Upload
job-weaver
View
224
Download
3
Embed Size (px)
Citation preview
Respiratory Respiratory DisordersDisorders
Respiratory Respiratory DisordersDisorders
Lola Oyedele MSN, RN, CTNLola Oyedele MSN, RN, CTNMajuvy L. Sulse MSN, RN, CCRNMajuvy L. Sulse MSN, RN, CCRN
LOWER AIRWAY AND LOWER AIRWAY AND PULMONARY VESSEL PULMONARY VESSEL
DISORDERSDISORDERS
LOWER AIRWAY AND LOWER AIRWAY AND PULMONARY VESSEL PULMONARY VESSEL
DISORDERSDISORDERSPneumoniaPneumonia
SARSSARSTuberculosisTuberculosis
Inhalation AnthraxInhalation AnthraxChronic Airflow LimitationChronic Airflow Limitation
Pneumonia • Excess of fluid in the lungs resulting
from an inflammatory process• Inflammation triggered by infectious
organisms and inhalation of irritants• Atelectasis• Hypoxemia
Pneumonia• Nosocomial or hospital-
acquired• Community acquired
Laboratory Assessment
• Gram stain, culture, and sensitivity testing of sputum
• Complete blood count• Arterial blood gas level• Serum blood, urea nitrogen level• Electrolytes• Creatinine
Impaired Gas Exchange
• Interventions include:– Cough enhancement– Oxygen therapy– Respiratory monitoring
Ineffective Airway Clearance
• Interventions include:– Help client to cough and deep
breathe at least every 2 hours.– Administer incentive spirometer—
chest physiotherapy if complicated.– Prevent dehydration.
(Continued)
Ineffective Airway Clearance (Continued)
– Monitor intake and output of fluids.
– Use bronchodilators, especially beta2 agonists.
– Inhaled steroids are rarely used.
Potential for Sepsis• Primary intervention is prescription
of anti-infectives for eradication of organism causing the infection.
• Drug resistance is a problem, especially among older people.
• Interventions for aspiration pneumonia aimed at preventing lung damage and treating infection.
Severe Acute Respiratory Syndrome
(SARS)• A virus from a family of virus types
known as “coronaviruses”• Virus infection of cells of the
respiratory tract, triggering inflammatory response
• No known effective treatment for this infection
• Prevention of spread of infection
Pulmonary Tuberculosis
• Highly communicable disease caused by Mycobacterium tuberculosis
• Most common bacterial infection• Transmitted via aerosolization• Initial infection multiplies freely in
bronchi or alveoli• Secondary TB• Increase related to the onset of HIV
Assessment
• Diagnosis of TB considered for any client with a persistent cough or other compatible symptoms (weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills)
• Bacillus Calmette-Guerin vaccine within previous 10 years produces positive skin test, complicating interpretation of TB test.
Clinical Manifestations of TB
• Progressive fatigue• Lethargy• Nausea• Anorexia
Clinical Manifestations of TB• Weight loss• Irregular menses• Low-grade fever, night sweats• Cough, mucopurulent sputum,
blood streaks
Diagnostic Assessment
• Manifestation of signs and symptoms• Positive smear for acid-fast bacillus• Confirmation of diagnosis by sputum
culture of M. tuberculosis• Tuberculin test (Mantoux test) purified
protein derivative given intradermally in the forearm
• Induration of 10 mm or greater diameter indicative of exposure
(Continued)
Diagnostic Assessment (Continued)
• Positive reaction does not mean that active disease is present, but does indicate exposure to TB or dormant disease.
Interventions
• Combination drug therapy strict adherence
• Isoniazid• Rifampin• Pyrazinamide• Ethambutol or streptomycin • Negative sputum culture indicative
of client no longer being infectious
Health Teaching• Follow exact drug regimen.• Proper nutrition must be
maintained.• Reverse weight loss and severe
lethargy.• Educate client about the
disease.
Lung Abscess• Localized area of lung destruction
caused by liquefaction necrosis, usually related to pyogenic bacteria
• Pleuritic chest pain• Interventions
• Antibiotics• Drainage of abscess• Frequent mouth care for Candida albicans
Inhalation Anthrax• Bacterial infection is caused by the
gram-positive, rod-shaped organism Bacillus anthracis from contaminated soil.
• Fatality rate is 100% if untreated.• Two stages are the prodromal
stage and the fulminant stage.• Drug therapy includes
ciprofloxacin, doxycycline, and amoxicillin.
Pulmonary Empyema
• A collection of pus in the pleural space• Most common cause: pulmonary
infection, lung abscess, and infected pleural effusion
• Interventions include:– Emptying the empyema cavity– Re-expanding the lung– Controlling the infection
Activity Intolerance
• Interventions to increase activity level:– Encourage client to pace activities
and promote self-care.– Do not rush through morning
activities.– Gradually increase activity.– Use supplemental oxygen therapy.
Interventions for Palliation
• Oxygen therapy• Drug therapy• Radiation therapy• Laser therapy• Thoracentesis and pleurodesis• Dyspnea management• Pain management
Chronic Airflow Chronic Airflow LimitationLimitation
Chronic Airflow Chronic Airflow LimitationLimitation
AsthmaAsthmaEmphysemaEmphysema
Chronic BronchitisChronic Bronchitis
Chronic Airflow Limitation
• Chronic lung diseases of chronic airflow limitation include:– Asthma– Chronic bronchitis– Pulmonary emphysema
• Chronic obstructive pulmonary disease includes emphysema and chronic bronchitis characterized by bronchospasm and dyspnea.
Asthma
• Intermittent and reversible airflow obstruction affects only the airways, not the alveoli.
• Airway obstruction occurs due to inflammation and airway hyperresponsiveness.
Aspirin and Other Nonsteroidal
Anti-Inflammatory Drugs
• Incidence of asthma symptoms after taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)
• However, response not a true allergy• Results from increased production of
leukotriene when other inflammatory pathways are suppressed
Collaborative Management
• Assessment• History• Physical assessment and clinical
manifestations:– No manifestations between attacks– Audible wheeze and increased
respiratory rate– Use of accessory muscles– “Barrel chest” from air trapping
Laboratory Assessment
• Assess arterial blood gas level.• Arterial oxygen level may
decrease in acute asthma attack.• Arterial carbon dioxide level may
decrease early in the attack and increase later indicating poor gas exchange.
(Continued)
Laboratory Assessment (Continued)
• Atopic asthma with elevated serum eosinophil count and immunoglobulin E levels
• Sputum with eosinophils and mucous plugs with shed epithelial cells
Pulmonary Function Tests
• The most accurate measures for asthma are pulmonary function tests using spirometry including:– Forced vital capacity (FVC)– Forced expiratory volume in the first
second (FEV1)– Peak expiratory rate flow (PERF)– Chest x-rays to rule out other causes
Interventions • Client education: asthma is often an
intermittent disease; with guided self-care, clients can co-manage this disease, increasing symptom-free periods and decreasing the number and severity of attacks.
• Peak flow meter can be used twice daily by client.
• Drug therapy plan is specific.
Drug Therapy
• Pharmacologic management of asthma can involve the use of:
• Bronchodilators• Beta2 agonists
• Short-acting beta2 agonists
• Long-acting beta2 agonists
• Cholinergic antagonists(Continued)
Drug Therapy (Continued)
• Methylxanthines• Anti-inflammatory agents• Corticosteroids• Inhaled anti-inflammatory
agents• Mast cell stabilizers• Monoclonal antibodies• Leukotriene agonists
Other Treatments for Asthma
• Exercise and activity is a recommended therapy that promotes ventilation and perfusion.
• Oxygen therapy is delivered via mask, nasal cannula, or endotracheal tube in acute asthma attack.
Status Asthmaticus• Status asthmaticus is a severe, life-
threatening acute episode of airway obstruction that intensifies once it begins and often does not respond to common therapy.
• If the condition is not reversed, the client may develop pneumothorax and cardiac or respiratory arrest.
• Emergency department treatment is recommended.
Emphysema
• In pulmonary emphysema, loss of lung elasticity and hyperinflation of the lung
• Dyspnea and the need for an increased respiratory rate
• Air trapping, loss of elastic recoil in the alveolar walls, overstretching and enlargement of the alveoli into bullae, and collapse of small airways (bronchioles)
Classification of Emphysema
• Panlobular: destruction of the entire alveolus
• Centrilobular: openings occurring in the bronchioles that allow spaces to develop as tissue walls break down
• Paraseptal: confined to the alveolar ducts and alveolar sacs
Chronic Bronchitis
• Inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially tobacco smoke
• Inflammation, vasodilation, congestion, mucosal edema, and bronchospasm
• Affects only the airways, not the alveoli• Production of large amounts of thick
mucus
Complications
• Chronic bronchitis• Hypoxemia and acidosis • Respiratory infections• Cardiac failure, especially cor
pulmonale• Cardiac dysrhythmias
Physical Assessment and Clinical
Manifestations
• Unplanned weight loss; loss of muscle mass in the extremities; enlarged neck muscles; slow moving, slightly stooped posture; sits with forward-bend
• Respiratory changes• Cardiac changes
Laboratory Assessment
• Status of arterial blood gas values for abnormal oxygenation, ventilation, and acid-base status
• Sputum samples• Hemoglobin and hematocrit blood
tests
• Serum alpha1-antitrypsin levels drawn
• Chest x-ray• Pulmonary function test
Impaired Gas Exchange
• Interventions for chronic obstructive pulmonary disease:– Airway management– Monitoring client at least every 2
hours – Oxygen therapy– Energy management
Drug Therapy• Beta-adrenergic agents• Cholinergic antagonists• Methylxanthines• Corticosteroids• Cromolyn sodium/nedocromil• Leukotriene modifiers• Mucolytics
Surgical Management• Lung transplantation for end-
stage clients• Preoperative care and testing• Operative procedure through a
large midline incision or a transverse anterior thoracotomy
• Postoperative care and close monitoring for complications
Ineffective Breathing Pattern
• Interventions for the chronic obstructive pulmonary disease client:– Assessment of client– Assessment of respiratory infection– Pulmonary rehabilitation therapy– Specific breathing techniques– Positioning to help alleviate
dyspnea– Exercise conditioning– Energy conservation
Ineffective Airway Clearance
• Assessment of breath sounds before and after interventions
• Interventions for compromised breathing:– Careful use of drugs– Controlled coughing– Suctioning – Hydration via beverage and
humidifier (Continued)
Ineffective Airway Clearance (Continued)
– Postural drainage in sitting position when possible
– Tracheostomy
Imbalanced Nutrition
• Interventions to achieve and maintain body weight:– Prevent protein-calorie
malnutrition through dietary consultation.
– Monitor weight, skin condition, and serum prealbumin levels.
– Address food intolerance, nausea, early satiety, loss of appetite, and meal-related dyspnea
Anxiety
• Interventions for increased anxiety:– Important to have client
understand that anxiety will worsen symptoms
– Plan ways to deal with anxiety
Health Teaching• Instruct the client:
– Pursed-lip and diaphragmatic breathing
– Support of family and friends– Relaxation therapy– Professional counseling access– Complementary and alternative
therapy
Potential for Pneumonia or Other Respiratory
Infections
• Risk is greater for older clients• Interventions include:
– Avoidance of large crowds– Pneumonia vaccination– Yearly influenza vaccine
Cystic Fibrosis • Genetic disease affecting many
organs, lethally impairing pulmonary function
• Present from birth, first seen in early childhood (many clients now live to adulthood)
• Error of chloride transport, producing mucus with low water content
• Problems in lungs, pancreas, liver, salivary glands, and testes
Nonpulmonary Manifestations
• Adults: usually smaller and thinner than average owing to malnutrition
• Abdominal distention• Gastroesophageal reflux, rectal
prolapse, foul-smelling stools, steatorrhea
• Vitamin deficiencies• Diabetes mellitus
Pulmonary Manifestations
• Respiratory infections• Chest congestion• Limited exercise tolerance• Cough and sputum production• Use of accessory muscles• Decreased pulmonary function• Changes in chest x-ray result• Increased anteroposterior diameter of
chest
Exacerbation Therapy
• Avoid mechanical ventilation• Airway clearance• Increased oxygenation• Antibiotic therapy• Heliox (50% oxygen, 50% helium)
therapy• Bronchodilator and mucolytic
therapies
Surgical Therapy
• Lung and/or pancreatic transplantation do not cure the disease; the genetic defect in chloride transport and the thick, sticky mucus remain.
• Transplantation extends life by 10 to 20 years.
• Single-lung transplant as well as double-lung transplantation is possible.
Primary Pulmonary Hypertension
• The disorder occurs in the absence of other lung disorders, and its cause is unknown although exposure to some drugs increases the risk.
• The pathologic problem is blood vessel constriction with increasing vascular resistance in the lung.
• The heart fails (cor pulmonale).• Without treatment, death occurs
within 2 years.
Interventions
• Warfarin therapy• Calcium channel blockers• Prostacyclin agents• Digoxin and diuretics• Oxygen therapy• Surgical management
Interstitial Pulmonary Disease
• Affects the alveoli, blood vessels, and surrounding support tissue of the lungs rather than the airways
• Restrictive disease: thickened lung tissue, reduced gas exchange, “stiff” lungs that do not expand well
• Slow onset of disease • Dyspnea common
Sarcoidosis
• Granulomatous disorder of unknown cause that can affect any organ, but the lung is involved most often
• Autoimmune responses in which the normally protective T-lymphocytes increase and damage lung tissue
• Interventions (corticosteroids): lessen symptoms and prevent fibrosis
Idiopathic Pulmonary Fibrosis
• Common restrictive lung disease• Example of excessive wound healing• Inflammation that continues beyond
normal healing time, causing extensive fibrosis and scarring
• Mainstays of therapy: corticosteroids, which slow the fibrotic process and manage dyspnea
Occupational Pulmonary Disease
• Can be caused by exposure to occupational or environmental fumes, dust, vapors, gases, bacterial or fungal antigens, or allergens
• Worsened by cigarette smoke• Interventions: special respirators
that ensure adequate ventilation
Lung Cancer
• A leading cause of cancer deaths worldwide
• Metastasizes at late-stage diagnosis• Paraneoplastic syndromes• Staged to assess size and extent of
disease• Etiology and genetic risk
(Continued)
Lung Cancer (Continued)
• Incidence and prevalence make lung cancer a major health problem.
• Health promotion and illness prevention is primarily through education strategies and reduced tobacco smoking.
Manifestations of Lung Cancer
• Often nonspecific, appearing late in the disease process
• Chills, fever, and cough• Assess sputum• Breathing pattern• Palpation• Percussion• Auscultation
Surgical Management• Lobectomy• Pneumonectomy• Segmentectomy (wedge
resection)
Pulmonary Embolism
• A collection of particulate matter—solids, liquids, or gases—enters venous circulation and lodges in the pulmonary vessels.
• In most people with pulmonary embolism, a blood clot from a deep vein thrombosis breaks loose from one of the veins in the legs or the pelvis.
Etiology • Prolonged immobilization• Central venous catheters• Surgery• Obesity• Advancing age• Hypercoagulability• History of thromboembolism• Cancer diagnosis
Health Promotion and Illness Prevention
• Stop smoking.• Reduce weight.• Increase physical activity.• If traveling or sitting for long
periods, get up frequently and drink plenty of fluids.
• Refrain from massaging or compressing leg muscles.
Clinical Manifestations
• Assess the client for:– Respiratory manifestations: dyspnea,
tachypnea, tachycardia, pleuritic chest pain, dry cough, hemoptysis
– Cardiac manifestations: distended neck veins, syncope, cyanosis, hypotension, abnormal heart sounds, abnormal electrocardiogram findings
– Low-grade fever, petechiae, symptoms of flu
Interventions • Evaluate chest pain• Auscultate breath sounds• Encourage good ventilation and
relaxation
(Continued)
Interventions (Continued)
• Monitor the following:– respiratory pattern– tissue oxygenation– symptoms of respiratory failure– laboratory values–effects of anticoagulant medications
• Surgery
Decreased Cardiac Output
• Interventions include:– Intravenous fluid therapy– Drug therapy
•Positive inotropic agents•Vasodilators
Risk for Injury (Bleeding)
• Interventions include:– Protect client from situations that
could lead to bleeding.– Closely monitor amount of
bleeding.– Assess often for bleeding,
ecchymoses, petechiae, or purpura.
– Examine all stool, urine, nasogastric drainage, and vomitus and test for occult blood.
Anxiety • Interventions include:
– Oxygen therapy– Communication– Drug therapy: anti-anxiety
agents