Medical Surgical

1
Chpt 27 Disorders of Lower Respiratory Tract

• Medical Surgical

2
Acute bronchitis PG 374

• Characterized by inflammation of the mucous
  membranes that line the major bronchi and their
  branches.
• Most common cause is a viral infection
• Signs symptoms fever, malaise, and a dry,
  non-productive cough that later becomes
  productive of mucopurulent sputum

3
Acute Bronchitis

• Acute bronchitis differs from pneumonia in that
  with acute bronchitis there is initially a
  nonproductive cough.
• They have paroxysmal(sudden violent) attacks of
  coughing and may have wheezing
• May also have laryngitis and sinusitis.
• Moist inspiratory crackles may be heard

4
Acute Bronchitis

• Usually self limiting, lasting for several days
• Treated with bedrest, antipyretics, expectorants
  and antitussives and lots of fluids
• If secondary bacterial infection occurs then it
  becomes a serious condition. Has persistent cough
  and thick purulent sputum if secondary infection
  occurs

5
Nursing Care

• Auscultate breath sounds
• Monitor vitals
• Encourage to cough and deep breathe q 2 hrs.
  while awake and to expectorate rather than
  swallow sputum
• Change damp clothing and linen
• Offer fluids frequently

6
Prevent Spread

• Wash hands frequently especially when handling
  soiled tissues
• cover mouth when sneezing and coughing
• Discard soiled tissues in a plastic bag
• Avoid sharing articles

7
Pneumonia PG 374

• Infalmmatory process affecting bronchioles and
  alveoli
• Viral pneumonias are most common cause

8
Types of Pneumonia

• Viral,Bacterial,Radiation,Chemical
• Aspiration
• Lobar--confined to one or more lobes
• bronchopneumonia--patchy and diffuse infection
  scattered thruout both lungs
• hypostatic--hypoventilation in immobile

9
Pneumonia

• Organisms that cause pneumonia reach the alveoli
  by inhalation of droplets, aspiration of
  organisms from upper airway, or from bloodstream.
• When organisms reach alveoli, an intense
  inflammatory reaction occurs. This produces
  exudate which impairs gas exchange .

10
Pneumonia

• Capillaries surrounding the alveoli become
  engorged and cause the alveoli to collapse
  (atelectasis)
• If untreated consolidation occurs and the
  infection gets worse causing hypoxemia.
• Lung tissue gets necrotic and death can occur
  from failure.

11
Complications of Pneumonia

• CHF
• empyema-collection of pus in pleural cavity
• pleurisy-infalmmation of the pleura...major
  complication of pneumonia
• septicemia-infective microorganisms in the
  blood--can cause endocarditis, pericarditis and
  purulent arthritis
• atelectasis
• hypotension and shock

12
Bacterial Pneumonia

• Onset of bacterial is sudden. he has fever,
  chills, a productive cough, and discomfort in
  chest wall muscle from coughing. Malaise,
  breathing may cause pain and he breathes
  shallowly
• Classic symptom is rusty colored sputum

13
Viral Pneumonia

• Differs from bacterial in that blood cultures are
  sterile, sputum may be more copious, chills are
  less common, and pulse and resp rates are
  characteristicly slow.
• Mortality rate low as less serious than
  bacterial. Mortality rate increases if secondary
  bacterial infection occurs. Wheezing, crackles,
  decreased breath sounds. Nail beds, lips oral
  mucosa may be cyanotic

14
Nursing

• When he has pneumonia, adequate oxygenation can
  be accomplished by placing him in a semi-fowlers
  position
• Semi-fowlers increases the amount of air taken in
  with each breath
• Assess for classic symptoms of chest pain, fever,
  shallow respirations. Assess for signs of Acute
  respiratory failure. Use of accessory muscles of
  respiraton is Ist sign

15
Nursing

• Auscultate lung sounds and monitor for signs of
  respiratory difficulty
• assess cough and nature of sputum production
• Increase fluids
• Monitor I O, skin turgor and serum electrolytes
• Monitor pulse oximetry, ABGs and quality of
  breathing

16
Important Information

• Review nursing guidelines 27-1 page 377 and care
  of the client with TB page 382 as nursing care is
  same

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Pleurisy PG 377

• Acute inflammation of the parietal and visceral
  pleura
• Respirations become shallow secondary to
  excruciating pain caused by inflamed pleura
  rubbing together. This causes severe, sharp pain.
  Pleura fluid increases because it separates the
  pleura and he develops a dry cough, fatigues
  easily and has shortness of breath. Friction rub
  heard

18
Nursing Care

• Teach to splint the chest by turning onto the
  affected side. May also splint by using hands or
  a pillow when coughing

19
Pleural effusion PG 377

• collection of fluid between the visceral and
  parietal pleura
• Complication of pneumonia, lung cancer, TB,
  pulmonary embolism and CHF
• Accumulated fluid may be so great that it
  collapses the lung on that side and pressure is
  placed on the heart and other organs

20
Pleural effusion

• Fever, pain, and dyspnea are the most common
  symptoms. Chest percussion reveals dullness over
  the involved area. May have diminished or absent
  breath sounds. Friction rub may be heard.
• Thoracentesis sometimes done.

21
Lung abscess PG 378

• Localized area of pus formation within the lung
  parenchyma. As pus increases, necrosis of the
  tissue occurs. Later the area collapses and
  creates a cavity
• Signs and symptoms --chills, fever, weight loss,
  chest pain and a productive cough. Sputum may be
  purulent or blood streaked
• There will be dull or absent breath sounds in the
  area of abscess

22
Surgical Management

• A lobectomy may be done to remove the abscess and
  surrounding lung tissue
• Teach to cough and deep breathe and to eat a diet
  high in protein and calories

23
Empyema PG 378

• Presence of pus in a body cavity..usually refers
  to pus or infected fluid in the pleural cavity
• Fever chest pain, dyspnea, anorexia and malaise.
  there will be diminished or absent breath sounds
  over area. Appears acutely ill
• Thoracentesis and chest tube drainage used to
  drain purulent drainage. Following a
  thoracentesis must observe for resp distress

24
Chest Tubes

• The use of chest tubes is usually necessary to
  drain secretions, air, and blood from the
  thoracic cavity in order to re-expand the lung.
• Chest tubes are inspected frequently since any
  break in the system could allow air to be drawn
  into the pleural space and collapse the lung

25
Chest Tubes

• When inspecting chest tubes connected to an
  underwater seal system, the nurse makes sure the
  system is kept below the level of the bed
• If any break or major leak occurs the nurse
  immediately clamps the chest tube
• Clamps must be taped to the bed frame when chest
  tubes are inserted to use in an emergency

26
Influenza pg 379

• Acute respiratory disease caused by virus.
  Transmitted thru respiratory tract
• Fatalities usually due to secondary bacterial
  infection and complications, especially in
  pregnant women, elderly and debilitated or ones
  with chronic conditions (cardiac, emphysema,
  COPD, diabetes)

27
Nursing Management

• Prevention and influenza vaccinations recommended
• Respiratory isolation required
• Review table 27-2 page 379 for symptoms

28
Pulmonary Tuberculosis Pg 380

• Bacterial infection disease that primarily
  affects lungs but can affect kidney and other
  organs
• Tubercle bacilli are gram-positive, rod-shaped,
  acid fast bacteria. It can live in the dark for
  months in particles of dried sputum, exposure to
  direct sunlight, heat and ultraviolet light
  destroys them in a few hours.

29
TB Pathophysiology

• The microorganism is difficult to kill with
  ordinary disinfectants.
• Tubercle bacilli are killed by pasteurization, a
  process widely used in preventing the spread of
  TB by milk and milk products.

30
TB

• Most commonly transmitted by direct contact with
  a person who has the active disease thru
  inhalation of droplets produced by coughing,
  sneezing, and spitting.
• Brief contact usually does not result in disease.
• Bacilli may stay dormant for years and reactivate

31
S/S

• Symptoms may not appear until the disease is
  advanced. as they develop they are often vague
  and can be overlooked
• Fatigue, anorexia, weight loss, and a slight
  nonproductive cough are early symptoms
• Low grade fever, particularly in late afternoon,
  and night sweats are common as it progresses.
  Cough becomes productive of mucopurulent and
  blood-streaked sputum.

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• Marked weakness, wasting, hemoptysis and dyspnea
  are common late stage. Chest pain may result from
  spread to pleura
• Must identify bacteria to diagnose. Cultures of
  sputum ordered. Can do gastric washings to
  retrieve swallowed bacteria.Gastric gavage,
  gastric aspiration and bronchoscopy used.

33
Medications

• Combined therapy with two or more drugs decrease
  the likelihood of drug resistance, increases the
  action of drugs
• antibubercular drugs are given for long periods
  and without interruption because healing is slow
  and resistance to drugs is increased by
  interrupted treatment.

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Drug Regimen for TB table 27-1 pg 382

• The primary focus of a teaching plan for TB is to
  encourage them to complete the prescribed meds
• Drug typically used for treatment initially is
  isoniazid. Rifampin, PZA is also given
• Isoniazid may be given alone initially or a
  combination drug of the three above may be taken
  for...may take meds up to 18 to 24 months

35
Surgical Management

• surgery may be done if disease is located
  primarily in one section of lung.
• Segmental resection--one section removed
• Wedge resection
• lobectomy
• pneumonectomy--entire lung

36
Assessment

• Breath sounds, breathing patterns, and overall
  respiratory status
• Any pain breathing?
• Inspect sputum for color, viscosity, amount and
  for signs of blood
• Review page 382 and 383 for nursing care

37
Teaching

• Take meds exactly as prescribed and observe time
  intervals between each dose
• Drugs must be taken for a long time, complete the
  entire series
• Stress importance of continuous therapy because
  lapses in taking the drugs result in reactivation
  of infection
• Notify Dr if symptoms worsen or sudden chest pain
  or dyspnea

38
Teaching for TB

• Drink extra fluids. Take med for fever but if it
  continues call Dr
• Stop smoking and avoid second hand smoke
• Eat a balanced but light diet. Call Dr if more
  than a few pounds lost
• Avoid people with infections
• follow up care is important!!

39
Obstructive Pulmonary Disease pg. 383

• COPD is a broad, nonspecific term that describes
  a group of pulmonary disorders with symptoms of
  chronic cough and expectoration, dyspnea, and an
  impaired expiratory air flow.
• Bronchiecstasis, atelectasis, chronic bronchitis
  and emphysema are COPD disorders.

40
Obstructive Disease

• Asthma is also an obstructive disorder that is
  more episodic--generally more acute than chronic
• Sleep apnea syndrome is the cessation of airflow
  in and out of the lungs during sleep. Can be
  caused by obstructive causes

41
Bronchiecstasis pg. 383

• Chronic disease characterized by irreversible
  dilation of the bronchi and bronchioles and
  chronic infection
• When clearance of airway is impeded an infection
  can develop in the walls of the bronchus or
  bronchiole. This leads to changes in the
  structure of the wall tissue and results in the
  formation of saccular dilatations which collect
  purulent material

42
S/S

• Chronic cough with expectoration of copious
  amounts of purulent sputum and possible
  hemoptysis.
• Cough becomes worse when changing positions. Can
  spit up several ounces of sputum

43
Bronchiectasis

• When sputum is collected it settles in three
  distinct layers
• Top layer--frothy and cloudy
• Middle layer--clear saliva
• bottom layer--heavy, thick and purulent
• Also have fatigue, weight loss, anorexia and
  dyspnea

44
Bronchiectasis Nursing Care

• A major treatment used is postural drainage as it
  helps mobilize and expectorate secretions
• Performed three times a day in each position
  while he inhales slowly and blows the breath out
  thru the mouth. Usually takes 5 to 15 min.see
  picture pg 385 (used to drain lower lobes) chest
  percussion and vibration also used

45
Atelectasis pg 384

• Collapse of lung tissue. May involve a small
  portion of lung or entire lung.
• Symptoms related to size of collapsed area
• Small areas may have few symptoms. Large areas
  cause cyanosis, fever, pain, dyspnea, increased
  pulse and resp rates and increased pulmonary
  secretions
• Crackling may be heard but usually absent breath
  sounds in the area

46
Nursing Management

• Care focus is on prevention. Deep breathing and
  coughing post-op can prevent
• If it occurs encourage him to cough and deep
  breathe frequently and to use incentive
  spirometer (review guidelines pg. 386)

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Chronic Bronchitis pg 384

• Persistence of a chronic cough with excessive
  production of mucus for at least 3 months a year
  for 2 consecutive years
• Characterized by hypersecretions of mucus by the
  bronchial glands and recurrent or chronic
  respiratory tract infections
• Secretions remain in lungs and form plugs within
  smaller bronchi can cause necrosis and fibrosis

48
Chronic Bronchitis

• Earliest symptom is a productive cough of thick
  white mucus, especially when rising in the
  morning and in the evening.
• Bronchospasm may occur during severe bouts of
  coughing
• As condition worsens the sputum becomes yellow,
  purulent, copious and after paroxysms of
  coughing, blood streaked

49
Chronic Bronchitis

• Cyanosis secondary to hypoxemia may be noted,
  especially after coughing.
• Dyspnea begins with exertion (dyspnea on exertion
  is a common symptom of pulmonary hypertension)
  but leads to dyspnea with minimal activity and
  later at rest

50
Chronic Bronchitis

• Called the blue bloater as color is dusky and
  cyanotic

51
Medical Management

• Stop smoking
• Bronchodilators
• Increased fluid
• Well balanced diet Postural drainage
• steroids
• change in occupation if exposure to dust and
  chemicals
• Air filters and antibiotics

52
Nursing

• Identify ways to eliminate environmental
  irritants
• Avoid cold air and wind exposure that causes
  bronchospasms
• Avoid others with resp. infections
• Get flu and pneumonia immunizations
• Monitor sputum for signs of infection, teach
  postural drainage
• Teach how to use inhalers (27-3 pg.387)

53
Pulmonary Emphysema pg. 387

• Emphysema is a chronic disease characterized by
  abnormal distention of the alveoli
• Major cause is smoking. Exposure to second hand
  smoke, air pollution, chronic infection and
  allergens also cause it.
• The alveoli lose elasticity, trapping air that
  normally should be expired

54
Emphysema

• The walls of the alveoli break down and form one
  large sac
• Shortness of breath occurs with minimal activity
  (exertional dyspnea) and is often the first
  symptom
• Breathlessness occurs even with rest
• Chronic productive cough and inspiration is
  difficult because of barrel chest

55
Emphysema

• Uses accessory muscles to breathe
• expiration is prolonged, difficult and has
  wheezing
• Advanced emphysema pt. Appears drawn, anxious,
  pale and speak in short jerky sentences. They
  lean forward and are short of breath. Neck veins
  distend during inspiration

56
Emphysema

• In advanced cases memory loss, drowsiness,
  confusion, and loss of judgment may occur
• CO2 levels may reach toxic levels resulting in
  lethargy, stupor, and eventually coma
• Will have decreased breath sounds, wheezes and
  crackles. Heart sounds will be diminished

57
Nursing Management

• Respiratory center is sensitive to the level of
  CO2 in the blood. If level increases slightly,
  the respiratory rate and depth increases to
  eliminate excess. If it is chronically increased
  the resp center becomes insensitive to CO2
• As long as oxygen is low he breathes, if it
  becomes high he stopsdo not give oxygen over 2-3
  liters

58
Emphysema

• Safest to give O2 using a nasal cannula
• If color improves but level of consciousness
  decreases DC O2 as may go into resp arrest
• Teach to use diaphragm and abdomen to help
  breathe and to use pursed lip breathing
• Take a deep breath and bend forward at the waist
  while exhaling

59
Important Information

• Review care for obstructive pulmonary disorder
  and patient teaching page 389 390

60
Asthma pg. 390

• Reversible obstructive disease. Three types
• allergic asthma--pollen, dust, spores, animal
  dander
• idiopathic asthma--upper resp infections,
  emotional upsets and exercise
• mixed asthma--both of above--most common type

61
asthma

• Acute occurs as a result of increasing airway
  obstruction caused by bronchospasm and
  bronchoconstriction, inflammation and edema of
  lining of bronchi and production of thick mucus
  that can plug airway

62
Asthma

• Will have interference with gas exchange, poor
  perfusion, possible atelectasis and respiratory
  failure if not treated

63
S/S of Asthma

• Will have paroxysms of shortness of breath,
  wheezing and coughing and production of thick,
  tenacious sputum
• Every breath becomes an effort and may have
  sensation of suffocation
• classic sitting position used--body leaning
  slightly forward and arms at shoulder height

64
Asthma

• Coughing starts early and is non-productive
  early, but when gets better will expectorate
  large quantities of thick, stringy mucus
• Skin is pale but if severe will have cyanosis
• Perspiration is profuse
• Status asmaticus can be life threatening

65
Medical Management

• Should use humidified air when he begins to have
  an attack as dehydration of respiratory mucus
  membranes may lead to asthma attacks. The use of
  steam or cool vapor humidifiers help. Push fluids
  to liquify secretions
• When assessing for bronchial asthma usual
  symptoms found are dyspnea, wheezing and cough

66
Nursing Management

• Adverse drug effects (epinephrine, aminophyllin
  may cause palpitations, nervousness, trembling,
  pallor and insomnia.
• Review teaching page 392

67
Cystic Fibrosis pg. 392

• Cystic Fibrosis (CF) is a multisystem disorder
  that affects infants, children, and young adults.
  
• CF results from a defective autosomal recessive
  gene.
• Inherits from both parents.

68
Cystic Fibrosis

• Major abnormalities include
• Faulty transport of sodium and chloride in cells
  lining organs, such as the lungs and pancreas, to
  their outer surfaces.
• Production of abnormally thick, sticky mucus in
  many organs, especially the lungs and pancreas.
• Altered electrolyte balance in the sweat glands.

69
Cystic Fibrosis S/S

• 3 major reasons to suspect CF in children are
  respiratory symptoms, failure to thrive, and
  foul-smelling, bulky, greasy stools.
• Salty-tasting skin.
• Frequent resp. infections
• Finger clubbing is common.
• Hymoptysis
• Malabsorption of fats and fat soluble vitamins,
  difficulty gaining weight.
• Risk of bowel obstruction, cholecystitis, and
  cirrhosis is increased.

70
Medical Management

• Promoting the removal of the thick sputum through
  postural drainage, chest physical therapy with
  vigorous percussion and vibration, breathing
  exercises, hydration to help thin secretions,
  bronchodilator meds, nebulized mist treatments
  with saline or mucolytic meds and prompt
  treatment of lung infections with antibiotics.

71
Medical Management

• When the digestive system is involved, clients
  take pancreatic enzyme replacements (Pancrease)
  with meals to aid with digestion and absorption
  of fats.
• Fat-soluble vitamin supplements
• High-calorie diet
• Lung and/or liver transplant

72
Nursing Management

• Strict adherence to a vigorous pulmonary toilet
• Chest physical therapy (postural drainage,
  percussion, and vibration) 2-4 x a day
• Deep breathing and coughing exercises
• Nebulized treatments
• Medications
• New methods, such as high-frequency chest wall
  oscillation through the use of an inflatable vest

73
Pulmonary Hypertension pg. 394

• Results from heart or lung disease or both.
• Most common symptoms are dyspnea on exertion and
  weakness and cardiac symptoms ( chest pain,
  fatigue, weakness, distended neck veins,
  orthopnea and peripheral edema.
• Nursing focus is on identifying symptoms of resp
  distress, and reducing O2 requirements

74
Pulmonary Embolism pg 395

• Involves the obstruction of one or more pulmonary
  vessels.
• The blockage is the result of a thrombus that
  forms in the venous system or right side of the
  heart.
• An embolus is any foreign substance, such as a
  blood clot, air, or particle of fat that travels
  in the venous blood flow to the lungs.

75
PE S/S

• Small area of the lung involved pain,
  tachycardia, and dypnea. Fever, cough and
  blood-streaked sputum may also occur.
• Larger area severe dyspnea, severe pain,
  cyanosis, tachycardia, restlessness, and shock.
• Sudden death may follow a massive pulmonary
  infarction when a large embolism occludes a main
  section of the pulmonary artery.

76
PE Medical Management

• IV heparin
• IV injection of a thrombolytic drug
• Complete bed rest, oxygen, analgesics
• May require surgery pulmonary embolectomy-----

77
Nursing Management PE

• Patent IV stat
• Administer vasopressor for TX hypotension
• Oxygen
• Continuous EKG monitoring
• Monitor anticoagulant blood studies

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Pulmonary Edema pg. 397

• Accumulation of fluid in alveoli of lungs
• will have dyspnea, breathlessness, and a feeling
  of suffocation. Cool moist, and cyanotic
  extremities
• Skin color is cyanotic and gray. Has a productive
  cough of blood tinged frothy fluid.

79
Pulmonary Edema

• Hallmark symptoms is a cough producing copious
  frothy blood tinged sputum often appearing
  pinkish.

80
Adult respiratory distress syndrome

• Important to recognize stat
• Elderly, neuro patients and drug overdose
  increases risk
• Review factors that precipitate resp. failure
  table 27-4 page 397.

81
Malignant Disorders

• Review on own

82
Trauma pg 401

• A client with a chest injury must be observed for
  dyspnea, cyanosis, chest pain, weak and rapid
  pulse, and hypotension---all s/s of respiratory
  distress.

83
Fractured Ribs pg 401

• Common injury and may be caused by hard fall,
  blow to the chest, MVA, household accidents.
• Not usually serious unless the sharp end of the
  broken bone tears the lung or thoracic blood
  vessels.
• If no complications, may return home after
  emergency tx.

84
Fractured Ribs

• Flail chest occurs when two or more adjacent ribs
  are fractured in multiple places (more than two),
  and the fragments are free-floating.
• The stability of the chest wall is affected and
  results in a paradoxical chest wall movement.

85
Flail Chest

• With inspiration the chest expands, but the
  free-floating segments move inward instead of
  outward.
• With expiration the free-floating segments move
  outward, interfering with exhalation.
• S/s severe pain on inspiration and expiration
  and obvious trauma

86
Nursing Management

• Apply the immobilization device
• Stress the importance of taking deep breaths
  every 1-2 hours
• Assess for s/s respiratory distress, infection
  and increased pain

87
Blast Injuries pg 402

• Compression of the chest by an explosion can
  seriously damage the lungs by rupturing the
  alveoli.
• Death often results from hemorrhage and
  asphyxiation
• Subcutaneous emphysema (air in SQ tissue) is a
  common finding because the lungs or air passages
  have sustained injury

88
Penetrating Wounds

• Serious because an opening into the thorax, which
  on inspiration normally is at negative pressure,
  creates continuous and direct communication with
  the outside, which is at positive pressure.
• An open or penetrating wound permits air to enter
  the thoracic cavity, causing a pneumothorax. If
  not recognized and Txdeath may occur.

89
Penetrating Wounds

• If the wound is large, a sucking noise may be
  heard as air enters leaves.
• Depending on the size of the wound, it takes
  seconds to hours before the lung collapses as the
  pressure in the thorax reaches atmospheric
  pressure.
• Txapplication of a tight pressure dressing over
  the injury site to prevent more air from entering
  the thorax. O2 given until further tx.

90
Thoracic Surgery pg 403

• Review on own