Gehrig's Gehrig's Disea Disease) se) a. affects affects motor motor neurons; neurons; autonomic, autonomic, sensory sensory and mental mental function function unchang unchanged ed b. manifests manifests as a chronic chronic,, progress progressive ive irreversib irreversible le disorde disorder r c. begins begins usual usually ly in in distal distal ends ends of upper upper extr extremi emitie tiess
d. e.
5.
6.
often leads leads to respirator respiratory y failure failure within within two to five five years years resu result ltss in eth ethic ical al issu issuee i. whet whethe herr clie client ntss want want mech mechan anic ical al vent ventil ilat atio ion n ii. ii. whet whethe herr nut nutri riti tion onal al supp support ort is desi desire red d iii. iii. if they they woul would d rathe ratherr die die when when diseas diseasee beco becomes mes this this sever severee f. results results in clients' clients' inabil inability ity to to communica communicate te or physic physically ally move from from voluntar voluntarily ily and/or clients lack involuntary reflexes, such as blinking or gag reflex Musc Muscul ular ar dyst dystro roph phie iess a. progressive progressive symmetric symmetrical al wasting wasting of voluntary voluntary muscles muscles with with no nerve nerve effect effect b. as thoraci thoracicc muscles muscles weaken, weaken, breathin breathing g becomes becomes more difficult difficult c. may not not swallow swallow well; well; risk risk for aspirat aspiration ion with with loss of protec protective tive airway airway reflexes reflexes Interv Intervent ention ionss common common to muscul musculosk oskele eleta tall disorde disorders rs
a. b. c. d. e. f. g. h. i. 2.
j. LRS LRS Diso Disord rder ers: s: Infe Infect ctio ious us
1.
monitor carefully for changes in condition assess regular swallowing and ability to protect the upper airway discuss chances of mechanical ventilation or nutritional support : does client wish it? assist with coughing and secretion clearance as indicated prevent infection assess for with appropriate referrals for depression that is often associated with these diseases administer medications specific to the disease condition assist/provide occupational or/and physical rehibilitation rehibilitation as indicated maintain adequate nutrition with with termina terminall disorde disorders, rs, provi provide de for for referra referrals ls for for family family
Pneumonia (illustration ) 3. Defi Defini niti tion on/e /eti tiol olog ogy y
a.
4.
5.
6.
7.
acute infection of lung parenchyma b. cause: cause: bacterium bacterium,, virus, protoz protozoan, oan, mycobac mycobacteri terium, um, mycoplas mycoplasma, ma, or rickett rickettsia sia c. pneumonia pneumonia is the the leading leading cause of death death from from infect infectious ious causes causes d. may affect affect only only a region region of lung: lobar pneumonia, pneumonia, bronchopneum bronchopneumonia onia e. may may be the the resu result lt of: of: i. primary infection ii. ii. seco second ndar ary y to to ot other her lun lung g dam damag agee iii. aspiration Risk Risk fact factors ors for for pne pneum umoni oniaa a. prepre-ex exis isti ting ng pulm pulmon onar ary y dise diseas asee b. b. abdom abdomin inal al and and tho thora raci cicc surge surgery ry c. mech mechan anic ical al vent ventil ilat atio ion n d. advanced ag age e. decreased decreased ability ability to to protect protect airway airway or cough cough effect effectivel ively y f. arti rtific ficial airway rway g. chron chronic ic illn illnes esss and debi debili lita tati tion on h. depre depress ssed ed immu immune ne func functi tion on i. cancer Diagnostics a. chest hest radi radiog ogra raph ph b. sputum sputum culture, culture, sensit sensitivity ivity and microsc microscopic opic analys analysis, is, Gram Gram stain, stain, cytolog cytology y c. ABG as indica indicated ted by clin clinica icall cond conditi ition on Management a. antimi antimicro crobia bials, ls, depend depending ing on pathoge pathogen n b. antipyret retic c. expectorants nts d. antitussives e. supple supplemen mental tal oxygen oxygen,, as indica indicated ted f. IV flui fluids ds to trea treatt dehy dehydra drati tion on Nurs Nursin ing g inte interv rven enti tion onss a. monitor monitor finger finger oximet oximeter er if hemoglobin hemoglobin levels levels within within normal limits limits
b. c. d. e. f.
8.
promot promotee hydra hydratio tion n to liqu liquify ify secret secretion ionss teach teach effecti effective ve coughing coughing techniques techniques to minimiz minimizee energy energy expendi expenditure ture suct suctio ion n if if nece necess ssar ary y teach teach the need need to continue continue entire entire cours coursee of antimicr antimicrobi obial al therap therapy y which which is usually seven to ten days teac teach h that that findi finding ngss are expec expecte ted d to be less less within within 48 to 72 hours hours of initia initiall therapy
Pulmonary tuberculosis (PTB) (illustration ) a. Etiology i. myc mycobac obacte teri rium um tub tuber ercculos ulosiis ii. ii. bac bacilli lli lodge odge in alveol veolii iii. ii. pulm pulmon onaary infi infilt ltra rattes iv. iv. can can spr sprea ead d thr throu ough ghou outt bod body y via via bloo blood d v. mult multii-dr drug ug resi resist stan antt PTB PTB is bec becom omin ing g more more prev preval alen entt vi. PTB incide incidence nce is risi rising ng with with increa increasin sing g homel homeless essnes nesss and and AIDS AIDS b. Findings i. weakness with fatigue ii. ii. anore norexi xiaa wit with wei weight ght los loss iii. night sweats iv. chest pain v. productive cough c. Diagnostics i. sput sputum um and and gastri gastricc conte content nts, s, anal analys ysis is for the the presen presence ce of acidacid-fa fast st bacilli ii. ii. chest chest x-ray x-ray for prese presence nce of of activ activee or calci calcifie fied d lesion lesions, s, "coin "coin"" lesion lesionss iii. tube uberculin testing 1. tine tine,, mant mantou oux x test testss 1. chec checke ked d 48 to to 72 hou hours rs for for ind indur urat atio ion n 2. positi positive ve if >10 mm mm indura induratio tion n in heal healthy thy person personss iv. establ establish ishes es if there there is is an anti antibody body respons responsee to the the tube tubercl rclee bacil bacillus lus v. if posit positive ive,, indica indicate tess prior prior exposu exposure re to bacill bacillus, us, not not an active active dise disease ase d. Management i. long long-t -ter erm, m, six six to 24 month months, s, anti antimi micr crob obia iall therap therapy y with with isonia isoniazi zid d (INH) (Hyzyd) or rifampin (Rifadin), with ethambutol HCL (Etibi) in some cases ii. ii. bed bed res restt or or cha chair ir rest rest unti untill fin findi ding ngss aba abate te iii. iii. surgic surgical al rese resecti ction on of involv involved ed lung lung if medi medicat cation ion is not not effe effecti ctive ve iv. high high carbo carbohyd hydrat rate, e, high high protei protein n diet diet with with freque frequent nt smal smalll meals meals e. Nurs Nursin ing g int inter erve vent ntio ions ns i. with with activ ctivee infe infecction, ion, clie client nt must must be isola solate ted d with ith airb airbor orne ne precautions when in the hospital ii. teach client 1. prope properr tech techni niqu ques es to prev preven entt spre spread ad of infe infect ctio ion: n: hand hand washing, etc. 2. to repo report rt bloo bloody dy sput sputum um 3. not to use over over the count counter er (OTC) (OTC) medi medica cati tion onss with withou outt health care provider's approval 4. import importanc ancee of takin taking g medica medicati tions ons as pres prescri cribed bed 1. adhe adhere renc ncee to tre treat atme ment nt reg regim imen en 2. return return at at sched schedule uled d times times for for lab lab testin testing g of liver liver enzymes
3. 2.
an incre ncreas asee in B6 to minimi minimize ze periph periphera erall neuropa neuropathi thies, es, a common common side side effect effect of drug drug therapy
Lung ab abscess 3. Loca Locali lize zed d area area of of lung lung infe infect ctio ion n 4. Usuall Usually y follow followss pneumo pneumonia nia,, TB or or aspir aspirati ation on 5. Treatment Treatment consis consists ts of draining draining and and culturing culturing absces abscesss and antimic antimicrobia robiall therapy therapy
IX. IX.
LRS LRS Diso Disord rder ers: s: Misc Miscel ella lane neou ouss
A.
B.
Pulmonary embolism 1. Definition/etiology ogy a. clot clot bloc blocks ks blood blood from from the "bed" "bed" of arte arterie riess that that feed feed the the lung lung b. client client is is breath breathing ing but but gases gases are are not exch exchang anged ed - venti ventilat lation ion with without out perfu perfusio sion n c. hypoxemia re results d. can be be mild mild or imme immedia diatel tely y fatal fatal,, based based on the the size size and and locati location on of clot clot(s) (s) e. usuall usually y clot clot has travel traveled ed from deep deep veins veins in the leg leg or pelvis pelvis 2. Diagnostics a. ventil ventilati ation/ on/per perfus fusion ion (V/P) (V/P) scan, scan, also also called called V/Q scan scan b. ABG c. EKG 3. Management a. oxygen via mask b. antico anticoagu agula latio tion n - hepa heparin rin in acut acutee and and coum coumadi adin n for for chroni chronicc risk risk c. thrombolytics d. filte filterr surgi surgical cally ly placed placed in vena vena cava cava for long long term term care care Acut Acutee res respi pira rato tory ry dist distre ress ss synd syndrom romee (AR (ARDS DS)) 1. Definition/etiology ogy a. alveol alveolar ar capi capilla llary ry memb membran ranee becom becomes es more more perme permeabl ablee to fluids fluids b. b. incr increa ease sed d ext extra rava vasc scul ular ar lun lung g flu fluid id c. pulm pulmon onar ary y comp compli lian ance ce decr decrea ease sess d. intr intrap apul ulmo mona nary ry shun shuntt incr increa ease sess e. refractory hypox poxemia f. usuall usually y seen seen afte afterr lung lung inju injury ry or or massi massive ve mult multi-s i-syst ystem em orga organ n disea disease se 2. Findings a. restlessness, anxiety b. dyspnea c. tachycardia d. cyanosis e. inte ntercos rcosttal retra etracction tionss 3. Diagnostics a. clin clinic ical al pres presen enta tati tion on and and hist histor ory y of findi findings ngs
b.
4.
hypoxemia on ABG despite increasing inspired oxygen level c. ches chestt x-ra x-ray y sho shows ws dif diffu fuse se infi infilt ltra rate tess Management a. optimize oxygenation I. mechan hanical ve ventilation II. sedation ma may be be re required red III. III. para paraly lyti ticc age agent ntss may may be nece necess ssar ary y
5.
b. b. anti ntibiot biotic ics, s, as indi indiccated ated c. corticosteroids Nursing inte nterventions a. plan plan for for fre frequ quen entt re rest peri period odss b. monit monitor or tren trends ds in in oxygen oxygenati ation on stat status, us, ABGs, ABGs, resp respira irator tory y effo effort rt
c. C.
observe for behavioral changes and vital signs; confusion and hypertension may indicate cerebral hypoxia
Lung cancer 1. Definition/etiology ogy a. types of lung cancer
I. II. III. IV.
2.
3.
squamous cell carcinoma small-cell (oat cell) carcinoma adenocarcinoma
large cell carcinoma b. b. prog progno nossis is gen geneeral rally poor poor c. largel largely y preve preventa ntable ble if if smoker smokerss stop stop and nons nonsmok mokers ers avoid avoid secon second d hand hand smoke smoke Findings a. hoarse voice b. changes in breathing c. pers persis iste tent nt coug cough h or or cha chang ngee in in cou cough gh d. bloo bloodd-st stre reak aked ed or bloo bloody dy sput sputum um e. ches chestt pai pain n or or tig tight htne ness ss in ches chestt wal walll f. recu recurr rrin ing g pneu pneumo moni nia, a, ple pleur ural al eff effus usio ion n g. weight loss Diagnostics a. medi edical cal ima imaging ging exa exami mina nattions ions b. b. cytol tologi ogical cal sput sputum um ana anallysis ysis c. bronchoscopy d. biopsy
SQUAMOUS CELL CARCINOMA
A.
Risk factors 1. Is most most often often asso associa ciated ted with with ciga cigaret rette te smoki smoking ng 2. Exposure Exposure to environmen environmental tal carcinogens carcinogens e.g. uranium, uranium, asbestos asbestos
B.
Characteristics 1. Accoun Accounts ts for for 30-3 30-35% 5% of lung lung cancer cancer case cases s 2. Is more more comm common on amon among g men men 3. Findin Findings gs occur occur earlie earlierr becaus because e of bronchial bronchial obstruct obstructive ive characte characteris ristic tics s (arise (arises s from from bronchial epithelium) 4. Causes Causes cavita cavitatin ting g pulmo pulmonar nary y lesi lesions ons 5. Usua Usuall lly y meta metast stas asiz izes es loca locall lly y
C.
Therapy 1. Life Life expecta expectancy ncy is bette betterr than smal smalll cell carci carcinom noma a 2. Surgic Surgical al rese resecti ction on is is often often attemp attempted ted
SMALL CELL CARCINOMA
A.
Risk Factors 1. Ciga Cigare rett tte e smok smokin ing g
2.
Envi Enviro ronm nmen enta tall carc carcin inog ogen ens s
B.
Characteristics 1. Accoun Accounts ts for for 15% 15% to 25% 25% of lung lung cancer cancers s 2. Spreads ea early 3. Very Very mali malign gnan antt for form m 4. Is often often assoc associat iated ed with with endocri endocrine ne distur disturban bances ces
C.
Therapy 1. Poor Poores estt prog progno nosi sis s 2. Avera Average ge surv surviv ival al is is less less than than one year year
ADENOCARCINOMA
A.
Risk Factors 1. Not relate related d to to cigare cigarette tte smokin smoking g 2. Lung sc scarring 3. Chro Chroni nic c inter interst stit itia iall fibro fibrosi sis s
B.
Characteristics 1. More More comm common on amon among g wome women n 2. Accoun Accounts ts for for about about half half of all lung lung cancer cancers s 3. Usuall Usually y locate located d in perip peripher heral al secti section on of lungs lungs 4. Often Often no clinical clinical signs or findin findings gs until until well advanced advanced
C.
Treatment 1. Does Does not not respo respond nd well well to chem chemoth othera erapy py 2. Most Most often, often, surg surgica icall resect resection ion is is attemp attempted ted
LARGE CELL CARCINOMA
A.
Risk Factors 1. Ciga Cigare rett tte e smok smokin ing g 2. Envi Enviro ronm nmen enta tall carc carcin inog ogen ens s
B.
Characteristics 1. Occurs Occurs in 15-25% 15-25% of all lung lung cance cancers rs 2. Freq Freque uent ntly ly meta metast stas ases es via via blood blood 3. Usually Usually peripheral peripheral rather rather than centrally centrally located located in the lung lobes lobes
C.
Therapy 1. Usually Usually client client is not a candidate candidate for for surgery surgery due to the the high high frequency frequency of metast metastasis asis 2. Tumors Tumors often often responds responds to radiati radiation on therapy therapy but frequen frequently tly recurs recurs A. Managem gement A. nonsurgical A. chemo hemotthera herapy py B. radi radiat atio ion n the thera rapy py C. laser laser therap therapy y to to de-b de-bulk ulk tumor tumor
D. thoracentesis and pleurodesis surgical A. thor horacotomy A. wedge wedge resect resection ion - part part of a lobe lobe B. segmen segmental tal resect resection ion-- part part of a lobe lobe C. lobe lobect ctom omy y - one one or more more lobe lobess D. pneumo pneumonec nectom tomy y - entire entire righ rightt or left left lung lung Nurs Nursin ing g inte interv rven enti tions ons A. post post-o -ope pera rati tive ve care care A. chest hest dra draiinage nage B. rout routin inee post post oper operat ativ ivee care care A. monito monitorr respira respirator tory y status status frequ frequent ently ly B. teach teach effecti effective ve deep deep breathi breathing ng and and cough cough techniqu techniques es B.
B.
C.
C. D. E. F. 3.
refe referr to physic physical al thera therapy py for exer exerci cise sess for for shou should lder er on affected side D. rel relieve ieve pain ain opti optimi mize ze oxyg oxygen enat atio ion n provid providee opportuni opportuniti ties es for the client client to talk about about cancer; cancer; as needed, needed, refer to support groups teach teach informat information ion as as based based on treatment treatment plan and prognosi prognosiss opti optimi mize ze nut nutri riti tiona onall stat status us
Cor pulmonale A. Defi Defini niti tion on/e /eti tiol ology ogy
A.
B.
right ventricular hypertrophy ventricular hypertrophy and subsequent chronic heart failure B. cause: cause: heart heart must pump against against great great resist resistanc ancee from lung's lung's blood blood vessel vessels: s: called increased pulmonary vascular resistance (PVR) C. increased increased PVR results results from chronic chronic lung lung disease disease D. may be due due to primary primary pulmona pulmonary ry hyperte hypertension nsion as well well Diagnost ostics
A.
4.
pulmonary artery pressure readings via a catheter ( illustration ) B. echoc chocar ardi diog ogra ram m C. ches chestt radi radiog ogra raph ph D. ABG E. EKG C. Managem gement A. admini administe sterr oxyg oxygen en as ordere ordered d B. if hemoglobin hemoglobin withi within n normal limit limitss (WNL), (WNL), monitor monitor oxygenati oxygenation on with finger finger or pulse oximeter C. bed bed res restt, as as nee neede ded d D. monit monitor or effe effects cts of medi medicat cation ionss A. card cardia iacc glyc glycos osid ides es B. pulmon pulmonary ary artery artery vasodi vasodilat lator or C. diuretics D. restri restricte cted d fluid fluid intak intakee as indic indicate ated d E. nurs nursin ing g inte interv rven enti tion onss A. monito monitorr for chang changes es in oxyg oxygena enati tion on statu statuss B. pace pace activi activitie tiess in client clientss who tire tire easil easily y Resp Respir irat ator ory y fai failu lure re A. Definition Definition:: lungs cannot maintai maintain n arterial arterial oxygen levels levels or eliminate eliminate carbon carbon dioxide dioxide
A. B. C.
B.
PaCO2 > 50 mm Hg PaO2 < 50 mm Hg clients clients with chronic chronic lung lung disea disease se precautions precautions A. look look for drop from from basel baseline ine functi function on B. this this is a nurs nursing ing and and medi medical cal emer emergen gency cy C. client clientss are are always always hypoxe hypoxemic mic
Etiology
A.
lung diseases that harden the alveolar-capillary membrane to trap O 2 neuro-m neuro-musc uscula ularr or muscul musculosk oskele eletal tal disord disorders ers A. respir respirato atory ry driv drivee dulle dulled d or blun blunted ted B. musc muscle less too too weak weak to to brea breath thee Diag Diagno nost stic ics: s: ABG ABG Managem gement A. oxy oxygen gen pe per mas mask k B. mech mechan anic ical al ven venti tila lati tion on C. monitor monitor for improveme improvement nt in the underlyi underlying ng cause for for the respirat respiratory ory failure failure B.
C. D.
D.
Oxygen is essential for life. So, before all else , keep airways open and ease breathing effort. Clients Clients with chronic chronic lung lung disease disease use more oxygen oxygen and and energy to breathe breathe.. This can create create a vicious vicious cycle cycle in which the client works harder, and continually requires more oxygen and more energy. F. Nursing Nursing intervention interventionss for clients clients with chronic chronic lung disease disease should include include pacing pacing of activities, activities, because because these these clients have little reserve for exertion. G. Quality Quality of life for clients clients can be significantly significantly improved improved if clients clients routinely routinely use diaphragma diaphragmatic tic breathing breathing and pursed-lip breathing. E.
H.
Clients Clients with asthma asthma must understan understand d the different different types types of inhalers inhalers and when to use each each type. Some Some rescue inhalers are for acute dyspnea. Other inhalers are for maintenance or preventative types of drugs.
I.
A finger or pulse oximeter reading is simply one element of an assessment. It is not the whole picture. Cyanosis, Cyanosis, a late late finding, finding, is is determi determined ned by oxygenati oxygenation on and hemogl hemoglobin obin content content.. Clients Clients with anemia anemia may may be severely severely hypoxemi hypoxemicc and never turn turn blue, but rather rather "ashen". "ashen". Clients Clients with polycy polycythemi themiaa may be cyanotic cyanotic with with adequate adequate tissue tissue oxygenati oxygenation. on. The serious serious public health health issue of pulmonary pulmonary TB requires requires control and and reporting of any incidence incidence and recent recent contacts that the client had so prophalactic therapy for two to three months can be initiated. When caring caring for a client after after a chest tube tube insertion, insertion, an occlusive occlusive dressing dressing is placed placed around the chest chest tube insertion site and the connections of the chest tube system are taped to prevent air leaks at connections. An occlusive dressing is one that is totally covered, as well as the edges with non-porous tape. This dressing is typically not changed and not expected to have any drainage on it.
J. K. L. M. N.
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•
•
•
•
When caring for a client on a ventilator, if an alarm sounds, first, assess the client. See if the alarm resets or if the cause is obvious. If the alarm continues to sound and the client develops distress, disconnect the client from the ventilator, use a manual resuscitation bag to ventilate with 100% oxygen and page or call the respiratory therapist immediately. immediately. If the ventilator tube disconnects, the low pressure alarm will sound. If the high pressure alarm sounds on the ventilator, the nurse should check for some type of obstruction or occlusion of the airway: mucous plugs, biting of the tube by the client, tube slips into right main stem bronchus, or increased secretions. To maximize therapeutic effect of inhalers , the key is technique. It is critical to teach clients the right technique and observe how well they use the inhaler. Smoking cessation is critical to reduce the risk and severity of lung disease. Second-hand smoke enhances the risk of children to develop asthma or other chronic lung diseases. Best approach to pulmonary embolus is prevention. The use of intermittent compression stockings prevents clots in the deep veins. Clients Clients with pulmonary TB need intensive intensive community follow up to ensure ensure that they they contin continue ue with with pharmacological treatment once discharged from the hospital. Clients who stop therapy too soon are the source for the more deadly multi-drug resistant forms of pulmonary TB. Acidosis Alkalosis Antibiotic Anticholinergic Apnea Auscultation Bronchodilator Cheyne-Stokes COPD Cor Corticosteroid Crackles Cromolyn Croup Hypercapnia Hyperpnea Hyperventilation hypocapnia Hypoventilation Hypoxemia Hypoxia Influenza Kussmaul's Kyphosis Mucolytic
Pulmonale
sodium
breathing
Nosocomial
pneumonia
Pleurodesis Pneumoconiosis Scoliosis Tachypnea Thoracentesis Wheezes • • • • • • • • • • • • • • • • • • •
Action of Cilia Alveolocapillary membrane Alveolus of lungs Central venous catheter Drainage of lower lobes Epiglottis Glottis and vocal chords Heimlich manuever Larynx Lungs Paranasal Sinuses Pneumocystis Carinii Pneumonia Pneumothorax Postural drainage of lungs Respiratory System Sternum Trachea Tubercolosis Two views of the nasal cavity
