Mononucleosis

Symptoms Viral infection (Epstein-Barr virus) -mimics Strep

in presentation and physical findings Referred to as the "kissing disease" for it's

ability to be spread from one person to another via oral secretions

Sore throat, swollen lymph nodes, weakness, and fatigue that persists anywhere from days to weeks.

Mild hepatitis can also occur with mononucleosis - Pain right upper quadrant and enlargement of the liver

Evaluation

Phsyical will usually reveal Swollen glands (string of pearls-cervical lymph nodes) and tonsillitis.

There may be some mild tenderness over the spleen and liver.

Lab studies will include the monospot, CBC, and throat culture to rule out strep throat.

A liver profile may show mild elevations in liver enzymes

Treatment

Antibiotics are ineffective - Bed rest, liberal fluid intake, and low doses of acetaminophen

Most cases end in 2-3 weeks but medical follow-up is suggested.

Complications of Mono include splenic rupture and Guillain-Barre' syndrome

Mononucleosis Test or Monospot Venipuncture specimen The test involves mixing reagents with a drop of

blood on a microscope slide. Results of the test are read, usually in less than

one hour, as positive (mono) or negative. Because the test may be negative in the early part

of the illness, it must be repeated later if symptoms persist.

Peritonsillar Abscess

Symptoms Abscess located next to one of the Palatine tonsils Complication of bacterial tonsillitis. Starts with a sore throat and progresses to difficulty, or

complete inability, in swallowing liquids or saliva. Typically, this patient is UNABLE to open their mouth

widely, or swallow water, secondary to swelling. Other symptoms, common both to tonsillitis and

peritonsillar abscess, include: fever, chills, and pain upon swallowing

Evaluation

Hstory and physical examination. Patients UNABLE to open their mouths

OR swallow water are highly suspect for this problem.

Oral examination will often show tremendous swelling about the tonsil, deviating the uvula to one side.

Treatment Treatment requires an incision of the

abscess, allowing it to drain, so healing can occur. Antibiotics will likely be prescribed in follow-up. An ENT specialist is the expert in the management of this special situation

Cancers of the Head and Neck

Fairly common Includes cancer of the lips, tongue, mouth,

throat, and larynx. Invariably, squamous cell carcinomas occur

with the highest frequency in smokers It is rare for nonsmokers to get cancers of

the head and neck

Symptoms Persistent hoarse voice, weight loss, difficulty

swallowing, white or dark patches inside of the mouth, and an unexplained sore to the tongue, cheek, or lip that does not heal.

Spreading of this type of cancer is frequently to regional lymph nodes, before any kind of distant spread occurs.

It is extremely uncommon for cancer to spread beyond the head and neck area, when the disease is controlled (therapeutically) in that area

Treatment

Surgery Radiation therapy as the initial management

if cancer has spread to lymph nodes Chemotherapy has recently been purported

as a method of improving initial cure rates, when it is given in combination with radiation therapy prior to surgery

PROBLEMS ASSOCIATED WITH THE LOWER RESPIRATORY TRACT

Laryngitis and Voice Strain -Inflammation of the larynx

Viral infection in the larynx or secondary to postnasal drip

Voice strain can cause mechanical laryngitis

Symptoms

Hoarse or raspy voice May be associated with a sore throat, fever,

posterior nasal drip, or congestion of the sinuses.

It should not be accompanied by difficulty swallowing food or fluids. This symptom could indicate epiglottitis or peritonsillar abscess

Evaluation

History and physical examination Direct visual inspection of the throat done

to check for signs of bacterial infection In questionable cases, x-rays of the neck

may be useful to diagnose more serious bacterial upper airway infections. A throat culture may be needed to exclude the possibility of strep throat.

Treatment

Viral laryngitis is self-limiting and disappears by itself in approximately 7-10 days.

Avoid talking, smoking, alcohol, hot liquids, frequent coughing and clearing the throat.

Drink plenty of fluids and use analgesics or lozenges containing topical anesthetics as ordered.

Acetaminophen can be used for pain or fever, A cool mist vaporizer can be therapeutic.

Any suspicion of bacterial infection in the throat or sinuses will require antibiotic treatment.

Any hoarseness of greater than 3 weeks duration should be evaluated by a physician or ENT specialist

Laryngeal Cancer

Laryngeal Tumors can initially result in a hoarse voice, or, in more serious cases, the total blockage of the airway.

Slow onset of a hoarse voice occurring over a period of weeks

Laryngeal cancer is most commonly seen in those over 40 years of age who smoke or "chew" tobacco

Evaluation/Treatment

Laryngoscopy to visually inspect the vocal cords Questionable lesions mandate biopsy Treatment for documented laryngeal cancer is

based upon the extent the disease has progressed. Surgical removal of part, or all of the larynx, is

often necessary (laryngectomy). Radiation therapy has also been used to control

disease that has spread to surrounding tissue.

Laryngectomy Care

Total neck breather following surgery. CPR -ventilations must be made mouth to neck not mouth to mouth. Immediate post-op. Watch for respiratory obstruction from swelling of the airway or increased secretions

Post-op patients will be unable to form sounds. Air for speach no longer comes from the lungs. About 75% of postlaryngectomy patients learn to use "plosive" speech. Various mechanical aids are also available

The laryngectomy tube is shorter and thicker than a tracheostomy tube.

Laryngectomy tube used until the stoma heals. Observe for crusting: crust can be softened and removed with

petrolatum jelly Proper room humidification is helpful

INFLUENZA

Etiology Viral upper respiratory infection that commonly affects a large

percentage of children and adults Occurs more often in the winter months Transmitted through inhalation of particle droplets Wide variety of viruses responsible for flu-like illness Incubation period 1 to 6 days before onset of symptoms Viral upper respiratory infections can lead to pneumonia and

sinusitis Children are commonly infected because they transmit these

infections so easily. Flu in the elderly patient, more serious, can lead to a secondary

bacterial infection with dehydration

Symptoms

Fever, chills, runny nose, sore throat, swollen lymph nodes, frontal headache, muscle and body aches, joint pains, dry cough, pleurisy with coughing, and weakness

Children and infants can have wheezing, particularly in a related infection, known as bronchiolitis

Evaluation

H&P rule out bacterial infection CBC, blood cultures, and Chemogram as

indicated Chest x-ray to rule out pneumonia as

indicated Urinalysis to rule out UTI may be indicated

Treatment Flu is usually nonserious and self-limited Observe for signs of dehydration in infants and elderly Rest, nutrition, fever control, fluids , avoid alcohol and

caffeine Wheezing may require bronchodilators, Cool mist

vaporizer can reduce congestion in children Saltwater nose drops followed by suctioning with a bulb

syringe are helpful in infants Vaccines against certain viruses (flu shot) have been

quite successful and may be indicated in the elderly, diabetics, health-care workers, and other high risk groups.

BRONCHITIS Etiology and Symptoms Inflammation of the bronchi in the lungs, most often

occurs secondary to a bacterial infection in the airways Bronchitis common in the smoking population Smokers have difficulty clearing their secretions

(mucus) due to impaired ciliary action and have diminished immunity against infection.

Productive cough (in smokers, may be bloody) fever, and chills, Shortness of breath is seen in more severe cases

Similar symptoms to pneumonia Smokers may develop expiratory wheezes, breathing

OUT more difficult than breathing IN.

Evaluation

H&P and chest x-ray to rule out pneumonia, CBC, chemistry and sputum cultures

Patients with shortness of breath may have an ABG's to determine if their oxygenation is acceptable

Treatment

Oral antibiotics- Some cases (long standing smokers with COPD) require hospitalization.

Patients with "wheezing" will require bronchodilators

Follow-up chest x-ray for patients not responding to treatment. The x-ray may reveal a developing pneumonia.

Acetaminophen or aspirin should be used for fever control

PNEUMONIA

Etiology -Bacterial or viral infection of the lung tissue

The most common forms of pneumonia are viral - Antibiotics have NO effect on viral infections

Bacterial pneumonia - more severe and require antibiotics

Pneumococcal pneumonia and streptococcal pneumonia - rust-colored sputum

Foul smelling green or yellow sputum - Pseudomonas pneumonia and lung abscesses

Klebsiella pneumonia - blood tinged sputum Mycoplasmal pneumonia -neither bacterial nor viral.

Tends to have milder symptoms Produces whiter colored sputum. Associated with H/A

Smokers, elderly and immunocompromised (diabetics, cancer patients) are at risk for SERIOUS pneumonia

Symptoms

Productive cough, fever, shaking chills and extreme fatigue

Examination will usually reveal rales on asculatation,

WBC over 11,000 cu/ml Consolidation on the chest x-ray Crackling rales are likely to be heard anytime

there is fluid in interstitial and alveolar areas. More severe pneumonia - associated SOB and/or

pleuritic chest pain (pain worse with coughing and movement

Evaluation

History and physical examination for evidence of fever or upper respiratory infection

A chest x-ray can diagnose pneumonia, and, in most cases, is necessary for definitive diagnosis.

CBC, Blood Cultures, Chemogram and sputum cultures may be indicated

ABG's for evaluation of oxygenation in those who are short of breath

Treatment Eliminate the organism, support oxygenation, and limit

activity Older patients, diabetics, and COPD patients should be

admitted for IV antibiotics. Any patient SHORT OF BREATH while at rest, or

with evidence for inadequate oxygenation by arterial blood gas analysis, will require admission to the hospital.

Fatigue /activity intolerance is a common complication of pneumonia. May continue for weeks.

Pneumovax vaccine - protects against bacterial pneumonia in those at high risk for infection.

High Risk -over age 65, COPD, HIV, the chronically debilitated, or those who have had their spleen removed

ASPIRATION PNEUMONIA Etiology and Symptoms Results in serious pneumonia, related to the type of material

aspirated. Severe pneumonia can result from the aspiration of stomach

acid or petroleum distillates Aspiration - passage of foreign materials into the lungs. Aspiration pneumonia can become infected secondarily with

bacteria, requiring treatment with an antibiotic. Because of the anatomy of the respiratory tree, aspiration

is more likely to affect the Right lung, as the right mainstem bronchus extends more vertically downward into the lungs, while the left bronchus is more horizontal.

Situations associated with a high risk for aspiration

Stroke patients (those who cannot swallow well and protect their airway)

Unconscious patients Children playing with toys or food (the "peanut"

or toy aspiration is well known) Alcohol intoxicated patients Drowning Petroleum distillate ingestions (kerosene, gas,

furniture polish, etc.) Powder aspiration - talcum powder with babies

Symptoms Coughing, shortness of breath, and

wheezing Fever is a delayed symptom

Evaluation History to evaluate risk of aspiration, and

physical examination. Chest x-ray may show the foreign object or

changes in the lung, indicating a pneumonia.

Arterial blood gas analysis will indicate the patient's overall lung function, including any need for oxygen therapy

Treatment

Suction patients who are unable to protect their airway

Bronchoscopy may be indicated in cases where a foreign object must be retrieved (generally children).

Bronchodilators for wheezing Antibiotics for bacterial contamination Respirator for patients who cannot breath on their

own. Fever control as indicated.

PLEURISY AND PLEURITIS Etiology/ Symptoms Pleura of the lung become inflamed Resulting chest pain is known as pleurisy Pain is sharp or "knife-like", and increases in severity

as the patient breathes in Pleurisy is often one-sided and can radiate pain to the

neck or shoulder. Movement of the thorax, including bending, stooping,

or even turning in bed can increase pleural pain Shortness of breath with pleurisy may indicate a more

serious problem such as pulmonary embolism Pleurisy can easily confused with chest wall pain which is

much less serious. Chest wall pain can sometimes be distinguished from pleurisy by pressing down (palpation) on a region of the chest wall which will reproduce pain in the patient

Causes of pleurisy

Pneumonia (viral or bacterial) Pulmonary Embolism Pneumothorax Lung cancer

Evaluation

Chest x-ray to rule out pneumothorax or pneumonia.

Those short of breath may require ABG's. May need an EKG to exclude the possibility

of angina (angina pain in rare cases can be pleuritic in nature)

Treatment

Ventilation/perfusion scanning of the lung is performed in cases of suspected pulmonary embolism.

Treatment is directed at the underlying cause.

Narcotic analgesics may be necessary when pain is severe.

Anti-inflammatory agents (ibuprofen) can be helpful in mild to moderate pleurisy

CHRONIC OBSTRUCTIVE

PULMONARY DISEASE (COPD)

Etiology Progressive disease with occasional exacerbations

requiring hospitalization Most common chronic respiratory disorder Spectrum of diseases characterized by limited

airflow and poor oxygenation of the blood. The two main disease processes are emphysema

and chronic bronchitis. Chronic asthma, cystic fibrosis, and chronic

bronchiectasis are also COPD smoking is the leading cause of COPD

Other causes, cystic fibrosis, alpha-antitrypsinase enzyme deficiency (inherited condition), and chronic exposure to some chemicals/irritants (asbestos, silica, and coal dust)

Smoking 10 years or more Inflammation and destruction of the bronchioles

and destruction of the alveolar walls Increased obstruction to air flow Hyperinflation of the alveoli poor oxygenation of the bloodstream

Continued smoking Breathing becomes more difficult Wheezing will develop. COPD patients also have increased risk of

pulmonary infection (pneumonia and bronchitis) due to compromised immune system function in the upper respiratory tree.

Smokers have a 25 fold increased risk of lung cancer, and they are also at high risk for heart disease and stroke through the acceleration of atherosclerosis in the blood vessels

Symptoms -begin insidiously

Chronic productive cough Barrel chest Increasing tolerance of high CO2 levels and

low O2 levels Shortness of breath upon exertion Club fingers Wheezing Fever if an infection (bronchitis) is present

Evaluation

History and physical Pulmonary function tests Chest x-ray may show changes consistent with emphysema

(lung "disappearing" on the x-ray), scarring, or tumor Normally, excessive levels of CO2 stimulate respirations.

However, in the COPD patient, the Chemoreceptors become insensitive to CO2 and respond only to hypoxia.

If too much Oxygen is given to a COPD patient, the stimulus to breathe is removed and the client may stop breathing completely.

Most clients with COPD can tolerate Oxygen at 2 per N/C at 2-3 l/min, but ABG's need to be monitored

CHRONIC BRONCHITIS

Etiology Prolonged exposure to bronchial irritants

such as smoking It is more common in females, whites, and

city dwellers. Chronic bronchitis causes inflammation of

the bronchi with enlargement and hypersecretion of the mucous glands which causes diffuse airway obstruction

Symptoms of the "Blue Bloater

Heavy productive cough, particularly at night, generally worse in cold, damp weather

Progression Cough becomes continuous Dyspnea and wheezing become more severe. Cyanosis is common secondary to the chronic

hypoxemia, and hypercapnia caused by the airway obstruction

Generalized edema is also often present, and this swollen appearance, together with the cyanosis, gives rise to the phrase "blue bloater" used to describe these patients.

EMPHYSEMA

Etiology Chronic progressive disease Enlargement of air spaces - destruction of the alveolar

walls by enzymes. Smoking is primary cause but any continuous irritant (coal

dust) can destroy alveoli. Deficiency of alpha-antitrypisn (an enzyme inhibitor) also

indicated in the development/ progression of emphysema. Enzymes in the lung destroy elastic structure around

the alveoli; resulting in loss of elasticity, stiffening of the lungs, and decreased compliance.

The loss of alveolar function diminishes lung recoil (like an overstretched elastic band) and weakens expiration.

The lung therefore remains partially expanded following expiration, producing air trapping and a visible barrel chest over time

Symptoms

Chronic cough Dyspnea - hallmark of emphysema,

worsens over time, may be present even at rest and is severe on exertion.

Pursed-lip breathing with prolonged expiration.

Barrel chest Use of accessory muscles

Hyperresonance on percussion Decreased vocal fremitus on palpation. Distant Breath and heart sounds Anorexia, Weakness, Decreased muscle, Weight

loss The patient remains acyanotic until very late in

the disease because of compensatory mechanisms. Thus, emphysema patients are referred to as "pink puffers" as opposed to the oxygen-starved "blue bloaters" with chronic bronchitis.

COMMON COMPLICATIONS OF

COPD

HYPOXEMIA (PaO2 of 55mmHg or less, with an oxygen saturation of 85% or less

HYPERCAPNIA (elevated CO2) and Respiratory acidosis.

Respiratory infections COR PULMONALE (RIGHT

VENTRICULAR HEART FAILURE

Symptoms of Hypoxemia

Mood changes Forgetfulness Inability to concentrate Later signs are increasing restlessness.

Cyanosis is a late sign of hypoxemia

HYPERCAPNIA (elevated CO2) and Respiratory acidosis Decreased in oxygen/carbon dioxide exchange Rising carbon dioxide levels result in respiratory

acidosis. Symptoms of hypercapnia Increased respiratory rate SOB Headache Confusion Lethargy Nausea and Vomiting

Respiratory infections

Frequent respiratory infections related to: Increased production of mucus Increased irritability of the bronchial smooth

muscle Edema of the respiratory mucosa. Many COPD patients are prescribed antibiotics on

a PRN basis and the client self-administer the antibiotic according to changes in sputum appearance, which may indicate infection.

COR PULMONALE (RIGHT

VENTRICULAR HEART FAILURE)

Most frequently associated with chronic bronchitis Detection of cor pulmonale (pulmonary heart disease) is

difficult because its clinical signs are generally masked by those of COPD.

As COPD progresses, the amount of oxygen in the blood decreases, which causes major blood vessels in the lung to constrict.

The body produces more RBC's to attempt to carry more oxygen.

Leads to polycythemia and increased blood viscosity. Right side of the heart must pump harder, enlarges and

leads to right-sided heart failure

Symptoms of cor pulmonale Increasing dyspnea Fatigue Enlarged and tender liver Warm cyanotic extremities with bounding pulses Cyanotic lips Distended neck veins Right ventricular hypertrophy Nausea Dependent edema Metabolic and respiratory acidosis

TREATMENT FOR COPD STOP SMOKING BRONCHODILATORs for Wheezing (Proventil

and Theophylline) ANTIBIOTICS (in infection) HOME OXYGEN THERAPY Most clients with

COPD can tolerate Oxygen at 2 per N/C at 2-3 l/min, but ABG's need to be monitored

Steroid medications (Prednisone) for severe cases to reduce inflammation in bronchial tissue.

Pulmonary disease diet is recommended

RESPIRATORY EMERGENCIES PNEUMOTHORAX- Common symptoms of a pneumothorax include

the sudden onset of breathing difficulty, accompanied by chest pain (pleurisy) that INCREASES while breathing in. Will also have diminished lung sounds on the affected side. CXR will show collapsed lung.

Treatment Surgical placement of a plastic tube into the chest cavity to remove the excess air and restore the negative air pressure within the pleural space

HEMOTHORAX

Common symptoms include: chest pain, difficulty in breathing, and hemorrhagic shock, if the accumulation of blood in the chest is massive.

Evaluation includes a chest x-ray which allows diagnosis and estimation of the hemothorax size. Blood tests (CBC) to check blood counts will help gauge the overall extent of blood loss

Treatment involves placement of a chest tube to remove the accumulated blood. The chest tube will remain in place until the bleeding has stopped and the lung (indicated by x-ray) has adequately re-expanded.

PULMONARY EMBOLISM Clot which obstructs perfusion in the lung Can result in infarction of a portion of the lung Symptoms include a SUDDEN onset of

shortness of breath, pleurisy, elevated pulse and respirations and Pink frothy sputum

A nuclear scan of the lung, known as a ventilation-perfusion scan can diagnose most pulmonary emboli

A more specific test is the pulmonary angiogram

Treatment

Streptokinase- dissolves clots and heparin -keeps further clots from forming