Unit 10 Respiratory

*Upper respiratory Disorders* RSV Causes majority of Resp illness in infants and young children; adults present with S/S like a common cold; Immunocompromised and older adults may also develop lower resp disease when exposed and present with those SX ;(like pnuemonia). Older children and adults are not as seriously ill. Direct contact and droplet spread. Contact isolation precautions used. Not airborn; can live on soap, countertops, tissues for 6 hours. Incubation 4 days. . Infants/child: affected by 2nd birthday, refinfection is common when around many other children(daycare). 2-7 months of age is a critical time due to the size of air passages which are prone to thick mucus and obstruction. Manifestations: (adult) Runny nose, cough, sore throat, headache, mailaise, low grade fever; basically similar to a common cold. (Child/infant) Mild fever, clear nasal discharge which can be in copious amounts, chest congestion. wheezing cough, signs of respiratory distress. Very high fever, dyspnea, younger age, and apnea, usually leads to hospitalizations of the illness. Treatment: (child).Treat symptoms;fever and dehydration to name a few ;Report tachycardia or tachypnea, could be a sign of hypoxemia; Sudden quiet chest can be a sign of an increased risk of respiratory arrest. (adults/olderchildren) Treatment is also based on symptoms, as antibiotics do not treat viral infections. Virazole(ribavirin)- Antiviral med for very ill infants, or those with pre existing cardiac/pulmonary issues; aerosol mist, minimum 3 days, 18-24 hrs a day; not used regularly due to serious side effects.Immunizations postponed 9 months with use. Respigam(IV immune globulin)- high risk infants; watch for fluid volume overload; Synagis IM(paivizumab)- high risk infants; No intereference with MMR or Varicella.

Allergic rhinitis (hay fever) - allergens; whitish or clear nasal discharge; can be seasonal, pollen or ragweed for ex; Histamine response causes the S/S, the leaky capillaries and vasodilation; could lead to snoring or post nasal drip.Headache is common symptom.

Acute viral rhinitis(common cold) -Highly contagious; most adults have 2-4 a year; hand to hand and inhalation spreads it; contageous a few days before and after SX appear. S/S : Low grade fever, headache, malaise, muscle aches. Mild, self limited; Can last few days to 2 weeks. Otitis media, sinusitis, may follow as a possible complication. Treatment is symptom based; decongestants; nasal sprays; Influenza - Highly contagious; viral; Abrupt onset, 1-2 weeks duration, but fatigue and cough may last longer; secondary sinusitis, otitis media, pnuemonia(BACTERIAL) and bronchitis may follow. S/S : Sore throat, coryza, dry cough, not productive but may become so, substantial burning; Chills, fever, headache, malaise, muscle aches, fatigue and weakness. Older adults have increased risk of death and complications Airborne droplet and direct contact. Sinusitis: Inflammation of mucus membranes in the sinuses; red swollen sinuses; Viral and bacterial causes; often secondary to other upper respiratory infections; can become chronic for some, especially smokers and people with allergies. SX worsen after waking, less severe in the afternoon/evening due to drainage; Nasal congestion, purulent discharge, fatigue, fever, pain/tenderness across sinuses, headaches. Infection can spread; Treatment: antibiotics, decongestants, antihistamines, surgery to drain and open sinuses, antral irrigation (sinus irrigation) ; Based on severity and if purulent drainage noted. Pharyngitis : Inflammation of the throat; Bacterial, viral, environmental causes, usually viral. Strep throat is most common bacterial cause. Manifestations: (Viral) Gradual onset, low grade fever throat bright pink-red, headache, mild hoarseness. (Bacterial) Abrupt, higher fever, severe sore throat, dysphasia, maliase and muscle aches, enlarged tender cervical lymph nodes, bright red throat; patches on throat and/or tonsils. Treat findings; if culture shows bacteria, use antibiotics

Complications include acute glomerulonephritis and rheumatic fever, an abnormal response to the bacteria., 1-5 weeks after acute infection. Early treatment vital to prevent complications. Droplet nuclei spread. Tonsillitis Inflammation and/or infection of tonsils; Acute form is usually bacterial; Treat findings; if culture shows bacteria, use antibiotics Manifestations: sore throat, enlarged tender cervical lymph nodes, bright red, swollen, white exudate, swollen uvula, malaise, fever, pain in ear, difficulty swallowing. Also spread via droplet nuclei.

Upper respiratory continued

Peritonsillar abscess Complication of acute tonsillitis; If swelling is massive, can endanger airway; Pus forms behind tonsil; possible inability to swallow; contraction of chewing muscles may occur; deviation of uvula; Laryngitis inflammation of vocal cords and surrounding mucous membranes; occurs in viral and bacterial infections, or alone; excessive use of voice, dust, pollutants also a risk factor; hoarseness or aphonia may occur; Resting voice speeds recovery, encourage no smoking and singers to have voice training and to not sing out of their range.

Nursing care related to Upper Respiratory infections and conditions: Educate regarding good general health and reducing stress; frequent hand washing; Annual flu shots; Educate regarding ABX resistance due to overuse of ABX, which relates to the lack of need for ABX in viral infections; Educate the need to finish ALL ABX when a bacterial infection is present, which further reduces ABX resistance. Report fevers higher than 101.F, or a fever that continues for more than 3 days; Watch for increasing dyspnea, productive cough with green or rust colored sputum; Signs such as localized pain, swelling, loss of hearing, and inability to swallow can indicate that an infection is spreading. Monitoring for these things helps to prevent major complications. Assess for color of sputum, presence of pain, coughing-productive or non productive?; SOB, dyspnea of any kind, altered taste or smell, recent illness, past medical history, allergies, respiratory disease, diabetes, smoking. -Semi fowlers is a good position to help with breathing -Throat swab for strep throat if suspected; LA antigen and Elisa allow for rapid

identification of bacteria.

Epistaxis Nosebleed; May begin in many ways, for example trauma or infection, substance abuse. Most occur in the rich vascular anterior septum; Posterior nosebleeds tend to be secondary to systemic disorders, hypertension and diabetes for example; more severe, frequently in older adults. Identify and control source of bleeding; Anterior nosebleed usually managed by pinching nose toward septum and leaning FORWARD; 5-10 min, apply ice packs for vasoconstriction; client should spit out blood; Posterior bleeds may require extra care, including nasal packing for up to 5 days; They require monitoring for respirations, and supplemental O2 is given. Posterior packing risks include MI, dysrhythmias, hypertension, and toxic shock. Chemical or surgical cautery may be used to stop bleeding,, is an alternative to packing for posterior bleeds; scab must be left in place until mucosa is healed.

Upper respiratory cont..

Laryngeal cancer Most tumors of the larynx are squamous cell carcinoma; slow growing; More common among men; 60 + Tobacco and alcohol use are primary risk factors; synergistic effect when used together; chronic exposure to chemicals DX with X rays, CT, and MRI scans; determine extent and exact location, soft tissue involvement; DX Laryngoscopy can be done if there are manifestations; Also visualizes tumor, obtain biopsy, which definitively determines cell type and stage; (return of gag reflex, airway, bleeding, are important with this test) DX bone scan and PET scan can determine METS; Needle Biopsy of lymph nodes also helps to confirm DX.; Barium swallow evaluates swallowing and tumor extension S/S Persistent ear pain, weight loss, dyspnea, persistent sore throat, cough, or voice change, pain/difficulty swallowing; Lumps. Foul breath. RADS is treatment of choice, preserves tissue and voice; used early on, or if surgery risk is too great. Chemo is not treatment of choice; could be combined with RADS if increased risk of METS, or for inoperable tumors, or with excisional surgery.(smaller surgery) Surgery- Not a TX of choice; type/extent is based on size/site/invasiveness; some surgeries do not allow for speech. Laryngectomy-remove Larynx; , based on need. Partial Laryngectomy- or a little more of Larynx; resume normal speaking, breating, swallowing; Trach to maintain airway in early post op period, temporary < 1 week. Total Laryngectomy- Entire larynx, surrounding tissues, permanent trach needed; Speech lost; Choking not possible; begin with soft foods not liquids when oral intake resumed; Fluids via IV, enteral feedingd may be needed; Immediate priority is airway patency and maintenance; Increased risk of respiratory infection with permanent trach. Client uses CLEAN TECHNIQUE for stoma care after a tracheostomy; Laryngectomy tube inserted in stoma, help prevent contractures Neck dissection needed if cervical lymph nodes are involved, along with total laryngectomy; difficulty lifting and turning head, shoulder drop on affected side due to 11th cranial nerve; rehab can be done.

Leukoplakia- Precancerous white lesions, develop first. Erythroplakia- Red velvety patches; later stage tumor Diet high in protein and calories Anticipate suctioning needs related to airway, thickened liquids, upright position, monitor vital signs and O2 SATS, blood loss or hemorrhage; pain.

Lower respiratory Disorders Lung Cancer Often not DXd until advanced stage when METS occurs; 5 year survival rate less than 15% Cigarette smoking is primary risk factor; 2nd hand smoke, environmental, asbestos, occupational, are a few other risk factors. Initial S/S are often blamed on smoking or bronchitis; Persistent cough without or without blood tinged sputum; dyspnea, Unilateral wheezing, recurrent respiratory infections, weakness, Pleural effusion, pain is a LATE sign. Prevention is a primary goal; educate the public and clients; urge cessation of smoking; DX tests like Bronchial washing is an option, we can use to Biopsy; Percutaneous needle Biopsy aspirates pleural fluid by thoracentesis if tumor is in lung periphery. It is performed under fluoroscopy or xray guidance; Chest X-RAY often shows the first signs of lung CA. Bronchoscopy allows viewing ; can use it to obtain a biopsy sample. ***Return of gag reflex is a consideration for scopy tests when local anesthesia is used. *** Biopsy is always best DX tool; accurate! Lung Cancer types Non-small cell lung cancerSqamous cell carcinoma 30%-32% of all Lung CA; Central mass in large bronchi. Cough, dyspnea, atelectasis, wheezing. Spreads by local invasion Adenocarcinoma 20%-40% of all Lung CA; Peripheral mass, few symptoms; Early METS to CNS, bone, adrenal glands. Large cell carcinoma- Large peripheral lesions; may cause gynecomastia or thrombophlebitis; early METS Small Cell CarcinomaSmall cell(oat cell) 15% of all cases; Central mass; may cause endocrine symptoms(cushings or SIADH) or thrombophlebitis. Aggressive, Distant METS common at diagnosis. Treatments : Complete surgical removal is the only real hope for a cure; type depends on location and size Adjuvant(combo) therapy is often used since Lung CA is DXd too late for complete surgical treatment.

RADS is used alone or as adjuvant; shrinks tumors pre surgery; used alone if surgery is not an option; Complication of Superior Vena Cava syndrome can be treated with RADS. Lung Surgery 1. Wedge resection- Small section removal; small peripheral lesions; Turn patient on unaffected side after this surgery. 1. Segmental resection- removal of a single bronchovascular segment of a lobe; localized peripheral lung tumors 1. Lobectomy- Removal of a lung lobe; tumors confined to a lobe; Either side turning 1. Pneumonectomy- Removal of an entire lung; tumors throughout the lung, main bronchus, or fixed to the hilum. Turn patient on AFFECTED SIDE. **Remember turn cough and deep breathe; maintain airway, effective breathing. **Complications include superior vena cava syndrome, as well as extensive METS **Report new sudden symptoms; Elevate head of bed to 60 degrees; monitor activity tolerance, pain, grieving, emotional needs, and educate regarding continuity of care assess, assess, assess! Evaluate! Discuss follow up care and resources.

Pulmonary embolism Blockage of pulmonary artery, disrupts blood flow to lungs. Thromboemboli are most common pulmonary emboli; tumors, amniotic fluid, bone marrow fat, and foreign matter can become emboli. Most begin as clots in deep veins of legs, or from pelvis; risk factors are the same as with a DVT. Prolonged immobilization is primary risk; Large PE can be fatal Manifestations: Abrupt dyspnea, chest pain; Anxiety, apprehension; Tachycardia, tachypnea, Diaphoresis, Cyanosis(not an early sign). Pleural friction rub may be heard; Hemoptysis can occur, shallow resps. Arrhythmias can occur, shock; could see redness and swelling in legs, a visible clots. Prevention: early ambulation after surgery-as allowed; TEDs or SCDs, anticoagulant therapy; Elevating legs but no pillows under knees, exercises; No dangling without support; Handle patients joint to joint to prevent dislodging a clot. Treatment: Supportive in nature; O2 given, analgesics, clot busting drugs may be given(risk of intercranial bleeding, monitor), IV Heparin is given, so PTT is monitored, and is continued until oral anticoagulant therapy is effective, 5-7 days after; are continued for 2-3 months.(risk of bleeding) Warfarin and coumadin monitored via PT. **maintaining effective gas exchange highest priority in care. Homans sign- a positive sign for DVT/CLOTS. Surgery: Umbrella like filter in inferior vena cava for people with recurrences; embolectomy, go directly after clot. Assess: recent surgery, pregnancy, malignancy, recent DX of venous thrombosis; LOC, skin color, heart rate, resp rate, breath sounds, O2 SATS. Complication: can be deadly; medical emergency; PE that obstructs major artery can affect pulmonary output and perfusion; impaired cardiac output, shock. **Prevention is key. Teach to prevent DVT by making stops when in a long car ride or air travel; do not cross legs, exercise, wear elastic support hose if standing for prolonged period of time, avoid hose which bind at knee or thigh. Encourage fluids to prevent hemoconcentration; Anticoagulants if immobile; DX Tests: D-DIMER is specific for thrombus; Pulmonary angiogram(contrast used); Chest x-ray, ECG, coagulation studies, CT scans, ventilation perfusion scan. **Immediately report manifestations of shock and impaired cardiac output.(complication) Dopamine: Is a common drug given for shock; Morphine is a common drug because it helps with pain and respirations, watch for slowing effect on resps.

Anticoagulants: Warfarin/coumadin : takes time to be effective; Antidote is Vitamin K, Synkavite(sp) Heparin : Immediately effective; Protamine Sulfare is antidote -Normal NR ratio is 1-3; another way to assess for patients receiving anticoagulation therapy. Lovenox: Give DEEP SUB Q; tuberculin synringe, no aspiration, 90 degree angle; given in abdomen; ** Monitor for bleeding: Watch for kidney pain when taking anticoagulants, bleeding can occur(complication) No taking aspirin concurrently! Cardiac tamponade=bleeding into heart; Epistaxis and bleeding into lungs can occur.

Lower Respiratory disorders cont.. Pneumonia - Inflammation of bronchioles and alveoli Community Acquired: Usually Streptococcal (Pneumococcal pnuemonia); Rusty brownish reddish sputum in 48 hours; Acute onset; shaking chills, fever, productive cough, chest pain, fine crackles, diminished sounds, rapid bounding pulse. Pleurisy is common complication; Can cause lung damage; Empyema; Staph Pneumonia has yellow blood streaked mucus; often Pt has HX of viral infection Nonbacterial pneumonia: (AKA atypical community acquired) Patchy inflammation of supportive lung tissue; (Mycoplasma) ; generally a less severe type; Symptoms tend to mimic FLU; fever, headaches, muscle aches, malaise, cough tends to be dry/hacking, and can last up to 6 weeks, worse at night.Complications are rare, but laryngitis, abnormal immune response, Hypoxia/Resp distress. Lobar : All or part of ONE lobe Bronchopneumonia: Patchy, more than one lobe. Consolidation occurs during pneumonia, due to the collection of blood cells and bacteria Lower lobes tend to be most often affected, thanks to gravity. Nosocomial Pneumonia: Klebsiella/Staph; health care acquired Immunocompromised Pneumonia: AIDS; Pneumoina Carnii(Jiroveci is the new name) Opportunistic infection; alveoli thicken, edema, fill with foamy proteiny fluid. Treatment: Strep Pneumonia with Penicillin G, erythromycin, cephalosporins, Clindamycin, Bactrim. Bronchodilators, expectorants, steroids may be given. Percussion and postural drainage to assist with secretion expulsion; Avoid breasts, sternum, kidney, and spinal column area; Increase fluid intake 2.5-3.0 Liters. DX tests: X-Ray is primary test; identifies extent; Atelectasis, fluid, and consolidation can be identified. CBC with WBC count ABGs to evaluate gas exchange SaO2s

-Vaccine for >65 or for immunocompromised/chronic illnesses/asthma/healthcare workers. Nursing Care: Priority care involves airway and gas exchange; Monitor for complications and treatment which is not showing effectiveness; Unstable vital signs, deterioration of condition, breathing; Turn, cough, deep breathe, to help ventilate lungs and clear airways; Promote those extra fluids; Upright position/semi upright to promote ventilation; teach slow ABD breathing for good lung expansion; Assess activity tolerance/intolerance as it relates to ADLs; Educate need for rest, smoke free environment, small frequent meals, etc, when patient is treated at home, aside from the above.

Unit 10 Respiratory
Pneumothorax: air in pleural space; Injury ; chronic lung disease; Lung deflates/collapses due to this Primary affects tall, slender young adult men/normally healthy people(risk factor is smoking); Secondary affects people with pre existing lung disease(higher risk of complications); Tension pneumothorax: Trachea shifts towards unaffected side; hypertensive, signs of shock; absent sounds; air enters, cannot escape, accumulates rapidly. Traumatic: Chest trauma; open wound can hear and feel air moving in and out of wound. Hemothorax: Blood inside of the pleural space; shock is a risk due to hemorrhage possibility; Dull percussion sound can be heard over collected blood. -Severe chest pain, dyspnea, diminished breath sounds on affected side; Both have similar manifestations. -Chest tube needed to reinflate lung, remove fluids; Tube is placed in pleural space; (Thoracentesis can be used, but chest tubes are usual treatment.) Connected to closed drainage system; Water sealed via second middle compartment; keep tube underwater, cuz it seals off pull of air or fluid;Does not continuously bubble, but may have one or 2 small bubbles or tide with inspirations/expirations or cough. If accident happens place tube in water to maintain seal; We only double clip if continuous bubbles to check for leaks or for a quick change, the risk is mediastinal shift. 3rd is connected to suction, continuous bubbles, doc orders amount of suction. Water controls pressure pulling against lung tissue. IF we have 2 chest tubes, the upper tube is for air, the lower tube removes a fluid of some sort;2 separate vacs. When tube is accidently removed: Occlusive dressing is applied when air is removed(Vaseline type dressing) Prevents air from entering, but allows for exit. When lung is collapsed, gas exchange no longer occurs at that part of lung. Fowlers or High Fowlers to facilitate lung expansion; Give O2 as ordered; Keep drainage system below level of chest when ambulating or sitting; -Empyema: Pus in pleural space; Thoracentesis is done, hold breath during insertion of needle; ABX and follow up chest X-ray to monitor for collapse or complications. -Rib fracture : Simple is usually single rib; pain on inspiration and coughing; Bruising over FX site, crepitus, diminished sounds in base due to splinting to reduce pain; Rib binders, belts, and taping not recommended.

-Flail Chest: Inspiratory movement- sucking in of rib, expiratory movement- puffing out of ribs; Two or more ribs are broken in several places, chest wall becomes free floating. Pain, dyspnea, uneven chest expansion, sounds diminished, crackles, crepitus. May need taping or surgical stabilization; -Tracheostomy: The Trach cuff allows the trach tube to remain without using the strings; Other reasons include sealing off area to prevent aspiration of orpharyngeal secretions; air leakage between tube and treachea; Limit to 20cc of pressure to prevent necrosis, follow uncuffing policy for care. -Respiratory Failure: PaO2 less than 50(hypoxemia), Pco2 increases(hypercapnia); not a disease, but a result.Must use mechanical ventilation with O2 administration due to respiratory center depression and loss of CO2 being stimulus to breathe. Prognosis depends on underlying cause/disease.(COPD is most common cause) Due to Hypoxemia: Metabolic acidosis; hypertension, restlessness, confusion, anxiety, dysrythmias; Due to Hypercapnia: Respiratory acidosis; Drowsiness, coma, headache, heart failure.

-ARDS: Severe form of acute resp failure; Non cardiac pulmonary edema, progressive hypoxemia that does not respond to O2 ; Can follow injury, drowning, H1N1; Alveoli surfactant is inactivated, cells are damaged, they collpase; Hypoxemia and PCO2 rises, PH lowers; Manifestations usually 24-48 hours after initial insult, Dyspnea and tachypnea are initial; breath sounds initially clear