Respiratory Review II

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Respiratory Review II

• Ana H. Corona, MSN, FNP-C
• Nursing Instructor
• October 2007

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What is a TB skin test?

• A "TB Skin Test" is a test to see if TB germs are
  present in the body.
• L.A. County uses the Mantoux method only for
  testing.
• Los Angeles County
• Department of Public Health
• Tuberculosis Control Program

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Why would someone need a skin test?

• A skin test is used to see if a person has been
  exposed and infected by M. tuberculosis or
  tubercle bacilli.
• A test may also be required by an employer as an
  employment screening or to enter school.

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What does a positive TB skin test result mean?

• A positive skin test means that a person has been
  infected with TB germs sometime during that
  person's life.
• It does not indicate that a person is contagious
  or symptomatic.

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What should a person do if positive?

• A person with a positive reaction requires
  further evaluation.
• This person should be referred to a healthcare
  provider to have a chest x-ray or other clinical
  exams if indicated.

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When should a TB test be examined? (read or
checked)

• The skin test should be examined (or read) 48-72
  hours after it is administered.
• It is acceptable to read the skin test up to 96
  hours after administration if it is not possible
  to read it earlier.
• After 96 hours, a skin test of less than 10 mm of
  induration should be repeated.
• A skin test of 10 mm or more is positive at any
  time.

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Should a person who had a BCG vaccination get a
TB skin test?

• Yes. Not all BCG vaccinations are effective.
• A history of BCG vaccination does not exempt
  students or employees from the skin test.

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What is latent TB infection?

• A person with a positive skin test, no symptoms,
  and a normal X-ray has latent TB infection.
• This person is NOT contagious.

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When is TB contagious?

• TB can be contagious in adolescents and adults,
  who are coughing, have a positive skin test, and
  an abnormal chest X-ray.
• TB medications will make the person
  non-contagious very quickly.
• Because of the efficacy of TB medicines, patients
  are not quarantined and are usually able to
  return to school or work within several weeks. 

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Are children with active TB contagious?

• Children under the age of 12 rarely have
  contagious TB.
• This is because they have TB in a different area
  in the body and do not aerosolize or cough up
  their germs into the air.

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Remember

• People who have a positive TB skin test with a
  normal chest x-ray are NOT contagious, but may
  need medicine to prevent them from developing
  active TB.  
• Children under the age of 12 with active TB are
  rarely contagious, and generally do not need to
  be kept out of school. 

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Pneumonia

• Pneumonia is an infection of the lungs. Many
  different organisms can cause it, including
  bacteria, viruses, and fungi.
• Pneumonia can range from mild to severe, and can
  even be deadly.
• The severity depends on the type of organism
  causing pneumonia, as well as your age and
  underlying health.

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Causes

• Pneumonia is a common illness that affects
  millions of people each year in the United
  States.
• Bacterial pneumonias tend to be the most serious
  and, in adults, the most common cause of
  pneumonia.
• The most common pneumonia-causing bacterium in
  adults is Streptococcus pneumoniae
  (pneumococcus).
• Respiratory viruses are the most common causes of
  pneumonia in young children, peaking between the
  ages of 2 and 3. By school age, the bacterium
  Mycoplasma Pneumoniae becomes more common.

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Pneumonia

• In some people, particularly the elderly and
  those who are debilitated, bacterial pneumonia
  may follow influenza or even a common cold.
• Many people contract pneumonia while staying in a
  hospital for other conditions.
• This tends to be more serious because the
  patient's immune system is often impaired due to
  the condition that initially required treatment.
• In addition, there is a greater possibility of
  infection with bacteria that are resistant to
  antibiotics.

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The main symptoms of pneumonia are

• Cough with greenish or yellow mucus bloody
  sputum happens on occasion
• Fever with shaking chills
• Sharp or stabbing chest pain worsened by deep
  breathing or coughing
• Rapid, shallow breathing
• Shortness of breath
• Headache
• Excessive sweating and clammy skin
• Loss of appetite
• Excessive fatigue
• Confusion , especially in older people
• Exams and Tests

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Diagnostic Tests for Pneumonia

• Chest x-ray
• Gram's stain and culture of your sputum to look
  for the organism causing your symptoms
• CBC to check white blood cell count if high,
  this suggests bacterial infection
• Arterial blood gases to check how well you are
  oxygenating your blood
• CAT scan of the chest
• Pleural fluid culture if there is fluid in the
  space surrounding the lungs

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Pneumonia Treatment

• If the cause is bacterial, the goal is to cure
  the infection with antibiotics.
• If the cause is viral, typical antibiotics will
  NOT be effective, however sometimes your doctor
  may use antiviral medication.
• In some cases it is difficult to distinguish
  between viral and bacterial pneumonia, so
  antibiotics may be prescribed.

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Pneumonia

• Many people can be treated at home with
  antibiotics.
• Patients with chronic disease, severe symptoms,
  or low oxygen levels, you will likely require
  hospitalization for intravenous antibiotics and
  oxygen therapy.
• Infants and the elderly are more commonly
  admitted for treatment of pneumonia.

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Complications of Pneumonia

• Empyema or lung abscesses are infrequent, but
  serious, complications of pneumonia.
• They occur when pockets of pus form around or
  inside the lung.
• These may sometimes require surgical drainage.

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PreventionCohen J, Powderly WG. Infectious
Diseases. 2nd ed. New York, NY Elsevier, 2004.

• Hand washing
• Smoking Cessation tobacco damages the lung's
  ability to ward off infection.
• Vaccines can help prevent pneumonia in children,
  the elderly, and people with diabetes, asthma,
  emphysema, HIV, cancer, or other chronic
  conditions
• Pneumococcal vaccine (Pneumovax, Prevnar)
  prevents Streptococcus pneumoniae.
• Flu vaccine prevents pneumonia and other
  infections caused by influenza viruses.
• Hib vaccine prevents pneumonia in children from
  Haemophilus influenzae type b.
• Taking deep breaths may help prevent pneumonia
  while recovering from surgery.

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Influenza A B (Flu)

• The flu is a contagious infection of the nose,
  throat, and lungs caused by the influenza virus.
• The flu usually begins abruptly, with a fever
  between 102 to 106F.
• Other common symptoms include a flushed face,
  body aches, and lack of energy.
• The fever usually lasts for a day or two, but can
  last 5 days.
• CDC Recommends Against the Use of Amantadine and
  Rimantadine for the Treatment or Prophylaxis of
  Influenza in the United States during the 2005-06
  Influenza Season. Atlanta, Ga. U.S. Centers for
  Disease Control and Prevention January 14, 2006.

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Influenza

• Somewhere between day 2 and day 4 of the illness,
  the "whole body" symptoms begin to subside, and
  respiratory symptoms begin to increase.
• The flu virus can settle anywhere in the
  respiratory tract, producing symptoms of a cold,
  croup, sore throat, bronchiolitis, ear infection,
  or pneumonia.

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• The most prominent of the respiratory symptoms is
  usually a dry, hacking cough.
• Most people also develop a sore throat and
  headache.
• Nasal discharge and sneezing are common.
• These symptoms (except the cough) usually
  disappear within 4-7 days.
• Cough and tiredness usually last for weeks after
  the rest of the illness is over.

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• The flu usually arrives in the winter months.
• The most common way to catch the flu is by
  breathing in droplets from coughs or sneezes.
  Symptoms appear 1-7 days later (usually within
  2-3 days).
• Because the flu spreads through the air and is
  very contagious, it often strikes a community all
  at once.

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Anyone at any age can have serious complications
from the flu, but those at highest risk include

• People over 50
• Children between 6 months and 2 years
• Women more than 3 months pregnant during the flu
  season
• Anyone living in a long-term care facility
• Anyone with chronic heart, lung, or kidney
  conditions, diabetes, or weakened immune system

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Signs Symptoms

• Fever - may be high
• Headache
• Tiredness
• Dry cough
• Sore throat
• Stuffy, congested nose
• Muscle aches and stiffness
• Nasal discharge
• Shortness of breath
• Wheezing

• Croupy cough
• Chills
• Fatigue
• Malaise
• Sweating
• Loss of appetite
• Vomiting
• Dizziness
• Worsening of underlying illness, such as asthma
  or heart failure

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Diagnostic Tests

• If pneumonia is suspected, a chest x-ray.
• Additional blood work may be needed.
• They may include a complete blood count, blood
  cultures, and sputum cultures.
• The most common method for diagnosing the flu is
  an antigen detection test, which is done by
  swabbing the nose and throat, then sending a
  sample to the laboratory for testing.
• The results of these tests can be available
  rapidly, and can help decide if specific
  treatment is appropriate. However, the diagnosis
  can often be made by simply identifying symptoms
  without further testing.

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Treatment

• Rest
• Medicines to relieve symptoms
• Hydration
• Avoid aspirin (especially teens and children)
• Avoid alcohol and tobacco
• Avoid antibiotics (unless necessary for another
  illness)
• Antiviral medications If the flu is diagnosed
  within 48 hours of when symptoms begin,
  especially if you are high risk for complications

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Antiviral Medications

• Oseltamivir (Tamiflu) or zanamivir (Relenza),
  which are active against both influenza A and B.
• Each of these medicines has different side
  effects and affects different viruses.

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• Oseltamivir is the best choice for children. It
  is available in a liquid formulation and may be
  easier to give to the child
• Zanamivir is given inhaler and is not
  FDA-approved for children under age 12.
• Treatment will only help if started early and
  only if the illness is actually influenza. It
  will not help treat a regular cold.

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Complications

• The flu goes away within 7 to 10 days.
• Possible Complications
• Pneumonia
• Encephalitis (infection of the brain)
• Bronchitis
• Sinus infections
• Ear infections

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Prevention

• A flu shot can help lower one's chances of
  getting the flu. A flu shot is generally
  available to people who
• Are over 6 months old
• Don't have a serious allergy to eggs
• Haven't had a serious reaction to flu shots in
  the past
• A new nasal spray-type flu vaccine called FluMist
  is available to people aged 5 to 49 years old.
• FluMist uses a live, weakened virus instead of a
  dead one like the flu shot.
• In one study, the nasal spray provided protection
  against the flu in up to 93 of children.

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Lung CancerOnocology Nursing Society

• Second most common cancer among both men and
  women and is the leading cause of cancer death
  for both.
• In the 30-54 year age group, incidence rates
  among men are double those among women in most of
  the racial/ethnic groups.
• An estimated 160,440 Americans will die in 2004
  from lung cancer, accounting for 28 of all
  cancer deaths.

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Lung Cancer Risk Factors

• Diets low in fruits and vegetables may cause lung
  cancer.
• Risk increases after the age of 45 and increases
  more dramatically after the age of 65.
• Cigarette smoking accounts for nearly 90 of all
  lung cancers.
• Smokers or former smokers with a 30-pack-year or
  greater history are at risk of lung cancer.

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Pack Year

• Pack year is the number of years someone has
  smoked multiplied by the number of packs smoked
  per day.
• Example A person with a 30-pack-year history
  will have smoked one pack of cigarettes per day
  for 30 years or three packs per day for 10 years.
  
• Cigar smoking and pipe smoking also cause lung
  cancer.
• Marijuana contains more tar than cigarettes, and
  the smoke is held in the lungs for a longer time.
  Marijuana is difficult to study because it is an
  illegal substance and many marijuana smokers also
  smoke cigarettes.

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Risk Factors

• Women smokers may have a higher risk of lung
  cancer than male smokers.
• Passive smoking also contributes to the
  development of lung cancer among non-smokers.
• Occupational exposures to asbestos and radon are
  linked with lung cancer.
• Asbestos workers have a seven times greater risk
  of developing the disease.
• Asbestos workers who smoke have a 50-90 times
  greater risk developing the disease.

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Risk Factors

• Air pollution also is a cause (small factor in
  incidence and mortality).
• Lung cancer is a disease of older people. Lung
  cancer is fairly rare in people under 40.
• If one stops smoking before lung cancer develops,
  damaged lung tissue gradually will return to
  normal.
• Ten years after quitting, the risk is reduced to
  one-third of what it was previously.

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Prevention Screening

• There is no widespread screening test for lung
  cancer.
• At this time, the use of spiral CT scans are
  being studied for screening.
• Eighty percent of lung cancers can be prevented
  by avoiding tobacco use.

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Signs Symptoms

• Cough (persistent, dry)
• Shortness of breath
• Wheezing
• Chest pain
• Hemoptysis
• Anorexia and weight loss
• Frequent pneumonias

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Other Signs Symptoms

• Fatigue
• Chills
• Swallowing difficulties
• Hoarseness
• Clubbing of the finger tips
• Skin paleness or bluish discoloration
• Muscle contractions or atrophy (shrinkage)
• Joint pain
• Facial swelling or paralysis
• Eyelid drooping
• Bone pain
• Gynomastia

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Lung Cancer Diagnostic Tests

• Physical exam A thorough physical examination
  with attention to the chest and thoracic lymph
  nodes and sputum sample. If sputum analysis does
  not provide a definite diagnosis, biopsy is
  required.
• Chest X-ray
• CT scan of the chest
• MRI of the chest
• MRI of the chest

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Diagnostic Tests

• Bronchoscopy To obtain washings of the
  respiratory tissues. If the bronchoscopy is
  negative, proceed to a needle biopsy.
• Needle biopsy Fine needle aspiration (FNA) uses
  a slim, hollow needle that is attached to a
  syringe. Large needle or core biopsy uses a
  larger needle. Mediastinoscopy. Used to rule out
  metastatic disease and sample mediastinal nodes.
• Tumor markers
• PTH (parathyroid hormone)
• CEA (carcinogenic antigen). A CEA level greater
  than 50 may indicates advanced diseases.
• CYFRA21-1 (cytokeratin fragment 19)

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Pathology

• Non-small cell lung cancer (NSCLC) includes three
  histologies
• Epidermoid or squamous carcinoma
• Adenocarcinoma
• Large cell carcinoma

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Nursing Diagnosis

• Knowledge deficit r/t lung cancer
• Anxiety
• Pain
• Impaired gas exchange
• Impaired tissue integrity
• Ineffective airway clearance
• Anticipatory grieving
• Risk for fluid volume excess

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Treatment

• The best way to treat lung lancer is to prevent
  it from happening in the first place.
• A diagnosis of lung cancer is not a death
  sentence.
• Effective treatment options are available.

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Treatment by Stage

• Stage 0
• Surgery alone. No chemotherapy or radiation
  therapy is needed.
• Stage 1 and Stage 2
• Surgical resection. If margins are involved, RT
  recommended. If surgery is not feasible,
  radiation alone is an option.

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Stage 3

• Stage 3 with abnormal and enlarged lymph nodes
  No surgery. Recommend concurrent radiation and
  chemotherapy.
• Stage 3 with normal mediastinal nodes May
  proceed to surgery for tumor resection. In many
  patients, histopathologic examination will reveal
  that the lymph nodes are actually cancerous. May
  also have pre-op chemotherapy or
  chemo-radiotherapy and, if a response is seen,
  the patient may then go to surgery.
• "Classic" Stage 3B No surgery. A combination
  treatment plan with chemo-radiotherapy should be
  considered for those who have non-cancerous
  effusions.

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Stage 4

• Chemotherapy alone versus palliative care.
• Chemotherapy may help to relieve symptoms in
  patients who experience significant symptoms from
  their disease.
• Chemotherapy options for stage 4 patients
  include Paclitaxel (Taxol) and carboplatin
  (Paraplatin), as well as newer agents such as
  vinorelbine tartrate (Navelbine), gemcitabine
  hydrochloride (Gemzar), docetaxel (Taxotere),
  and combinations of the above with cisplatin
  (Platinol).

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Oxygen Administration

• a. The goal for oxygen administration is to
  Improve or maintain systemic oxygenation
• (1) Increased oxygen saturation levels
• (a) Blood gas
• (b) Pluse oximetry
• (2) Less fatigue
• (3) Improved cognition
• (4) Less irritation

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Oxygen Administration

• b. Nursing goals
• (1) Prevent complications
• (a) Dry mucus membranes
• (b) Infection
• (c) Obstruction
• Patient education increased understanding of and
  compliance with treatment
• (a) Reason for treatment
• (b) Safety issues
• (c) Activity restrictions
• (d) Stop smoking
• (e) Home care

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Chest Radiograph

• Used to visualize the lungs, clavicles, humeri,
  scapulae, vertebrae, heart, and major thoracic
  vessels.
• (2) Provides information on alterations in size
  and location of the pulmonary structures.
• (3) Identifies the presence of lesions,
  infiltrates, foreign bodies or fluid.
• (4) Can distinguish if a disorder involves the
  parenchyma or interstitial spaces- can confirm
  pneumothorax, pneumonia, pleural effusion and
  pulmonary edema.
• (5) Patients should be instructed to remove
  jewelry and wear a hospital gown.

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Pulmonary Function Test

• Performed to assess the presence and severity of
  disease in the large and small airways-
• 0ne of the most important tools for diagnosing
  respiratory diseases is the capacity for carbon
  dioxide to be diffused.

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Pulmonary Function Tests

• 2) Composed of various procedures to obtain
  information on lung volume, ventilation,
  pulmonary spirometry and gas exchange.
• (a) Lung volume or vital capacity (VC) is a
  measurement of
• the volume of air that can be
  completely and slowly
• exhaled after maximum inhalation.
• (b) Inspiratory capacity (IC) is the largest
  amount of air that
• can be inhaled in one breath.
• (c) Total lung capacity (TLC) is calculated to
  determine the
• volume of air in the lung after maximal
  inhalation.
• (d) Ventilation tests evaluate the volume of
  air inhaled or
• exhaled in each respiratory cycle.
• (e) Pulmonary spirometry evaluates the amount
  of air that
• can be forcefully exhaled after maximum
  inhalation.

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COPD Nursing Diagnosis