reoport respi

8/9/2019 reoport respi

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LEGIONNAIRES DISEASE


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OVERVIEW

Legionnares Disease


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Legionnaires disease

is a common name for one of the

several illnesses caused by

Legionnaires' disease bacteria (LDB).


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PNEUMONIA

Community-Acquired Pneumonia

occurs in the community setting

first 48 hours after hospitalization

Causative Agents:

Streptococcus pneumoniae

Haemophilus Influenzae

Legionella pnuemophilla (legionnaires

disease) Mycoplasma pneumoniae

Viral pneumoniae (influenza viruses types A, Badenovirus, parainfluenza, cytomegalovirus,coronavirus, varicella-zoster)

Chlamydial pneumoniae


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Hospital-Acquired Pneumonia

Nosocomial pneumonia

More than 48 hours after admission in

patients with no evidence of infection atthe time of admission.

Causative agents:

Pseudomonas aerginosa

Staphylococcal aureus Klebsiella pneumoniae


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Pneumonia in the

immunocompromised host

Causative Agents:

Pneumocytisis jiroveci[Pneumocytisis pneumonia (PCP)]

Aspergillus Fumigatus (Fungal

Pneumonia)

Mycobacterium tuberculosis

(Tuberculosis)


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AspirationP

neumonia

refers to the pulmonary consequences

resulting from entry of endogenous or

extrogenous substances into the lower

airway.

Anaerobic Bacteria (S. Pneumoniae, H.

influenzae, S. aureus)


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SIGNS AND SYMPTOMS (Legionnaires Disease)

Legionnaires' disease usually develops two

to 14 days after exposure to the legionella

bacteria. It frequently begins with the

following signs and symptoms

Headache

Muscle pain

Chills Fever that may be 104 F (40 C) or higher


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If you have Legionnaires' disease, by thesecond or third day, you'll develop other signsand symptoms that may include:

Cough, which may bring up mucus and sometimes blood

Shortness of breath Chest pain

Fatigue

Loss of appetite

Gastrointestinal symptoms, such as nausea, vomiting anddiarrhea

Confusion or other mental changes


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Complications:

Respiratory failure

Septic shock

Acute kidney failure


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Anatomy and Physiology

Function:

The function of the respiratory system is to give us asurface area for exchanging gases between the air

and our circulating blood. It moves that air to andfrom the surfaces of the lungs while it protects thelungs from dehydration, temperature changes andunwelcome pathogens. It also plays a part in makingsounds such as talking, singing, other nonverbalsounds and works with the central nervous systemfor the ability to smell.


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Upper Respiratory Anatomy

The upper respiratory system

consists of the nostrils (externalnares), nasal cavity, nasalvestibule, nasal septum, bothhard and soft palate,nasopharynx, pharynx, larynx andtrachea. Within the nostrils,course hairs protect us from dust,

insects and sand. The hard palateserves to separate the oral andnasal cavities. There is aprotective mucous membranethat lines the naval cavities andother parts of the respiratorytract. It is secreted over the

exposed surfaces and then thecilia sweeps that mucus and anymicroorganisms or debris to thepharynx, so it is swallowed andthen destroyed in stomach acids.


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Lower Respiratory Anatomy

The trachea branches off into what is known as thebronchi (more commonly called bronchial tubes).These two main bronchi have branches forming thebronchial tree. Where it enters the lung, there isthen secondary bronchi. In each lung, the secondary

bronchi divides into tertiary bronchi and in turnthese divide repeatedly into smaller bronchioles. Thebronchioles control the ratio of resistance to airflowand distribution of air in our lungs. The bronchiolesopen into the alveolar ducts. Alveolar sacs are at the

end of the ducts. These sacs are chambers that areconnected to several individual alveoli, which makesup the exchange surface of the lungs.


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The Lungs

The human respiratory system has two lungs, whichcontain lobes separated by deep fissures.

Surprisingly, the right lung has three lobes while the

left one has only two lobes. The lungs are made up

of elastic fibers that gives it the ability to handlelarge changes in air volume. The pleural cavity is

where the lungs are located. The diaphragm is the

muscle that makes up the floor of the thoracic cavity

and plays a major role in the pressure and volume ofair moving in and out of the lungs.


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Significance

Our lungs filter and deliver oxygen that is

necessary for healthy red blood cells. It isimportant that we keep the respiratory tract

healthy through proper rest, hydration, diet

and exercise


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Pathophysiology

Risk factors include:

Alcoholism

Cigarette smoking

Diseases such as kidney failure or diabetes

Diseases that weaken the immune system, including cancer

Long-term (chronic) lung disease, such as chronic obstructivepulmonary disease (COPD)

Long-term use of a breathing machine (ventilator)

Medicines that suppress the immune system, includingchemotherapy and steroid medications

Older age


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Virulent Microorganism

Legionella pneumophila

Microorganism enters the nose (nasal passage)

Passes through larynx, pharynx and trachea

Microorganism enters and affects both airway and lungparenchyma

Airway damage

Lung invasionInfiltration of bronchi

Flattening of epithelial cells


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Infectious organism lodges

Macrophages and leukocytes

Stimulation in bronchioles

necrosis of bronchial tissues

mucus and phlegm production

Alveolar collapse narrowing of air passage

COUGHING

Productive/non-productive


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DIFFICULTY OF BREATHING

Increased pyrogen in the body

FEVER

Necrosis of pulmonary tissue

Overwhelming sepsis

DEATH


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Nursing History

Onset, duration, triggers and severity of symptoms

Signs and symptoms:

Legionnaires' disease usually develops two to 14 days afterexposure to the legionella bacteria. It frequently begins withthe following signs and symptoms:

Headache

Muscle pain

Chills Fever that may be 104 F (40 C) or higher


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If you have Legionnaires' disease, by the second or thirdday, other signs and symptoms that may include:

Cough, which may bring up mucus and sometimesblood

Shortness of breath

Chest pain

Fatigue

Loss of appetite

Gastrointestinal symptoms, such as nausea, vomitingand diarrhea

Confusion or other mental changes

Occupation/environmental exposures Smoking history

Family history of respiratory diseases


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2. Physical Assessment

high fever and tachypnea and bradycardia Absence of inflammation of the upper respiratory tract

Chest auscultation findings may be normal or mayreveal rales, rhonchi, or signs of consolidation.

Pericarditis and endocarditis may be present. Hepatomegaly may be seen in rare cases.

The neurologic examination findings or the patient'smental status may be abnormal.

blood-streaked sputum. Mild, generalized abdominal pain and bloating may be

present.


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Diagnostic/Laboratory Results

1. Arterial blood gases

Blood gases is a measurement of how muchoxygen and carbon dioxide is in your blood.

It also determines the acidity (pH) of yourblood

2. Chest x-ray-Definition

A chest x-ray is an x-ray of the chest, lungs,heart, large arteries, ribs, and diaphragm


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3.Complete blood count (CBC), including white blood

cell count

a basic evaluation of the cells (red blood cells,

white blood cells, and platelets) suspended in the

liquid part of the blood (plasma). It involves

determining the numbers, concentrations, and

conditions of the different types of blood cells

4. Erythrocyte sedimentation rate

ESR stands for erythrocyte sedimentation rate. It is

a test that indirectly measures how muchinflammation is in the body.


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5. Liver function tests

Liver function tests, or LFTs, include tests for

bilirubin, a breakdown product of hemoglobin,and ammonia, a protein byproduct that isnormally converted into urea by the liverbefore being excreted by the kidneys.

6. Sputum indirect fluorescent antibody test

Sputum direct fluorescent antibody (DFA) is atest that looks for microorganisms in lung

secretions


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Pharmacological management:

Antibiotics commonly used to treat this

condition include:

Quinolones (ciprofloxacin, levofloxacin,moxifloxacin, or gatifloxacin)

Macrolides (azithromycin, clarithromycin, or

erythromycin)


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Other treatments may include:

Fluid and electrolyte replacement

Oxygen (given through a mask or breathingmachine)


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NURSINGMANAGEMENT

Improving airway patency

Encourage hydration (2 to 3 L/day)

Humidification

because it thins and loosens pulmonary secretions Encourage hydration

Lung expansion maneuvers, such as deep breathing withan incentive spirometer may induce cough.

Chest physiotherapy (percussion and postural drainage) isimportant in loosening and mobilizing secretions

Oxygen therapy


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Promoting rest and conserving energy

Encourage the patient to rest and avoid

overexertion and possible exacerbation of

symptoms.

Semi-fowlers position

Change position frequently to enhance secretion

clearance and pulmonary ventilation andperfusion.


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Maintaining Nutrition

Fluid with electrotytes (commercially available

drinks, such as Gatorade) may help provide fluid,

calories and electrolytes.

IV fluids and nutrients


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Monitoring and managing potential

complications

Antibiotic therapy

Monitor for changes in physical status (deteriorationof condition or resolution of symptoms) and forpersistent recurrence of fever, which may result ofmedication allergy,

Monitor for continuing symptoms and complications


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PNEUMOCONIOSIS

REPORT-NCM 103 LECTURE


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DEFINITION

Any disease of the lung

caused by chronic inhalation of

dust, usually mineral dust of

occupational or environmental

origin.


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DEFINITION

Some kinds of

pneumoconioses are

asbestosis, coal workers

pneumoconiosis and silicosis.


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The development of pneumoconiosis

is dependent on the following:

The amount of dust retained in the lung and

airways.

The size and shape of the particles (particlesbetween 1 and 5 m are the most dangerous).

Solubility and physiochemical properties of

the particles.

Concomitant effects of other irritants, such as

smoking.


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Examples of Pneumoconiosis

Asbestos exposure from mining,

insulation related work: asbestosis.

Coal dust exposure from coal mining:coal workers pneumoconiosis.

Silica exposure from foundry work,

sandblasting, stone cutting: silicosis


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ASBESTOSIS

Chest X-ray in asbestosis shows

plaques above diaphragm


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ASBESTOSIS

-a breathing disorder caused by inhaling

asbestos fibers.

-prolonged accumulation of these fibers inyour lungs can cause scarring of lung tissue

and shortness of breath.

-symptoms can range from mild to severe,

and usually don't appear until years after

exposure.


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ASBESTOSIS

Signs and Symptoms:

Shortness of breath

Decreased tolerance for physical activity Coughing

Chest pain

Finger deformity (clubbing) in some cases


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COAL WORKERS PNEUMOCONIOSIS

This chest x-ray shows coal worker's

lungs. There are diffuse, small, light

areas on both sides (1 to 3 mm) in all

parts of the lungs


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-also called as black lung disease.

-caused by long exposure to coal dust.

-common affliction of coal miners and otherswho work with coal.

-inhaled coal dust progressively builds up inthe lungs and is unable to be removed by the

body that leads to inflammation, fibrosis, andin the worst case, necrosis.


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Signs and Symptoms:

Chronic cough

Shortness of breath


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SILICOSIS


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SILICOSIS

-also known as Potter's rot, is a form of

occupational lung disease caused by

inhalation ofcrystalline silica dust, andis marked by inflammation and scarring

in forms ofnodular lesions in the upper

lobes of the lungs.


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SILICOSIS

Signs and Symptoms:

Shortness of breath following physicalexertion

Cough

Minor fatigue

Loss of appetite

Occasional chest pains

Bluish skinat edges of extremities


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SILICOSISThree types of silicosis:

Simple chronic silicosis-results from long-termexposure (more than 20 years) to low amounts of silicadust. Swellings caused by the silica dust form in thelungs and chest lymph nodes. This disease may causepeople to have trouble breathing.

Accelerated silicosis-occurs after exposure to largeramounts of silica over a shorter period of time (5 - 15years). Swelling in the lungs and symptoms occurfaster than in simple silicosis.

Acute silicosis-results from short-term exposure tovery large amounts of silica. The lungs become veryinflamed and can fill with fluid, causing severeshortness of breath and low blood oxygen levels.


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PATHOPHYSIOLOGY

ASBESTOSIS

Inhaled

asbestos fibers

Alveoli

Fibrous tissue

Fibrous changes


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PATHOPHYSIOLOGY

Pleura

Thicken and

develop plaque

Lung diseases

Decreased

Lung volume

Diminished exchangeof O2 and CO2

Hypoxemia Corpulmonale

Respiratoryfailure


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PATHOPHYSIOLOGY


Also known as black lung disease

Inhaled dusts mixtures of:

coal, kaolin, mica and

silica

Alveoli and respiratory

bronchioles

Macrophages that engulf

the dust can no longer be

cleared


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PATHOPHYSIOLOGY

Aggregate and

fibroblasts appear

Bronchioles and

alveoli clogged

Dying

macrophagesFibroblastsDust

Coal macules

Fibrotic lesions


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PATHOPHYSIOLOGY

SILICOSIS

Inhaled silica dust

Nodular lesions

Nodules enlarge

and coalesce

Dense masses


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PATHOPHYSIOLOGY

Loss of pulmonaryvolume

Fibrotic destruction

of pulmonary tissue

Lung diseases

EmphysemaPulmonary

hypertensionCor pulmonale


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ASSESSMENT

A.

N

ursingH

istoryTaking a nursing history prior to the physical

examination allows a nurse to establish a rapport

with the patient and family.

Onset, duration, triggers and severity of symptoms-Dyspnea (rest, exercise)

-Cough (dry, productive)

-Chest pain (pleuritic, constant)-Fever


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ASSESSMENT

Occupation/environmental exposures extremelyimportant

-Lungs exposed to environment more than any organ

besides skin

-Exquisitely sensitive to noxious agents:

a. Asbestos exposure from mining, insulation related

work.

b.Coal dust exposure from coal mining.

c.Silica exposure from foundry work, sandblasting,

stone cutting.


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ASSESSMENT

Smoking history Family history of respiratory diseases

Clients perception (Why they think they have been

referred/are being assessed; What they hope to gain

from the meeting) Emotional health (Mental health state, coping style)

Spiritual health (Is religion important? If so, in what

way? What/who provides a sense of purpose?)


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ASSESSMENT

B. Physical Assessment Inspection:

a. Skin characteristics & color

b. Nail beds

c. General appearance of thorax

d. Breathing pattern

Palpation

a. Assess tactile fremitus

b. Palpate skin temperature and texture

c. Respiratory excursion


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ASSESSMENT

Percussion

a. Percuss chest comparing one side with the other

Auscultation

a. Auscultate chest from apex to base Observe and document the overall pattern of the

patient's breathing. Note changes

a. body positioning

b. muscles used in breathing: accessory muscles


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ASSESSMENT

Observe and document and note changes in thepatient's respiratory pattern

a. rate

b. depth

c. use of pursed lipsd. stridor - crowing sound

e. abdomen and chest rising together or irregularly(chest rise, abdomen draws in)

f. slow or rapid respiration

g. apnea

h. restlessness


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ASSESSMENT

C.Diagnostic/Laboratory Test

Asbestosis

a. Pulmonary function tests.

-determine how well your lungs are

functioning and may help in the diagnosis.

-measure how much air your lungs can hold

and the airflow in and out of your lungs


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ASSESSMENT

b.Chest X-ray.

-can often detect abnormalities in your lungs

before you experience any symptoms.

-Asbestosis appears as excessive whiteness inyour lung tissue. If the asbestosis is

advanced, your entire lung may be

affected, giving it a honeycombappearance.


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ASSESSMENT

c.Computerized tomography (CT) scan. -these scansgenerally provide greater detail than does a usual

chest X-ray.

-this may help detect asbestosis in its early stages,

even before it shows up on the chest X-ray.

Lung mass, right

upper lobe - CTscan


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ASSESSMENT

Coal Workers Pneumoconiosis

a.Chest X-Ray

This chest x-ray

shows coal worker's

lungs. There are

diffuse, small, light

areas on both sides

(1 to 3 mm) in all

parts of the lungs


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ASSESSMENT

This chest x-ray

shows stage II

coal worker's

pneumoconiosis(CWP). There are

diffuse, small light

areas on both

sides of the lungs.


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ASSESSMENT

This picture showscomplicated coal workers

pneumoconiosis. There are

diffuse, massive light areas

that run together in theupper and middle parts of

both lungs. These are

superimposed on a

background of small andpoorly distinguishable light

areas that are diffuse and

located in both lungs.


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ASSESSMENT

Silicosis

a.Chest X-Ray

-small, discrete, nodular lesions distributed

throughout both lung fields but typicallyconcentrated in the upper lung zones; the

lung nodes may be enlarged and exhibit

eggshell calcification.


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MEDICAL/SURGICALMANAGEMENT Asbestosisa.Bronchoalveolar lavage

-helpful in diagnosing infections that may present

with diffuse infiltrates, which simulate asbestosis.

-can provide quantitative information by asbestos

fiber counts. More than 1 asbestos body (ie,

coated asbestos fiber) per milliliter of lavage

effluent suggests significant exposure.


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MEDICAL/SURGICALMANAGEMENT

b.Bronchoscopy

-performed to facilitate BAL.

-indicated for airway examination when radiologic

studies are suggestive of bronchogenic carcinoma.

-Transbronchoscopic lung biopsy is not

recommended for diagnosis of asbestosis. This

procedure yields inadequate tissue and may cause

crush alterations to the tissue.


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Open-lung biopsy is not indicated in most cases. However,this procedure provides sufficient tissue for the pathologistto make a definitive diagnosis.

Antibiotics may be prescribed to combat infection. Aspirinor acetominophen (Tylenol) can relieve minor discomfortand bronchodilators that are swallowed or inhaled can relaxand widen breathing passages.

Diuretics (drugs that increase urine production andexcretion) or digitalis glycoside (Digitalis purpurea) areprescribed for some patients. Others may need to usesupplemental oxygen or use less salt.


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Coal Workers Pneumoconiosis

a.Bronchodilator medications

b.Inhaled corticosteroids

c. Chest physiotherapyd. Oral corticosteroids.

e. Home oxygen therapy

f. Antibiotics for bronchitis

g. Influenza vaccine

h. Pneumonia vaccine


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Silicosis

a. Antibiotics for bacterial lung infection.

b. TB prophylaxis for those with positive tuberculin skin test.

c. Prolonged anti-tuberculosis (multi-drug regimen) forthose with active TB.

d. Chest physiotherapy to help the bronchial drainage of

mucus.

e. Oxygen administration to treat hypoxemia, if present.


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Bronchodilators to facilitate breathing.

Lung transplantation to replace the damaged lung

tissue is the most effective treatment, but is

associated with severe risks of its own.

For acute silicosis, Whole-lung lavage (see

Bronchoalveolar lavage) may alleviate symptoms,

but does not decrease overall mortality.


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NURSINGMANAGEMENT

Monitor vital signs.

Check for the presence of cyanosis (blue color) of

the feet or hands.

Check for the presence of edema (swelling) of thefeet and lower legs.

Supportive treatment of symptoms includes

respiratory physiotherapy to remove secretions

from the lungs by postural drainage, chestpercussion, and vibration.


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NURSINGMANAGEMENT

Position in high fowlers of semi fowlers.

Provide health teachings such as:

a. Stop smoking if you are a heavy smoker, it is

vital that you stop this habit as soon as you havebeen diagnosed with pneumoconiosis.

b. Prevent infections by avoiding crowds and

persons with colds or similar infections.

c. Avoid exposure to dust.


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REFERENCES

Mason RJ, Murray JF, Broaddus VC, Nadel JA, eds.Textbook of Respiratory Medicine. 4th ed.Philadelphia, Pa: Saunders Elsevier; 2005:1758-1763.

en.wikipedia.org/wiki/Pneumoconiosis

www.nlm.nih.gov/medlineplus/ency/article/000130.

htm www.answers.com/topic/pneumoconiosis

www.mayoclinic.com/health/asbestosis/DS00482

www.mamashealth.com/silicosis.asp

en.wikipedia.org/wiki/Coalworker's_pneumoconiosis


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Pleurisy


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Overview of the Disease

Also known as pleuritis, is an inflammation of the pleura thatproduces sharp chest pain with each breath.

The membranous pleura that encases each lung is composedof two close-fitting layers; between them is a lubricating fluid.

If the fluid content remains unchanged by the disease, the pleurisy issaid to be dry.

If the fluid increases abnormally, it is a wet pleurisy, or pleurisy witheffusion.

If the excess fluid of wet pleurisy becomes infected, withformation of pus, the condition is known as purulent pleurisy


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Two types of pleurisy

Dry pleurisy-the more common condition, the

inflamed pleurae rub directly against each

other.

Wet pleurisy- fluid oozes from the inflamed

tissue into the space between the lungs and

the chest wall. This fluid may compress the

lungs, making breathing difficult.


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Both types of pleurisy often occur as complications

of respiratory tract infections, such as pneumonia,

viral infections, and tuberculosis, and are more likelyto develop in persons who are highly susceptible to

such infections. They also can be caused by a tumor

or an injury.

Some cases are due to certain gastrointestinal tract

diseases, particularly of the liver and pancreas, which

can inflame the diaphragm (the large muscleseparating the chest and abdominal cavities) and the

portions of the pleurae that cover the diaphragm.


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Causes

Infections (pneumonia or tuberculosis.)

It is often a sign of a viral infection of the

lungs.

Immunocompromised

Tumor

Injury

Pulmonary Embolus


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Anatomy and Physiology

The Pleura

A thin, moist, and slippery membrane that covers the outer surface of theof the rib cage. Parietal Pleura- is the outer layer of the pleura that lines the walls of the

thoracic cavity, covers the diaphragm, and forms the sac containing each lung. Parietal means relating to the walls of the cavity

Visceral Pleura- is the inner layer of pleura that surrounds each lung. Visceral means relating to the internal organs.

Pleural Cavity- also known as pleural space is the airtight area betweenthe layers of the pleural membranes. This space contains a thin layer offluid that allows the membranes to slide easily during breathing


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Chest pain

Inflamed pleurae rubdirectly against eachother.

Worsen duringcoughing and deep

breathing

InfectionsConnective tissue diseasesOrgan FailuresCancersChemical ExposuresPulmonary Embolus

DryWet

Fever

Presence of infecting

organism

Release of

chemokines,

cytokines

Initiates inflammatoryresponse

Pathophysiology


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Compress the lungs

Fluid oozes from the

inflamed tissue into thespace between thelungs and the chest wall

Difficulty of Breathing

Cyanosis

Weight loss

phagocytosis

PusEmpyema

Poor appetite


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Assessment

Nursing History The history of patient with pleurisy is very important. It may

suggest pleural empyema.

A known diagnosis of SLE/ history of takingdrugs(precainamide, hydralazine, quinidine), associated with

lupus syndrome, sarcoidosis, rheumatoid disease/uremia should alert the clinician to the potential cause ofpleurisy.

An increase leucocytes count with a shift to left suggestbacteria infection, i.e. pneumonia, esophageal rupture(mediastinitis, empyema), hepatic/ splenic abscess/ severe

inflammation (pancreatitis). Leucopoenia maybe seen in patient with viral pleurisy or SLE.


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Signs and Symptoms:

fever

Shortness of breath

Weight loss Poor appetite

Sharp chest pain with breathing.

Inability to take a deep breath due to chestpain


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Physical Exam

Using a stethoscope, the doctor will listen to the patientsbreathing to find out whether your lungs are making anyabnormal sounds.

In pleurisy, the inflamed layers of the pleura make a Rough, scratchy (pleural friction rub).

If you have a pleural effusion, fluid buildup in the pleuralspace will prevent a friction rub. But if the theres a lot offluid, the doctor may hear a dull sound when he or she tapson your chest, or he or she may have trouble hearing anybreathing sounds.

Muffled or dull breathing sounds also can be a sign of apneumothorax.

Diagnostic Studies


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Diagnostic Studies

Chest X Ray

A chest x ray is a painless test that creates apicture of the structures in your chest, such asyour heart, lungs, and blood vessels. This testmay show air or fluid in the pleural space.

A chest x ray also may show what's causing apleural disorderfor example, pneumonia, afractured rib, or a lung tumor.

Sometimes a chest x ray is taken while you lie

on your side. This may show fluid that didn'tappear on an x ray taken while you werestanding


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Blood Tests

Blood tests can show whether you have anillness that may make it more likely that you'lldevelop pleurisy or another pleural disorder.

Such illnesses include bacterial or viralinfections, pneumonia, pancreatitis (an

inflamed pancreas), kidney disease, or lupus. Blood may show organ failure:

High BUN/Creatinine -- Kidney failure

High liver or pancreatic enzymes

l l d


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Arterial Blood Gas Tests

For this test, a small amount of blood is taken

from an artery, usually in your wrist. It's then

checked for oxygen and carbon dioxide levels.

This test shows how well your lungs are taking

in oxygen.


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Thoracentesis

Once your doctor knows whether fluid has built up in thepleural space and where it is, he or she can remove a samplefor testing.

This is done using a procedure called thoracentesis (THOR-a-

sen-TE-sis). During the procedure, your doctor inserts a thinneedle or plastic tube into the pleural space and draws outthe excess fluid. After the fluid is removed from your chest,it's sent for testing.

The risks of thoracentesis usually are minor and will get betteron their own, or they're easily treated. Your doctor may do achest x ray after the procedure to check for complications.


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Fluid Analysis

Doctors look at the fluid removed during

thoracentesis under a microscope. They look

at the chemicals in it and its color, texture, and

clearness for signs of infection, cancer, orother conditions that may be causing fluid or

blood to build up in the pleural space.


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Biopsy

If your doctor thinks that tuberculosis or cancer may havecaused fluid to build up in your pleural space, he or she maywant to look at a small piece of the pleura under amicroscope.

To take a tissue sample, your doctor may do one of the

following procedures: Insert a needle through the skin on your chest to remove a

small sample of the outer layer of the pleura.


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Insert a small tube with a light on the end(endoscope) into tiny cuts in your chest wall so thathe or she can see the pleura. Your doctor can thensnip out small pieces of tissue. This procedure mustbe done in a hospital. You'll be given medicine totemporarily put you to sleep while the procedure isdone.

Snip out a sample of the pleura through a small cutin your chest wall. This is called an open pleuralbiopsy. It's usually done if the sample from theneedle biopsy is too small for an accurate diagnosis.This procedure must be done in a hospital. You'll be

given medicine to temporarily put you to sleep whilethe procedure is done.


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Medical and Surgical Management

Treat underlying disorder

Rest

Oxygen, if levels are low

Aspirin and other NSAIDs (e.g., Ibuprofen, Indocin, etc.) are

effective in reducing the inflammation, fever, and pain. Painkillers such as codeine can help.

In severe pain, a nerve block is performed using a numbingagent (e.g., Xylocaine) that is injected into the nervesbetween the ribs for temporary relief of pain.

Therapeutic Thoracentesis is done to remove the effusion,which helps breathing.


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NursingManagement

Because the patient is in pain on inspiration, thenurse offers suggestions to enhance comfort, such as Lying on the painful side may be more comfortable,

because it will splint the chest wall, reduce the stretchingof the pleurae

Breathing deeply and coughing to clear mucus as the paineases

Getting rest

Limiting movement on the side of affected pleura to lessenthe pain.

Also teaches the patient to use hands or pillows to splintthe rib cage while coughing.


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Bronchogenic Carcinoma


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Overview

Lung Cancer Cancer is caused by a variety of malignant

neoplasm in which cells mutate and

invade surrounding tissue and can travelvia lymphatic system or blood vessels to

other secondary sites.


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Primary cancer is the body system or site

where the cancer was first observed

Secondary when it spreads (metastasizes)

from cancer in other areas of the body.


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Definition

Bronchogenic carcinoma refers to the

malignant tumor which grows in the

bronchus. Originating from mucus or gland

of bronchus.


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Classification of Lung Cancer

Cells


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Non Small Cell Lung Cancer (NSCLC)

Adenocarcinoma Squamous Cell Carcinoma

Large Cell Carcinoma

Small Cell Lung Cancer (SCLC)

Oat Cell

Intermediate Combined


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Non- small Cell lung Cancer

S ll i


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Squamous cell carcinoma

is usually more centrally

located and arises more

commonly in the

segmental and

subsegmental bronchi.

Slow-growing, late

metastasis

Ad i


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Adenocarcinoma

is the most prevalentcarcinoma of the lungin both men andwomen; it occurs

peripherally asperipheral masses ornodules and oftenmetastasizes.

Moderate growth rate,early metastasis

L ll i


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Large-cell carcinoma

Also called

undifferentiated

carcinoma

Is a fast growing tumorthat tends to arise

peripherally

Fast-growing, early

metastasis

Small cell carcinoma has three


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Small cell carcinoma has three

subtypes:

oat-cell carcinoma

intermediate cell type

Combined oat- cell

carcinoma. Tumors grows rapidlyand are often locatednear a major bronchusin the central part of the

lungs Fast-growing, early

metastasis

Eti l d P th i


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Etiology and Pathogenesis

Occupational associations: asbestos,uranium( in miners), arsenical fumes, nickel,radon gas.

Other factors include air pollutions , ionizingradiation .

Nowadays it is reported that tuberculosis isassociated with the incidence of lung cancer.

Eti l d P th i


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Many factors influence the formation of lung

cancer. The development of lung cancer is

multistep process. The transformation of normal

bronchial epithelial

cells to malignant cells is unknown.


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Perhaps It is related to:

damage to cellular DNA

alteration in cellular oncogene

expression; tumor-derived factors thatstimulate cellular division.

Eti l d P th i


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Chronic inflammation of the lung, such as

from interstitial fibrosis and areas of

scarring is associated with the occurrence

of adenocarcinoma.

Genetic factors also involve the formation

of lung cancer.


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TNM S t


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TNMSystem

a classification system developed and recently

revised by the American Joint Committee on

Cancer (AJCC) and the Union Internationale

Contre le Cancer (UICC; International UnionAgainst Cancer). According to this system:

T = tumor size

N = node involvementM = metastasis status

T mors


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Tumors

TX: Tumor cannot be evaluated or tumor isproven by the presence of cancer cells in thesputum or bronchial washings, but it cannotbe seen during imaging or bronchoscopy

("occult" tumor)

T0: No evidence of primary tumor

Tis: Carcinoma in situ


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T1: Tumor 3 centimeters (< 3 cm) or less ingreatest dimension, surrounded by lung orpleura, and not located in the main stembronchus

T2: Tumor more than 3 centimeters (> 3 cm) ingreatest dimension, or tumor involving themain stem bronchus, 2 cm or more from thecarina, or tumor invading the visceral pleura,

or tumor with incomplete lung expansion orobstructive lung infection that does notinvolve the entire lung

T3: Tumor of any size that directly invades the chest


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wall, diaphragm, pleura, or pericardium, or tumorthat involves the main stem bronchus less than 2

centimeters (< 2 cm) from the carina (ridge betweenthe right and left main stem bronchi), or tumor thatis associated with complete lung collapse orobstructive lung infection involving the entire lung.

T4: Tumor of any size that invades the heart, greatvessels (aorta, superior or inferior vena cava,

pulmonary artery, or pulmonary vein), trachea,esophagus, vertebral body, or carina, or separatetumor nodules in the same lung lobe, or tumorassociated with a malignant pleural effusion.

Nodes


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Nodes

The regional lymph nodes (N) are clinically divided intothe following categories:

NX: Regional lymph nodes cannot be assessed

N0: Regional lymph nodes contain no metastases

N1: Metastasis to same-side peribronchial (aroundthe bronchi) and/or hilar (pit in the lungs where

vessels enter and exit) lymph nodes and nodeswithin the lungs that are involved by direct spreadof the primary tumor

N2 M t t i t id di ti l


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N2: Metastasis to same-side mediastinal

and/or subcarinal (under the carina, or

tracheal ridge) lymph nodes.

N3: Metastasis to opposite-side mediastinal

or hilar nodes or to same- or opposite-side

scalene (neck/upper rib) or supracalvicular

(above collarbone) lymph nodes.

Metastasis


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Metastasis

Lung Cancer with Invasion Into SpineThe state ofmetastasis (M) is defined as follows:

MX: Distant metastases cannot be assessed

M0: No distant metastases are found

M1: Distant metastases are present (this alsoincludes separate tumor nodules in a different lobeof lung on either side).


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Anatomy

and

Physiology

Lung


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Lung

The Lungs are paired

elastic structures enclose

in the thoracic cage,

which is an airtightchamber, with distensible

walls.

Ventilation requiresmovement of the walls of

the thoracic cage and of

its floor, the diaphragm.

The effect of its movement is alternately to


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The effect of its movement is alternately toincrease and decrease the capacity of the

chest, when the capacity of the chest isincreased, air enters through the trachea(inspiration) because of the loweredpressure within and inflates the lungs.

When the chest wall and diaphragmreturn to their previous positions

(expiration), the lungs recoil and force theair out through the bronchi and trachea.

I i ti d i th fi t thi d f


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Inspiration occurs during the first third of

the respiratory cycle, expiration during thelatter two thirds.

The inspiratory phase of the respirationnormally requires energy, the expiratory

phase is normally passive requiring very

little energy.


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Pathophysiology

P h h i lP h h i l


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PathophysiologyPathophysiology

basal cells

epithelial cells

cilia

tar


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Assessment

Clinical Manifestations


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Clinical Manifestations

usually asymptomatic until late in its course cough or change in chronic cough

dyspnea

chest pain and tightness hoarseness

dysphagia

head and neck edema

Persistent cough Blood tinged sputum or coughing up frank

blood.


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Fatigue and weakness. Chest pain,

Shortness of breath.

Weight loss.

Shoulder, arm, or bone pain.

Sometimes the cancer is diagnosed onroutine examination, and the patient hasno or minimal symptoms. Symptoms andsigns are dependent upon the location and

spread of the tumor.


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Diagnostic Test

Chest X ray


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Chest X ray

WHY IS ITGIVEN?

Are done to detect

size and position ofthe heart and

structural

abnormalities of the

lungs.

HOW DOES THE TEST WORK?


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HOW DOESTHE TEST WORK?

Directs x-ray through the chest and ontofilm positioned behind the patients back.

As x-ray are directed to the patient, someare absorbed by the body and others passthrough the x-ray film.Areas of the bodythat absorb x-rays appear light on the x-

ray film. Dark areas on the film representx-ray that passed through the body.

WHAT TO DO?


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WHATTO DO?

Explain the test to the patient and that the

patient will be asked to hold his or her

breath while the x-ray is taken.

Before the test, remove all jewelry,

zippers, hooks, and any metal on the part

of the body being x-rayed.

Bronchoscopy


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Bronchoscopy

WHY IS IT DONE?

Bronchoscopy is used

to view the bronchialtree and to remove

foreign obstructions,

obtain tissues for

biopsy, or forsuctioning fluid.

HOW DOES IT WORK?


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HOW DOES IT WORK?

The patient is anesthetized and a

bronchoscope is inserted into the patients

mouth and down the trachea and

bronchial tree. The bronchoscope containsa tiny video camera and probes that the

physician manipulates to perform the

procedure.

WHAT TO DO?


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WHATTO DO?

Before the procedure

The patient must sign an informed consent for aninvasive procedure.

The patient is NPO for 8 hours except in an

emergency, to reduce chances of vomiting whenthe bronchoscope is passed down the throat.

During the procedure

Monitor vital signs, respiratory effort, and skincolor, cardiac monitor.

After the procedure:


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After the procedure:

The patient remains nothing by mouth, (NPO)until the gag reflex returns to avoid aspiration.

Verify the cough and gag reflex returns.

Monitor respirations for rate, effort, use of

accessory muscles, and breath sounds. Monitor heart rate and respiratory status for

change.

Monitor sputum for blood due to irritation

within bronchi.

Pulmonary Angiography


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Pulmonary Angiography

WHY IS IT DONE?

Provides a view of the

pulmonary circulatorysystem so that the

physician can

determine the

condition of bloodflow to the lungs.

HOW DOES THE TEST WORK?


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Radiopaque dye is inserted into the

patients veins after a catheter has been

passed through the heart into the

pulmonary artery fluoroscopically. Theimage is watched on a screen as the dye

flows through he pulmonary circulatory

system.

WHAT TO DO?


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WHATTO DO? Before the procedure:

Verify the patient is not allergic to contrast dye,iodine, or shellfish. If the patient is then eitheranother diagnostic study will be done, or the patient

will be premedicated for this test if no other test isdeemed appropriate. Diphenhydramine andprednisone may be given prior to the test to lessen orprevent an allergic reaction while closely monitoringthe patient.

The patient must sign an informed consent based oninstitutional policy.

Instruct the patient that a flushed feeling is commonhen the dye is injected intravenously.

During the procedure:


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During the procedure:

Monitor patient for tolerance of procedureand possible reaction to dye.

Afte

rthe p

roce

dure:

Monitor the insertion site for bleeding.

Sputum Culture and Sensitivity


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p y

WHY IT IS DONE?

Sputum from the patient

is cultured to determinewhich, if any, bacteria is

contained in the sputum

and determine which

antibiotic kills thebacteria.



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Sputum is collected from the patient in asterile container and sent to the lab where thesample is smeared in Petri dishes andincubated to grow the bacteria. Samples of

the bacteria are stained and examined undera microscope to identify the bacteria. Thesamples are checked periodically, but areusually given 72 hours to complete thetesting process. Once identified, bacteria are

exposed to known antibiotics to determinewhich antibiotic kills the bacteria.

WHATTO DO?


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Before the test:

Use a sterile specimen container to determine that thebacteria that grow in the lab have come from the patientand not from contamination.

Collect sputum only and not saliva- there are bacterianaturally found in the mouth, so saliva samples willgrow bacteria in the lab even though it is not causingany infection.

After the test:

Sample needs to go to lab

Teach the patient:

How to properly obtain sputum sample.

Thoracentesis


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WHY IT IS DONE?

Removal of fluid from

the pleural sac to

drain fluid or identifythe contents of the

fluid.



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The patient either sits at the edge of the

bed or lies on the unaffected side. The

affected site is anesthetized.A needle

work is inserted into the plural sac andfluid is drained using a syringe.

WHATTO DO?


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Befo

re the test:

The patient must sign an informed consent for aninvasive procedure.

Position the patient at the edge of the bed or lying

on the unaffected side with the head of the bedelevated 30 degrees.

During the test:

Monitor the patient for tolerance of the procedure. Monitor respiratory status for rate, effort, skin

color, use of accessory muscle, and breathsounds.


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After the test:

Lay the patient on the affected side for 1 hourfollowing the procedure. This applies directpressure to the puncture site, reducing thechance of bleeding.

Monitor the injection site for leakage;reinforce dressing noted.

Monitor respiratory status for changes.

Pulmonary Function Test (PFT)


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y ( )

WHY IS IT DONE?

This test assesses

the lungs ability to

move air. Monitorchange from normal

function; differentiate

obstructive from

restrictive disease.



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The patient takes a deep breath. Thespirometer is inserted into the patients mouthand the patient breathes outward quickly atfull force until all air is expelled.A deep

breath is then taken in through themouthpiece and this process is repeatedthree times.A computer then calculates thelungs volume and vital capacity bymeasuring the amount of air moving in and

out. The force of the air flow is measured.The duration of time of exhalation ismeasured.

What to do?


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Before the test:

The patient should not smoke prior to the

test. Smoking may have an effect on the

outcome of the test.

During the test:

Instruct the patient to take a deep breath

and then exhale completely into thespirometer followed by deep inhalation.


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After the test: Administer bronchodilators after the initial

testing is gone and repeat the test if

indicated. This will show the effect ofbronchodilators on pulmonary function.

Albuterol or levalbuterol are typically used.

LungBiopsy


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g p y

Why is it done?

Removal of a tissue

to be examined by thehistology lab for

abnormalities

How does the test work?


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A tissue sample can be extracted by

inserting a needle through the chest and

into the lung or by using a bronchoscope.

A biopsy can also be performed as anopen procedure through the chest wall,

opening the lung to remove tissue

samples.

What to do?


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Before the test:

The patient must sign an informed

consent. This is required for an invasive

procedure which will remove somethingfrom the body.

NPO for 8 hours to decrease the chance

of aspiration if done as an openprocedure.

During the test:


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During the test:

Monitor vital signs, skin color, andrespiratory effort; cardiac monitor;

After the test:

Examine the incision site for bleeding. Monitor respiration for changes, potential

for pneumothorax development after a

piece of the lung has been removed.

Arterial Blood Gas (ABG)


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Why is it done?

This determines the

patients ventilation,

tissue oxygenation,and acid-base status.

How does the test work?


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Three top five milliliters of blood is sampled froman artery in a heparinized syringe. If the samplecannot be analyzed right away, it should be placedon ice.

The normal results are; pH 7.35-7.45

Pa02 80-100 mmHg

PaCO2 35-45 mmHg

HCO3 22-26 mEq/L

What to do?


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Before the test:

Provide the lab with information on whetheror not patient is receiving supplementaloxygen or mechanical ventilation as well asthe amount of oxygen received or the settingof the ventilator. Oxygen supplementation atthe time of testing will be reported with theresults.

Note the patients temperature.Alteration intemperature may alter the results of the test.

Af h


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After the test:

Apply mechanical pressure to puncture

site for 5 minutes.

Apply pressure to puncture site for 30

minutes once the bleeding stopped.

Monitor the puncture site for bleeding.


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Medical Management

Surgical management


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Types of Lung Resection

Lobectomy: a single

lobe of lung isremoved.

Bilobectomy: Two

lobes of the lung are

removed.

Sleeve Resection


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cancerous lobe(s) is

removed and a

segment of the main

bronchus is resected.

Pneumonectomy


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Removal of entire lung

Wedge resection:


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Removal of small,

pie-shaped area ofthe segment.


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Chest wall resection with removal ofcancerous lung tissue: for cancers that

have invaded the chest wall.

Radiation Therapy to decrease tumor

size.

Chemotherapy


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use to alter tumor growth patterns totreat distant metastases or small cell

cancer of the lungsand as an adjunct

to surgeryor radiation therapy, often

with a combination of drugs:

cyclophosphamide, doxorubicin,

vincristine, etoposide, cisplatin, maysee relapse after treatment.

Oxygen therapy to supplement the needs ofthe body.


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the body.

Dietherapy

High- protein, high calorie, diet to meet theneeds of the body.

Pharmacological Intervention

Administer antiemetics to combat side effectsof chemotherapy: ondansetron,

prochlorperazine.Administer analgesics for pain control:

morphine, fentanyl


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Nursing Management

Monitor respiratory status, looking at rate,effort use of accessory muscles and skin


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effort, use of accessory muscles, and skin

color; auscultate breath sounds.

Monitor pain and administer analgesicsappropriately.

Monitor vital signs for changes, elevatedpulse, elevated respiration, change in BP,

and elevated temperature, which may signalinfection.

Monitor pulse oximetery for decrease inoxygenation levels


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oxygenation levels.

Assist patient with turning, coughing, anddeep-breathing exercise.

Place patient in semi-Fowlers position toease respiratory effort.

Explain to the patient: The importance of taking rest periods


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