MED SURG I CHAPTER 27

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MED SURG I CHAPTER 27

• CARING FOR CLIENTS WITH DISORDERS OF THE LOWER
  RESPIRATORY AIRWAY

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Acute Bronchitis

• Inflammation of the mucous membranes that line
  the major bronchi branches
• Causes an URI that travels downward, usually a
  virus, bacteria or chemical irritation
• S/S fever, malaise, dry cough, wheezing
• Usually self-limiting,- treat with bedrest,
  antipyretics, expectorants antitussives
• If secondary bacterial infection develops with
  persistent cough thick, purulent sputum broad
  spectrum antibiotics are usually ordered

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PNEUMONIA

• An inflammatory process involving the bronchioles
  alveoli usually associated with acute infection
  it may also be caused by radiation therapy,
  chemical ingestion or inhalation or aspiration of
  foreign bodies or gastric contents
• Bacterial typical pneumonias
• Atypical pneumonias see box 27-1
• Viral most common cause of pneumonia
• Bronchopneumonia fig 27-1
• Lobar pneumonia fig 27-1

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PNEUMONIA table 27-1

• Community acquired-pneumonia
• client acquired the pneumonia in a community
  setting or within 48 hours of admission to a
  healthcare facility
• Hospital acquired or nosocomial
• occurs in a healthcare setting more than 48
  hours post admission
• S/S vary depending if cause is bacterial or
  viral
• Medical mgmt-prompt use of antiobiotics if
  bacterial hydration, supplemental oxygen as
  needed, antipyretics, analgesics, antitussives,
  expectorants
• Nursing care auscultation of lungs, 02 sats
  checks, ABGs, hydration, positioning for comfort

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• PLEURISY-acute inflammation of the parietal
  visceral pleura-secondary to other infections
• shallow respirations r/t severe pain
• symptomatic relief

• PLEURAL EFFUSION-fig 27-2 - collection of fluid
  between the visceral parietal pleurae-secondary
  to other infections
• fever, pain dyspnea
• antibiotics, analgesics, thoracentesis,
  insertion of chest tube

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LUNG ABCESS

• A localized area of pus formation within the lung
  parenchyma due to aspiration, bacterial
  pneumonia, obstruction of the bronchi with a
  tumor
• S/S-chills, fever, wt loss, cxp, productive
  cough of purulent or blood streaked sputum
• May hear dull or absent breath sounds over the
  affected area.
• Postural drainage antibiotics

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• EMPYEMA-pus or infected fluid in the pleural
  cavity as a result of chest trauma, preexisting
  condition, pneumonia, TB, pleurisy or lung abcess
• fever, cxp, dyspnea, anorexia, malaise
• may need thoracotomy with chest tubes

• INFLUENZA acute self limiting, caused by a
  virus A,B, or C.
• occurs in epidemics
• S/S see table 27-2
• Prevention yearly vaccine for high risk clients

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PULMONARY TUBERCULOSIS

• Bacterial infection caused by M tuberculosis
  affects lungs, kidneys, other organs
• resistant strains present r/t immigration, HIV,
  inadequate public health
• can live months in particles of dried sputum
• easily killed by sunlight, heat, UV light
• transmitted via prolonged exposure to droplets
  produced by coughing, sneezing and spitting

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PULMONARY TUBERCULOSIS

• Classification based on clients hx, physical
  exam, skin test, cxr microbiological tests
• May be infected but not develop the disease
• Early infection bacilli enters the lungs
  starts to multiply migrates to the lymph nodes
  then into the blood
• immune activation within 2 weeks a granuloma
  forms
• healing of the primary lesion occurs a
  tubercle forms which will show up on xray

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PULMONARY TUBERCULOSIS

• Latent period- when lesion heals the person may
  not develop the disease be symptom free if
  inadequate immune response the person may develop
  disease show clinical s/s of TB
• Secondary TB-reactivation of the initial
  infection with subsequent formation of scar
  tissue cavities

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PULMONARY TUBERCULOSIS

• Onset is slow. May be asymptomatic until dz is
  advanced
• early- fatigue, anorexia, wt loss, slight,
  nonprod cough
• later-low-grade fever in the pm with night
  sweats
• much later-marked weakness, wasting, hemoptysis
  and dyspnea

• Dx TB skin test, cxr, CT scans, MRI and sputum
  cx
• Treatment-drug therapy table 27-1
• Nsy care-long term administration of drugs
  nursing process
• May become drug resistant, esp if treatment is
  interrupted then resumed

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OBSTRUCTIVE PULMONARY DZ

• BRONCHIECTASIS
• chronic, irreversible dilatation of the bronchi
  bronchioles chronic infection
• tumor, congenital abnormalities, exposure to
  toxic gases, chronic lung infections
• chronic cough with lge amts purulent sputum
  hemoptysis treated with postural percussion
  drng

• ATELECTASIS-collapse of alveoli - a small portion
  or entire lobe
• cyanosis, fever, pain, dyspnea, absent breath
  sounds over effected area
• O2, suctioning, deep breathing coughing,
  incentive spirometry nursing guidelines 27-2
• Preventing atelectasis box 27-4

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CHRONIC BRONCHITIS

• Fig 27-6
• cough w/excessive sputum that lasts at least 3
  months for 2 consecutive yrs
• S/S thick, white sputum upon rising in the
  morning bronchospasm prolonged expirations
  dyspnea
• DX based on symptoms
• Medical Treatment smoking cessation,
  bronchodilators, increase fluids, good nutrition,
  postural drainage, steriods
• nursing care help client manage dz, use of
  metered dose inhaler - nursing guidelines 27-3

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PULMONARY EMPHYSEMA

• chronic, permanent distention of the alveoli that
  happens over time caused by smoking, exposure to
  2nd hand smoke, air pollution, chronic infection,
  allergens
• S/S- sob w/min activity, exertional dyspnea use
  of accessory muscles of respiration, prolonged
  expiratory effort, usually appear thin, anxious,
  pale
• Medical mgmt bronchodilators, nebulized
  aerosols, antibiotics with acute infection
  corticosteroids, PT
• Nursing care Clients develop a hypoxic drive
  to breath due to chronic hypercapnia. If
  administering 02 only give via n/c at 2-3 l/min
  so as not to get the 02 level too high reduce
  the drive to breath.-
• Nursing process, client family teaching

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ASTHMA

• Reversable obstructive dz characterized by
  wheezing, SOB, coughing, thick, tenacious sputum
• allergic asthma-pollens, dust spores
• idiopathic asthma-URI, emotional upsets,
  exercise
• mixed asthma-most common

• Medical mgmt drug therapy table 27-2 treat
  symptoms then long term-prevention
• Nursing mgmt
• during an acute attack reassurance, 02prn,
  upright position, medication
• instruct in disease process, avoidance of
  triggers

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Cystic Fibrosis

• a multisystem disorder caused by defective
  autosomal recessive gene causing dysfunction of
  the exocrine gland involving the mucus-secreting
  glands the eccrine sweat glands
• S/S respiratory symptoms, failure to thrive,
  foul smelling, bulky stools, salty tasting skin
• Dx sweat test

• Treatment relieve symptoms, prevent
  complications those at end stage may receive
  lung transplant
• Nursing care
• teach how to prevent respiratory infections
• strict pulmonary toilet
• early recognition of infection
• medication administration

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Occupational Lung Diseases

• Pneumoconiosis
• silicosis
• asbestosis
• Prevention primary focus
• Treat symptoms prevent complications

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PULMONARY HTN

• Results from heart dz, lung dz or both mostly
  secondary to other dz caused by resistance to
  blood flow in the pulmonary circulation
• Fig 27-9
• S/S Exertional dyspnea, weakness orthopnea
• Medical mgmt administration of vasodilators
  anticoagulants

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• PULMONARY EDEMA-accumulation of fluid in the
  interstitium alveoli of the lungs
• dyspnea, breathlessness, feeling of
  suffocation.
• Cold, gray extremities, cont prod cough of blood,
  tinged, frothy sputum

• ADULT RESPIRATORY DISTRESS SYNDROME-ARDS
• complication of other dz processes-chest
  trauma, shock, drug OD, drowning, infections,
  emboli, major surgery
• severe resp distress within 8-48 hrs of illness
• Treat initial dz/cause

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LUNG CANCER

• Very common cancer for smokers those exposed to
  2nd hand smoke
• 1 cause of cancer related deaths in US
• Table 27-5 different types
• S/S usually dont appear until dz advanced
  when they do occur productive cough with
  mucopurulent or blood-streaked sputum hemoptysis
• cxr, CT scan, MRI, bronchoscopy
• treatment depends on type, stage

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TRAUMA

• FRACTURED RIBS
• common injury
• painful, but usually not serious unless other
  structures also injured
• flail chest fig 27-11
• rib belt, analgesics

• BLAST INJURIES
• death often results from hemorrhage
  asphyxiation
• SQ emphysema
• PENETRATING WOUNDS fig 27-12
• open pneumothorax
• tension pneumothorax

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THORACIC SURGERY

• Thoracotomy - surgical opening in the chest wall
  for removal of fluids, tumors, repair, revise
  structures, trauma, biopsy, remove foreign
  objects
• preop-vs, lung sounds
• postop care of chest tubes, note amt color
  of drainage, dressings

• Chest tube set up and maintenance fig 27-13
• Client family teaching 27-2
• Nursing care plan 27-1